Eating disorders: is there a correlation between severity of physical compromise and admission outcomes?

BACKGROUND: The Medical Emergencies in Eating Disorders (MEED) report was first released by the Royal College of Psychiatrists in 2022 (updated 2023) to aid clinicians in recognising medical compromise due to an eating disorder and to provide guidance for management. AIMS: This study looked at admissions over 5 years to explore whether there is a correlation between MEED medical compromise parameters and three outcomes: length of stay, detainment under the Mental Health Act 1983, and discharge destination. METHODS: A retrospective study of 26 patients admitted to a large teaching hospital for an eating disorder between 2018 and 2023. The risk assessment from the MEED report was used to create a score for physical compromise and analysed to determine whether there was a correlation between the score and discharge destination, detainment under the Mental Health Act and length of stay. FINDINGS: Demographic data were comparable with larger studies, with increasing numbers and 19.2% having autism spectrum disorder. There was no correlation between the scoring tool and detainment under the Act, discharge destination or length of stay. CONCLUSION: Increasing numbers of patients are presenting with eating disorders. Physical compromise was not a predictor for admission outcomes, but this could be further explored in larger studies.

Needs-based quality of life in adults dependent on home parenteral nutrition.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) provides life sustaining treatment for people with chronic intestinal failure. Individuals may require HPN for months or years and are dependent on regular intravenous infusions, usually 12-14 h overnight between 1 and 7 days each week. This regime can have adverse impact on the life of people dependent on the treatment. The aim of this study was to establish mean values for the Parenteral Nutrition Impact Questionnaire (PNIQ) and to determine the effect of disease, frequency of infusions per week and patient characteristics on quality of life of patients fed HPN. METHOD: The PNIQ was distributed to patients across nine UK HPN clinics. Data were analysed using linear regression, with PNIQ score as the dependent variable and potential confounders as independent variables. Unadjusted and adjusted models are presented. Higher PNIQ scores reflect poorer quality of life. RESULTS: Completed questionnaires were received from 466 people dependent on HPN. Mean PNIQ score was 11.04 (SD 5.79). A higher PNIQ score (effect size 0.52, CI 0.184 to 0.853) was recorded in those dependent on a higher frequency of HPN infusions per week. Respondents with cancer had a similar mean PNIQ score to those with inflammatory bowel disease (mean 10.82, SD 6.00 versus 11.04, SD 5.91). Those with surgical complications reported a poorer QoL (effect size 3.03, CI 0.642 to 5.418) and those with severe gastro-intestinal dysmotility reported a better QoL (effect size -3.03, CI -5.593 to -0.468), compared to other disease states. CONCLUSIONS: This large cohort study of quality of life in chronic intestinal failure demonstrates that HPN impacts individuals differently depending on their underlying disease. Furthermore, since the number of HPN infusions required per week is inversely related to an individual's needs-based quality of life, therapies that reduce PN burden should lead to an improvement in QoL.

Synergic production of neutrophil chemotactic activity by colonic epithelial cells and eosinophils.

The presence of eosinophils in the lumen and mucosa of the intestine is characteristic of both ulcerative colitis (UC) and Crohn's disease (CD). There is evidence of eosinophil activation in the intestine during acute inflammatory episodes of these diseases; these episodes are also characterized by an influx of neutrophils, which have the potential to cause extensive tissue damage. We undertook a study to determine whether eosinophils in contact with colonic epithelial cells produce factors that may attract neutrophils in response to immunological stimulation. Neutrophil chemotactic activity (NCA) and concentrations of three neutrophil-attracting CXC chemokines - CXCL1 (Groα), CXCL5 (Ena78) and CXCL8 (IL8) - were measured in supernatants of T84 colonic epithelial cells and blood eosinophils or eosinophil-like myeloid leukaemia cells (AML14.3D10), alone or in combination. Cells were stimulated with serum-opsonized zymosan (OZ) particles. NCA (P<0.005) and CXCL5 levels (P<0.05) in the supernatants of OZ-stimulated epithelial/eosinophil co-cultures were significantly higher than in the supernatants of either cell type alone. Release of CXCL1 (P<0.05) and CXCL8 (P<0.01) from OZ-stimulated co-culture supernatants was significantly higher than from OZ-stimulated eosinophils but not higher than from OZ-stimulated epithelial cells. Eosinophils and colonic epithelial cells exhibit synergy in production of neutrophil chemoattractants in response to immunological stimulation. This may represent a mechanism for exaggerated recruitment of neutrophils to the intestine in response to acute infection in conditions that are characterized by the presence of eosinophils in the bowel.

Crohn's disease affecting the small bowel is associated with reduced appetite and elevated levels of circulating gut peptides.

