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Anorexia nervosa is a potentially fatal illness that affects women and a smaller proportion of men. When a patient becomes so severely ill that admission to a medical unit is required, the risk of a poor outcome is high. Most medical services do not have sufficient expertise, without psychiatric help, to manage the nutritional, medical, behavioural and family problems that often appear. These problems interact and this can adversely affect outcome. This article discusses, with reference to the MARSIPAN report, the procedure that should be followed when such a patient presents to an acute medical service. It considers diagnosis, risk assessment, consent, re-feeding syndrome, underfeeding syndrome and treatment-sabotaging behaviours. It stresses the importance of collaboration between expert medical and psychiatric staff, and involvement of the family. When these issues are adequately addressed, the outcome for the patient is more likely to be positive.
•Be confident in diagnosing individuals with anorexia nervosa and identify when urgent in-patient medical treatment is required
•Be confident in assessing and managing physical risk in individuals with anorexia nervosa
•Be aware of the Royal College of Psychiatrists’ MARSIPAN report and its implications for the management of individuals with eating disorders in medical settings
Reports of Calicophoron daubneyi infecting livestock in Europe have increased substantially over the past decade; however, there has not been an estimate of its farm level prevalence and associated risk factors in the UK. Here, the prevalence of C. daubneyi across 100 participating Welsh farms was recorded, with climate, environmental and management factors attained for each farm and used to create logistic regression models explaining its prevalence. Sixty-one per cent of farms studied were positive for C. daubneyi, with herd-level prevalence for cattle (59%) significantly higher compared with flock-level prevalence for sheep (42%, P = 0·029). Co-infection between C. daubneyi and Fasciola hepatica was observed on 46% of farms; however, a significant negative correlation was recorded in the intensity of infection between each parasite within cattle herds (rho = −0·358, P = 0·007). Final models showed sunshine hours, herd size, treatment regularity against F. hepatica, the presence of streams and bog habitats, and Ollerenshaw index values as significant positive predictors for C. daubneyi (P < 0·05). The results raise intriguing questions regarding C. daubneyi epidemiology, potential competition with F. hepatica and the role of climate change in C. daubneyi establishment and its future within the UK.
Paul Robinson's article provides an excellent summary of some of the challenges faced by clinicians working with patients with severe and enduring eating disorders (SEED) and outlines a robust approach to the recognition and management of this complex group of patients. This commentary expands on some of the points raised, adds some further views and suggests a tailored approach to establishing a therapeutic alliance with patients and carers.
Eating disorders encompass physical, psychological and social pathologies that increase health risk. Anorexia nervosa has the highest mortality of any psychiatric disorder, but patients are not always managed by specialist eating disorders services and the duty of care sometimes falls to the general psychiatrist. This article is an aide-memoire for assessing and managing physical risk in patients with anorexia nervosa.
Abstract – In principle churches proclaim their invitation to worship to all sectors of the population. In practice some sectors appear more willing to respond. Alongside the more visible demographic bias in terms of sex and age, this article draws attention to the less visible bias in terms of psychological type. New data provided by 185 rural Anglican church-goers who completed the Francis Psychological Type Scales demonstrated that there were significantly higher proportions of individuals reporting IS FJ and ES FJ preferences in church congregations than in the population of men and women at large.
The invitation ‘Everybody Welcome’ remains a worthy and laudable theological aspiration for the notice board of rural Anglican churches. The inclusivity of the welcome is a proper reflection of the Great Commission recorded in Matthew 28:19-20. This inclusivity is also a proper reflection of the potential for the rural parish church to function as a community church rather than an associational church. On this account, a wide variety of people are likely to go to the rural parish church largely because they live in (belong to) the area rather than because they choose to associate with (belong to) a particular network of people.
This worthy and laudable theological aspiration, however, may be challenged by a range of empirical evidence. Analyses of the demographic profile of many congregations provide a highly visible challenge in terms of sex and age (see Francis, 1996). The breakdown by sex tends to demonstrate that there are two female churchgoers for every one male churchgoer. The proclamation is clearly made that men and women are equally welcome, but women are twice as likely to respond. Then it may become increasingly difficult for men to feel at home in an environment shaped largely by women for women.
Although most patients with severe eating disorders are treated in specialist eating disorder services, general psychiatrists are often responsible for the care of many with mild to moderate disorder. Treating and supporting these patients in a non-specialist setting can sometimes be challenging but this need not be the case. Having a clear understanding of the clinical features of these conditions forms the foundation on which a comprehensive assessment and management plan can be made. We summarise the clinical features of eating disorders and explore the unique role of the general psychiatrist in identifying people with these conditions, supporting them and directing them into evidence-based treatments.
To investigate the use of a new technique to close persistent tympanic membrane perforations under general anaesthesia, in patients in whom this has previously been considered impractical.
Twenty patients aged 50 years and over were recruited. All had a persistent, symptomatic tympanic membrane perforation in at least one ear. Pre-operatively, an audiogram was performed and the tympanic membrane was assessed in order to establish the site and size of the perforation. Under general anaesthesia, the edges of the perforation were freshened and a sheet of Epifilm, trimmed to a size roughly 2 mm larger in diameter than the perforation, was tucked through the perforation. The ear was dressed appropriately. Patients were seen two weeks post-operatively in the out-patients department and reassessed.
The study was based at Poole General Hospital, a District General Hospital.
Twenty patients were recruited from the out-patients clinics of Poole Hospital ENT department.
Main outcome measures:
(1) closure of the perforation, as a percentage of the original size; (2) improvement of hearing, as an average across all frequencies, expressed in dB hearing level; and (3) presence or absence of discharge.
Five patients were operated upon and assessed six weeks post-operatively. The Epifilm had dissolved but the perforations remained the same size in all five patients. There were no other adverse effects. Pure tone audiometry at this stage was redundant. The study was subsequently aborted.
The authors conclude that repair of tympanic membrane perforations with hyaluronic acid ester films is not to be recommended.
The quotation in my title — “And must I cease to speak of Dante if Italy marches against us?” — is taken from Carl Sternheim's adaptation of Friedrich Maximilian Klinger's drama Das leidende Weib. Its sentiment was to acquire a curious poignancy, in that when the play was written (October 3– 18, 1914) Italy was not one of the belligerent powers. Nor indeed was Italy at war when the first private performance, in a Max Reinhardt production for the Kammerspiele des deutschen Theaters in Berlin, was permitted by the censor on March 31, 1916. But by the time the play was first performed for a public audience on October 30, 1916 the issue had only historical significance: on August 29, 1916 Italy had declared war on Germany.
The outbreak of war in August 1914 was a personal and professional disaster for Carl Sternheim. From 1911 onwards he had established a major literary reputation with his comedies Die Hose, Bürger Schippel, and Der Snob, in effective collaboration with Max Reinhardt. But his difficulties with the censor, initially on moral grounds, began to give him the reputation of a liability on the German stage, and this fact, combined with his decision to move to Brussels in 1912, made his position in 1914 highly precarious. His personal experiences in Belgium on the outbreak of hostilities were harrowing. Having set out for Germany from the family home, La Hulpe, south of Brussels, Sternheim was briefly arrested as a potential German spy and then kept in protective custody.