Death themes in anorexia nervosa: dimensions for a reply to Jackson et al

OBJECTIVE

To provide a critical, theoretical response to some ideas argued initially by Jackson and Davidson (Int J Eat Dis, 5, 821-835, 1986). Those ideas developed an understanding of anorexia nervosa in terms of disturbed death ideation and the notion of the anorexia nervosa sufferer as a "survivor." This paper was intended to broaden the frame of reference for a consideration of the relationship between eating disorders and death ideation.

METHOD

The approach is a reflection on three domains of thinking about death and destructiveness, two within psychology, the third a perspective provided by philosophy. Specifically, early post-Freudian work, personal construct psychology, and the philosophical tradition that makes death generally significant in human life, that is, Existentialism, are discussed in terms of their illumination of the ideas under review.

RESULTS

The result is a series of speculative observations that constitute an argument that these three domains together provide a strong countercritical position to the idea of a universal, even a general significance of death, particularly etiologically, in anorexia nervosa.

DISCUSSION

The discussion suggests that the particular significance of death ideation in a multidimensional condition like anorexia nervosa must be derived in each particular case where it will sometimes be more, sometimes less significant, and, importantly, will mean something different to each individual sufferer.

Pigbel-like syndrome in a vegetarian in Oxford

Enterocolitis necroticans or pigbel is a rare condition characteristically affecting chronically malnourished people who abruptly increase their intake of protein. The classic presentation of the disease as seen in the highlands of Papua New Guinea is that of a necrotising enterocolitis after the ritual ingestion of contaminated pork. In this context, the presentation of the same disease in a well nourished white vegetarian in Oxford was all the more intriguing.

Heart rate response during handball singles match-play and selected physical fitness components of experienced male handball players

Limited information is available concerning the exercise response during handball (HB) singles match-play. Also, few studies exist that have examined VO2 peak and body composition of HB players. The purpose of this study was to examine the heart rate (HR) response during match play and peak physiologic responses and relative fat in twelve experienced HB players. Peak physiologic responses were measured during treadmill running and body composition was assessed via hydrodensiotometry. During HB match-play, HR was measured and stored every five seconds using a Polar Vantage XL heart watch. Physical characteristics and peak physiologic responses included the following: Age (yrs) 47.2; BW (kg) 78.0; height (cm) 178.9; % fat 18.9; VO2 peak (ml.kg-1.min-1) 48.0; RER peak 1.03; HR peak (bpm) 183.1 and lactic acid peak (mmol.l-1) 10.3. During HB match-play, HR averaged 85% of peak during one hour of play. Moreover, 67% of match-play time, HR was > 80% of peak. When HR responses were examined over one hour of match-play (twelve, five minute blocks) only the first five minutes were significantly different (lower) than the other 55 minutes. The exercise intensity and the relatively stable HR response observed during HB suggests that this activity appears to be appropriate for meeting the American College of Sports Medicine guidelines to develop and maintain cardiorespiratory fitness.

Complications and effectiveness of gastrostomy feedings in pediatric cancer patients

PURPOSE

The objective of this study was to assess the complications and efficacy of gastrostomy (GT) feedings in pediatric cancer patients.

PATIENTS AND METHODS

We reviewed the medical records of 33 pediatric cancer patients who received enteral nutrition via a GT.

RESULTS

Median age was 9.4 years (range, 1-19.8 years), and 28 of the 33 patients had solid tumors. Seventeen patients had a significant weight loss (median, 8.5%) and therapy-related weight loss was anticipated in 16 patients. The GT device was placed an average of 5.5 months after diagnosis. Twenty-five patients were fed via a tube and eight via a button device. The tube was placed surgically in 21 cases (including all eight button types) and endoscopically in 12. Nutritional support lasted a median of 9.5 months. One or more complications occurred in 30 patients and were categorized as (a) insertion site reactions (inflammation, 23; infection/colonization, 14; exuberant granulation tissue, 6); (b) mechanical problems (leaking, 3; obstruction, 2; breakage, 1; accidental dislodgement, 2); (c) insertion site bleeding, 8; and (d) feeding intolerance, 12. Only one insertion site cellulitis progressed to a systemic infection. All eight patients with a button GT experienced insertion site complications, with local infection occurring significantly more often in patients with the button than in those with the tube GT. There were no significant associations between insertion technique and type of complication. Twenty-seven patients (82%) achieved or maintained ideal body weight with this intervention.

CONCLUSIONS

GT feeding was associated with minor complications, but permitted effective nutritional support for pediatric cancer patients.

