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Security Hunger-Strike Prisoners in the Emergency Department: Physiological and Laboratory Findings

      Abstract

      Background

      Medical treatment of hunger-strike patients, especially those in incarceration facilities, may pose clinical and treatment challenges for the treating physicians.

      Objective

      The aim of our study is to describe the epidemiology and clinical and laboratory characteristics of hunger-strike prisoners presenting to the emergency department (ED) and to describe etiologies of hospitalization and complications among this group.

      Method

      We retrospectively examined clinical and laboratory manifestations of 50 hunger-strike prisoners who were referred for evaluation to the ED after a longstanding fast.

      Results

      After a mean of 38 (28-44) days of a hunger strike, the most common complaints were chest pain and abdominal pain (14/60 [23.3%], 13/60 [21.6%], respectively). Mean weight loss percentage was 18.5%, and most patients were bradycardic (25/40 [62.5%]), and some hypothermic (16/50, [32%]). We describe several laboratory disturbances observed in these patients; leukopenia was the most common hematologic manifestation (31/50 [62%]), and a prolonged international normalized ratio was observed in 12/29 (41.3%) patients. We hospitalized 12% of the patients; the most common hospitalization cause was bradycardia (3/6 [50%]).

      Conclusions

      Our study found that the most common clinical symptom was chest pain, which has not been previously reported among hunger strikers. We observed a substantial number of laboratory disturbances due to muscle wasting and protein loss and due to presumed vitamin and micronutrient deficiencies. We suggest monitoring electrocardiograms for heart rate, blood count, chemistry, coagulation tests, and vitamin levels.

      Keywords

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      References

        • World Medical Association
        Declaration on hunger strikers, adopted by the 43rd World Medical Assembly in Malta, Nov 1991 and revised at the 44th World Medical Assembly in Marbella, Spain, Nov 1992.
        World Medical Association, Ferney-Voltaire, France2006
        • Oguz N.
        • Miles S.
        The physician and prison hunger strikes: reflecting on the experience in Turkey.
        J Med Ethics. 2005; 31: 169-172
        • Heimburger D.C.
        Malnutrition and nutritional assessment.
        in: 18th edn. Harrison's principles of internal medicine. 1. McGraw-Hill, New York2012: 605-611
        • Challa J.
        • Lopez J.I.
        Medical management of hunger strikers.
        Nutr Clin Pract. 2013; 28: 128-135
        • Eichelberger M.
        • Joray M.
        • Perrig M.
        • et al.
        Management of patients during hunger strike and refeeding phase.
        Nutrition. 2014; 30: 1372-1378
        • Israeli Medical Association
        The physician's guide to treating the detainee/prisoner on a hunger strike.
        Israeli Medical Association, Ramat Gan2014
        • Muller M.
        • Enderle J.
        • Pourhassan M.
        • et al.
        Metabolic adaptation to caloric restriction and subsequent refeeding: the Minnesota Starvation Experiment revisited.
        Am J Clin Nutr. 2005; 102: 807-819
        • Swenne I.
        • Stridsberg M.
        Bone metabolism markers in adolescent girls with eating disorders and weight loss: effects of growth, weight trend, developmental and menstrual status.
        Arch Osteoporos. 2012; 7: 125-133
        • Galetta F.
        • Franzoni F.
        • Prattichizzo F.
        • et al.
        Heart rate variability and left ventricular diastolic function in anorexia nervosa.
        J Adolesc Health. 2003; 32: 416-421
        • Pérez Riera A.R.
        • Ferreira C.
        • Filho C.F.
        • et al.
        The enigmatic sixth wave of the electrocardiogram: the U wave.
        Cardiol J. 2008; 15: 408-421
        • Abed J.
        • Judeh H.
        • Abed E.
        • Kim M.
        • Arabelo H.
        • Gurunathan R.
        "Fixing a heart": the game of electrolytes in anorexia nervosa.
        Nutr J. 2014; 13: 90
        • Miller K.K.
        • Grinspoon S.K.
        • Ciampa J.
        • et al.
        Medical findings in outpatients with anorexia nervosa.
        Arch Intern Med. 2005; 165: 561-566
        • Skolnick A.
        • Schulman R.C.
        • Galindo R.J.
        • et al.
        The endocrinopathies of male anorexia nervosa: case series.
        AACE Clin Case Rep. 2016; 2: e351-e357
        • Cheng T.O.
        Mitral valve prolapse is a frequent cardiovascular finding in patients with anorexia nervosa.
        Rev Esp Cardiol. 2003; 56 (author reply 1246–7): 1246
        • Kalk W.J.
        • Felix M.
        • Snoey E.R.
        • et al.
        Voluntary total fasting in political prisoners–clinical and biochemical observations.
        S Afr Med J. 1993; 83: 391-394
        • Dubois F.
        • Sudre E.
        • Porte A.
        • et al.
        Evolution and follow-up of hunger strikers: experience from an interregional hospital secured unit.
        Rev Med Interne. 2011; 32: 669-677
        • Gétaz L.
        • Rieder J.
        • Nyffenegge L.
        • Eytan A.
        • Gaspoz J.M.
        • Wolff H.
        Hunger strike among detainees: guidance for good medical practice.
        Swiss Med Wkly. 2012; 142: w13675
        • Altun G.
        • Akansu B.
        • Altun B.
        • et al.
        Deaths due to hunger strike: post-mortem findings.
        Forensic Sci Int. 2004; 146: 35-38
        • Vande V.L.
        • Mazza J.J.
        • Yale S.H.
        Hematologic and metabolic abnormalities in a patient with anorexia nervosa.
        WMJ. 2004; 103: 38-40
        • Başoğlu M.
        • Yetimalar Y.
        • Gürgör N.
        • et al.
        Neurological complications of prolonged hunger strike.
        Eur J Neurol. 2006; 13: 1089-1097
        • Harris R.H.
        • Sasson G.
        • Mehler P.S.
        Elevation of liver function tests in severe anorexia nervosa.
        Int J Eat Disord. 2013; 46: 369-374
        • Shearer M.J.
        • Fu X.
        • Booth S.L.
        Vitamin K nutrition, metabolism, and requirements: current concepts and future research.
        Adv Nutr. 2012; 3: 182-195
        • Jackson J.M.
        • Blaine D.
        • Powell-Tuck J.
        • et al.
        Macro- and micronutrient losses and nutritional status resulting from 44 days of total fasting in a non-obese man.
        Nutrition. 2006; 22: 889-897
        • Bharadwaj S.
        • Ginoya S.
        • Tandon P.
        • et al.
        Table 3: Pros and Cons of Serum Nutritional Markers. In: Malnutrition: laboratory markers vs nutritional assessment.
        Gastroentrol Rep (Oxf). 2016; 4 (Available at:): 272-280