BACKGROUND & AIMS: Appetite disturbance is an important nutritional issue in Crohn's disease (CD), but the biological basis is unclear. Satiety signals such as polypeptide YY (PYY) and glucagon-like peptide-1 (GLP-1) are produced by enteroendocrine cells (EEC). In animal models, upregulation of EEC plays a mechanistic role in feeding disturbance and weight loss. We recently showed increased EEC activity in tissue from active small bowel CD. This study investigated EEC products in plasma in CD, and appetite-related symptoms. METHODOLOGY: Active CD patients and a healthy reference group were studied. Gut peptide responses to a mixed nutrient test meal were measured by ELISA. Symptoms were assessed by visual analogue score. A patient subset was re-studied in remission. RESULTS: CD subjects displayed reduced appetite (p < 0.0001) before and after eating. Total PYY was increased 2.2-fold (p = 0.04) and correlated with nausea (p = 0.036) and bloating (p = 0.037) scores only in small bowel CD. Postprandial plasma ghrelin levels were also elevated. Leptin correlated with body mass index (p = 0.0001) and weight loss (p = 0.01). GLP-1 and GIP were not elevated. In remission, postprandial PYY and ghrelin reverted to control levels. DISCUSSION: Enhanced EEC responses may directly and adversely affect appetite in CD patients through increased gut-brain signalling.

Complications of the cut-and-push technique for percutaneous endoscopic gastrostomy tube removal.

The use of the "cut-and-push" technique for percutaneous endoscopic gastrostomy (PEG) removal has been recognized since 1991. This technique is used in patients who are thought to have no risk of distal adhesions or strictures. Its use in selected patients is supported by current British Society of Gastorenterology guidelines. However, the risk of complications has long been debated. This report describes a patient who developed complications as a result of PEG removal using the cut-and-push technique. The patient had undergone previous abdominal surgery, and removal of the PEG endoscopically was not possible. A barium follow-through was performed in light of the history, and it excluded any mechanical blockage. Follow-up x-ray showed passage of the remnant beyond the pylorus. Despite this, the remnant became lodged in the small bowel, eventually resulting in perforation and death. This case highlights the fact that impaction of the remnant can occur in patients without evidence of mechanical obstruction on investigation. This raises a question about the need for serial x-rays to ensure passage of the remnant if the patient cannot confirm this visually.

Competent to care. Are all doctors competent in nutrition?

Optimising nutrition is known to improve outcome in a variety of specialities from elderly care to orthopaedics. The National Institute for Health and Clinical Excellence guidelines of 2006 have provided standards to positively influence the profile of nutrition within the National Health Service. However, what role do doctors have in this process? Clearly, not all doctors are competent in nutrition. In a recent US survey only 14% of resident physicians reported feeling adequately trained to provide nutrition counselling. A lack of knowledge has also been demonstrated by general practitioners (GP). The Intercollegiate Group on Nutrition is working to improve nutritional knowledge in British medical graduates. In addition, nutritional care is now a core competency assessed in the UK Foundation Programme curriculum, which can only be a positive step. The assessment process may even influence some of the supervising consultants. What about those doctors currently practising in the UK? Recently, a questionnaire study was undertaken to look at healthcare professionals' knowledge of the benefits and risks of percutaneous endoscopic gastrostomy (PEG) feeding. Important gaps in knowledge were found that were positively correlated with whether respondents had received relevant education. Referral for a PEG was considered to be appropriate for patients with advanced dementia by 31% of the GP compared with 10% of the consultants. Only 4% of these GP had received any training in this ethically-sensitive area at a time when they may be asked to countersign consent forms for patients who lack competence. So, what is the way forward? Positive steps are being taken in the undergraduate curriculum and Foundation Programme. Perhaps it is the responsibility of those doctors with the skills and opportunities to promote good nutritional knowledge in those doctors already practising in the UK.

Are medical students socially exclusive? A comparison with economics students.

CONTEXT: Medical students have long been perceived as socially segregated from other students. However, the evidence for this is mainly anecdotal. This study investigates this issue by comparing medical students with economics students. METHODS: Questionnaires measuring objective and subjective social life patterns were completed by 149 medical and 149 economics students at a campus-based university in the UK. RESULTS: Medical students drew significantly more of their close friends and housemates from among students on the same course than economics students. Significantly more medical than economics students had a partner on the same course, participated in departmental sports clubs and societies, and felt separated from the rest of university life. Commonly reported reasons for this separation among medical students were high workloads, that the medical school was located outside the main campus, and high numbers of contact hours, some of which took place at sites outside the university. DISCUSSION: Medical students are more socially exclusive than economics students, which may lead to 'in-group' attitudes and behaviours. This is educationally important and may affect their future professionalism. Universities should be aware of the issues involved when planning curricula, timetables, welfare initiatives and campus design. Prospective medical students should be informed of the social consequences of studying medicine.

Enteroendocrine cells: neglected players in gastrointestinal disorders?

Enteroendocrine cells (EEC) form the basis of the largest endocrine system in the body. They secrete multiple regulatory molecules which control physiological and homeostatic functions, particularly postprandial secretion and motility. Their key purpose is to act as sensors of luminal contents, either in a classical endocrine fashion, or by a paracrine effect on proximate cells, notably vagal afferent fibres. They also play a pivotal role in the control of food intake, and emerging data add roles in mucosal immunity and repair. We propose that EEC are fundamental in several gastrointestinal pathologies, notably Post-infectious Irritable Bowel Syndrome, infectious enteritis, and possibly inflammatory bowel disease. Further work is needed to fully illustrate the importance, detailed biology and therapeutic potential of these frequently overlooked cells.