Guidelines for the optimal management of chemotherapy-induced nausea and vomiting: a consensus

Nausea and vomiting are the most frequently reported adverse effects of cancer chemotherapy and have a significant impact on patients' daily functioning, quality of life and compliance with chemotherapy. Summarized in this article are the recommendations for the optimal management of nausea and vomiting developed by a multidisciplinary group of health care professionals. Issues relating to chemotherapy-induced nausea and vomiting are discussed; general principles of treatment are reviewed; treatment algorithms based on emetogenicity and types of chemotherapy are presented; and the importance of issues including non-pharmacological approaches, patient education and pharmacoeconomic perspectives are considered. The goal of antiemetic therapy should be no episodes of vomiting or retching and minimal or no nausea. Data from clinical trials support the clear superiority of 5-HT3 receptor antagonists in a variety of clinical situations. Their cost must be considered not only as an isolated item from the institutional perspective, but also from the perspective of the impact of successful therapy on the patient.

Comparison of a simulated 16.1-km time trial, VO2max and related factors in cyclists with different ventilatory thresholds

Differences in cycling performance have been observed in cyclists with similar VO2max values yet different lactate thresholds. The purpose of the current study was to compare a simulated 16.1-km cycling time trial, VO2max and related factors in cyclists who significantly varied in ventilatory threshold. From an original group of 18 category III or IV cyclists, two groups of 6 cyclists were formed based on ventilatory threshold values as high (77 +/- 4% of VO2max-Group H) or low (68 +/- 2.8% - Group L). VO2max and a 16.1-km time trial were completed on a Velodyne trainer. No significant difference (p > or = 0.05) was noted between groups in VO2max (Group H 4.00 +/- 0.281.min-1, Group L 4.15 +/- 0.671.min-1), however significant differences (p < or = 0.05) were found in ventilatory threshold and time trial scores. Group H completed the time trial in 16.29 +/- 2.08 min while Group L averaged 20.93 +/- 3.03 min. Group H completed the time trial 28% more quickly by working at a significantly higher percentage of VO2max, a higher power output and a faster pedal rate than Group L. From a battery of physiologic and body composition parameters, the ventilatory threshold expressed as VO2 (l.min-1) was the best predictor (r = -0.76) of time trial performance in the 12 cyclists. The findings of this study indicate that the ventilatory threshold was superior to VO2max in discerning performance differences in a 16.1-km cycling time trial, and was the best predictor of the simulated time trial performance.

Illiteracy among Medicaid recipients and its relationship to health care costs

Poor literacy is associated with poor health status, but whether illiteracy is also linked to higher medical care costs is unclear. We characterized the literacy skills of 402 randomly selected adult Medicaid enrollees to determine if there was an association between literacy skills and health care costs. Each subject's literacy skills were measured with a bilingual (English/Spanish) reading-assessment instrument. We also reviewed each subject's health care costs over the same one-year period. The mean reading level of this Medicaid population was at grade 5.6. Mean annual health care costs were $4,574 per person. There was no significant relationship between literacy and health care costs. While there are compelling reasons to improve poor reading skills among Medicaid enrollees, illiteracy in this population does not appear to contribute to the high cost of providing government-sponsored care.

[Promoting positive relations between parents and child--a counseling service for families with infants and young children in Sydney]

The "Early Intervention Programme" (EIP) in Sydney, Australia, is a home-based service for distressed families with children 0-3 years of age. It is funded as a child abuse prevention unit. The concept is based on the work of Selma Fraiberg (1980), who developed the first infant mental health program in Michigan, USA. The goal of the EIP is to strengthen the relationship between parents and child through developmental guidance, psychotherapy and/or provision of active help. The child is seen as an important partner in the intervention process.

Role of serology in monitoring treatment for Helicobacter pylori infection in elderly patients

Fifteen elderly patients with type B gastritis caused by Helicobacter pylori infection were treated with triple therapy consisting of colloidal bismuth subcitrate, amoxycillin and metronidazole. All were followed up every 6 weeks for 3 months. After triple therapy, eradication of the infection was confirmed in 12 patients (85%) by histology and bacteriology. In this group, a significant reduction in IgG antibody levels against H. pylori was detected (p < 0.001). In a control group of 15 patients with type B gastritis who received no antibacterial treatment, the specific IgG antibody titre remained unchanged during 3 months of follow-up. We conclude that this simple and noninvasive serological test would be suitable for follow-up after treatment of H. pylori infection in elderly patients.

Helicobacter pylori infection in elderly people: correlation between histology and serology

A hundred elderly dyspeptic patients were studied to assess the prevalence of Helicobacter pylori infection and the correlation between histological and serological findings. Eighty-one per cent of the patients with gastritis and 63% with gastric ulcer were H. pylori positive. All patients who had H. pylori negative gastritis and gastric ulcers were on nonsteroidal anti-inflammatory drugs (NSAIDs). There were 24 patients who had evidence of H. pylori infection and were on NSAIDs. H. pylori positive patients had more dyspeptic symptoms in comparison with those who were H. pylori negative. In patients who were taking NSAIDs, the presence of severe active gastritis seemed to correlate with the presence of H. pylori but not with the use of NSAIDs. Serology had a sensitivity of 90% and a specificity of 93% with a negative predictive value of 86%. There was a significant correlation between IgG titre and the degree of inflammation and H. pylori infection. We conclude that H. pylori gastritis is the commonest histopathological finding in elderly dyspeptic patients. H. pylori infection may be an important risk factor in elderly patients who take NSAIDs, increasing their risk of gastric ulcer. H. pylori serology in elderly people has a high sensitivity and specificity comparable with those in young age groups.

