First do no harm: iatrogenic maintaining factors in anorexia nervosa.

The aim of this paper is to reflect on the way that we as clinicians may play an inadvertent role in perpetuating eating disordered behaviour. This is considered within the theoretical framework of Schmidt and Treasures' maintenance model of anorexia nervosa (AN). The model includes four main domains; interpersonal factors, pro-AN beliefs, emotional style and thinking style. Interpersonal reactions are of particular relevance as clinicians (as with family members) may react with high expressed emotion and unknowingly encourage eating disorder behaviours to continue. Hostility in the form of coercive refeeding in either a hospital or outpatient setting may strengthen conditioned food avoidance and pessimism may hamper motivation to change. Negative schema common to eating disorders, for example low self-esteem, perfectionism and striving for social value may augment existing or initiate new eating disorder behaviour. Services can become a reinforcing influence by providing an overly protective, palliating environment which ensures safety, security and acceptance whilst reducing loneliness and isolation. This stifles the need for an individual to develop their own sense of responsibility, autonomy and independence allowing avoidance to dominate. Furthermore, the highly structured environment of inpatient care supports the rigid attention to detail and inflexibility that is characteristic of people with eating disorders, and allows these negative behaviours to thrive. Careful planning of service provision, reflective practice, supervision and regular team feedback is essential to prevent iatrogenic harm.

Retroaortic left renal vein fistula masquerading as pelvic congestion syndrome: case report.

This case study shows how aorto-left renal vein fistula in a female can present with left-sided pelvic pain secondary to ovarian vein reflux, a symptom of pelvic congestion syndrome, next to typical features such as epigastric and back pain.

An enlightened age: building the naval hospitals.

Summerson writes that, in the spirit of the Enlightenment, the notion of 'bienfaisance', literally meaning the desire to render society more reasonable and more humane, liberated the scope of both hospital and prison planning. Both types of institution housed people who were deprived of their freedom either by disability or by force of law; therefore, we find similarities in the disposition of space and in the degree of humanitarianism expressed in their outward appearance. This observation can be transferred to naval hospital design, where architecture was combined to fulfil a twofold purpose. The high walls, sturdy massing and pared-down details intimated a strict economy of means, but also a strong sense of gravitas and authority. This visual authoritarian character was fundamental to the identity of a naval hospital, for whilst the prime intention was to provide efficient medical care, an equally important consideration was to maintain discipline and prevent sailors from escaping.