Association of protein kinase C activation with induction of ornithine decarboxylase in murine but not human keratinocyte cultures

The goal of this study was to compare the response of mouse epidermal keratinocytes (MEKs) and human epidermal keratinocytes (HEKs) to 12-O-tetradecanoylphorbol-13-acetate (TPA) with respect to the activation and downregulation of protein kinase C (PKC), the expression of c-jun and c-fos, and the expression and induction of ornithine decarboxylase (ODC) activity. Keratinocytes from adult CD-1 mice and from discarded adult human skin were grown in primary culture in a high-calcium serum-free medium that supported proliferation and differentiation. Immunoblotting of freshly isolated and cultured MEKs and HEKs for isozymes of protein kinase C revealed that fresh HEKs contained PKC alpha, PKC beta, and PKC delta; no PKC gamma, PKC epsilon, or PKC zeta were detected. In fresh MEKs, PKC alpha, PKC beta, PKC delta, and PKC zeta were observed, but not PKC gamma or PKC epsilon. After 2 wk in culture, the isozyme profiles of MEKs and HEKs were similar except that PKC gamma was noticeably present in HEK cultures. Activation of partially purified total PKC by TPA was similar in freshly isolated and cultured MEKs and HEKs, indicating that the two species were similar in this regard and that 2 wk of culture did not alter this characteristic. When MEK and HEK cultures were treated with TPA for 3 h, less than 30% of the control level of PKC activity was detected, indicating that TPA-induced downregulation of PKC was similar in MEKs and HEKs. After treatment with TPA, MEK cultures produced a large induction of both c-jun and c-fos mRNA by 60 min, as determined by northern blot analysis, and a large induction of ODC mRNA and enzyme activity by 6 h. TPA treatment of cultured HEKs, however, did not induce ODC activity; in fact, less activity, compared with that of control cultures, was observed. Northern blot analysis also revealed no increase in c-jun, c-fos, and ODC mRNA in HEKs. However, c-jun and c-fos mRNA and both ODC mRNA and enzyme activity were induced in HEKs fed growth factors after several days of deprivation. This suggests that the lack of ODC induction by TPA in HEKs is probably due to species differences in downstream steps in PKC signal transduction.

Developing National Guidelines for Nurse Practitioner Education: An Overview of the Product and the Process

In 1988, the National Organization of Nurse Practitioner Faculties appointed an ad hoc education committee (AHEC) to review existing nurse practitioner (NP) education curricula and to formulate national guidelines. An overview of the new NP guidelines are presented along with the philosophy, content, objectives, and competencies that are viewed as the foundation for NP education today. The guidelines are presented within the structure outlined in Brykczynski's (1985) research about NP practice. Thus, as a "product" of the Advanced Nursing Practice: Nurse Practitioner Curriculum Guidelines (NPCG), a new NP graduate for the 1990s could be described as one who demonstrates beginning competencies in primary health care theory and research within the five domains of practice identified by Brykczynski.

Ceftriaxone (Rocephin) in abdominal trauma

A prospective study was undertaken to evaluate the use of ceftriaxone in patients with abdominal trauma admitted to our hospital over a period of 6 months. Because of the large trauma load and an unacceptable waiting period before surgery combined with the fact that many patients on 6-hourly antibiotic regimes often did not receive their second and third doses, it was decided to use ceftriaxone because of its long half-life with maintenance of fluid and tissue concentrations for 24-48 hours. Because ceftriaxone is not reliably effective against anaerobic organisms such as Bacteroides fragilis, it was decided to add metronidazole as a combined initial dose. Two hundred ninety patients were entered in this trial, of which there were 259 stab wounds (89.3%), 20 missile injuries (6.9%), and 11 blunt injuries (3.8%). It was found that the mean delay between injury and initial dosage of ceftriaxone was 9.1 hours, with a range of 1-126 hours, and the mean delay between antibiotic therapy and operation 6.3 hours, with a range of 0-39 hours. The organs most frequently injured were the small bowel, the large bowel, the stomach, and the liver. Wound infection developed in only 4 patients (1.4%); intra-abdominal sepsis did not occur; and 35 patients (12%) developed respiratory infections. There were no deaths. We conclude that ceftriaxone, because of its 24-hour dosage was not only convenient but also adequate to prevent intra-abdominal sepsis and there was no difference in cost between this product and our previous protocol of 6-hourly antibiotic regime.