A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa.

BACKGROUND: Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa. METHODS: The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis. RESULTS: Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium. CONCLUSIONS: Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Nasogastric tube feeding under physical restraint of children and young people with mental disorders: a comprehensive audit and case series across paediatric wards in England.

OBJECTIVE: To estimate the number of patients on paediatric wards in England who received nasogastric tube (NGT) feeding under physical restraint from April 2022 to March 2023, identify the demographics and clinical characteristics of these patients, and which personnel facilitated the restraint. DESIGN: Audit and anonymous case series SETTING: Paediatric wards in England. PATIENTS: Children and young people receiving this intervention in a 1-year period. OUTCOME MEASURES: An online survey was sent to all paediatric wards in England, with the option of submitting anonymous case studies. RESULTS: 136/143 (95.1%) acute paediatric units responded. 144 young people received this intervention across 55 (38.5%) paediatric units. The predominant diagnosis was anorexia nervosa (64.5%), age range 9-18 years (M=14.2, SD=2.1). The duration of NGT feeding under restraint ranged from 1 to 425 days, (M=60.2, SD=80.4). Numerous personnel facilitated the restraints, including mental health nurses, paediatric nurses, security staff, healthcare assistants and parents/carers. CONCLUSION: NGT feeding under restraint is a relatively common intervention in acute paediatric units in England. Understanding the demographics of those receiving this intervention may highlight where additional support is needed. Further research is needed to understand when this intervention transitions from a lifesaving intervention to ongoing management.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study.

BACKGROUND: Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. AIMS: To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. METHOD: PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. RESULTS: Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. CONCLUSIONS: Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Greater rate of weight loss predicts paediatric hospital admission in adolescent typical and atypical anorexia nervosa.

Hospital admissions for eating disorders (ED) are rapidly increasing. Limited research exists evidencing the factors that lead to hospital admissions or their outcomes. The current study aimed to identify predictors of hospital admission in adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN). Prospective observational study including participants (n = 205) aged 11-18 and diagnosed with AN or AAN at initial ED assessment, across eight London clinics. Physical health parameters at assessment, including heart rate, blood pressure, temperature and rate of weight loss, were compared between adolescents who were admitted to a paediatric ward following assessment and those who were not admitted. The mean rate of weight loss prior to assessment was significantly higher, and mean energy intake significantly lower, in the admitted vs not admitted groups (1.2 vs 0.6kg/week, p < 0.001 and 565 kcal/day vs 857 kcal/day, p < 0.001), independent of degree of underweight. No significant differences were identified between groups in all other parameters of physical risk. Underweight adolescents with AN were equally likely to be admitted as non-underweight adolescents with AAN.  Conclusion: This study provides evidence on predictors of hospital admission, from a sample representing the London area. The assessment of weight loss speed, duration and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in adolescent AN and AAN. Further research investigating outcomes of these hospital admission is needed. What is Known: • Hospital admissions for eating disorders (ED) are rapidly increasing. • Limited research exists evidencing the factors that lead to hospital admissions, or their outcomes. What is New: • This study provides evidence on predictors of hospital admission in young people with typical and atypical anorexia nervosa. • Weight loss speed, duration, and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in this patient group.

Nasogastric tube feeding under restraint: understanding the impact and improving care.

BACKGROUND: Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement. AIMS: To examine the impact of this intervention on people with lived experience, carers and staff. METHOD: People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed. RESULTS: Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored. CONCLUSION: This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

The NIH pediatric/young adult chordoma clinic and natural history study: Making advances in a very rare tumor.

BACKGROUND: Chordomas are rare tumors arising from the skull base and spine, with approximately 20 pediatric chordoma cases in the Unitedn States per year. The natural history and optimal treatment of pediatric chordomas, especially poorly differentiated and dedifferentiated subtypes, is incompletely understood. Herein, we present findings from our first National Cancer Institute (NCI) chordoma clinic and a retrospective analysis of published cases of pediatric poorly differentiated chordomas (PDC) and dedifferentiated chordomas (DC). METHODS: Patients less than 40 years old with chordoma were enrolled on the NCI Natural History and Biospecimens Acquisitions Study for Children and Adults with Rare Solid Tumors protocol (NCT03739827). Chordoma experts reviewed patient records, evaluated patients, and provided treatment recommendations. Patient-reported outcomes, biospecimens, and volumetric tumor analyses were collected. A literature review for pediatric PDC and DC was conducted. RESULTS: Twelve patients (median age: 14 years) attended the clinic, including four patients with active disease and three patients with PDC responsive to systemic therapy. Consensus treatment, management, and recommendations were provided to patients. Literature review returned 45 pediatric cases of PDC or DC with variable treatments and outcomes. CONCLUSIONS: A multidisciplinary expert clinic was feasible and successful in improving understanding of pediatric chordoma. While multimodal approaches have all been employed, treatment for PDC has been inconsistent and a recommended standardized treatment approach has not been defined. Centralized efforts, inclusive of specialized chordoma-focused clinics, natural history studies, and prospective analyses will help in the standardization of care for this challenging disease.

Nasogastric tube feeding under physical restraint: comprehensive audit and case series across in-patient mental health units in England.

AIMS AND METHOD: To identify the clinical characteristics of patients receiving nasogastric tube (NGT) feeding under physical restraint. Clinicians participated via professional networks and subsequent telephone contact. In addition to completing a survey, participants were invited to submit up to ten case studies. RESULTS: The survey response rate from in-patient units was 100% and 143 case studies were submitted. An estimated 622 patients received NGT feeding under restraint in England in 2020-2021. The most common diagnosis was anorexia nervosa (68.5-75.7%), with depression, anxiety and autism spectrum disorder the most frequent comorbidities. Patients receiving the intervention ranged from 11 to 60 years in age (mean 19.02 years). There was wide variation in duration of use, from once to daily for 312 weeks (mode 1 week; mean 29.1 weeks, s.d. = 50.8 weeks). CLINICAL IMPLICATIONS: NGT feeding under restraint is not uncommon in England, with variation in implementation. Further research is needed to understand how the high comorbidity and complexity contribute to initiation and termination of the intervention.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study.

BACKGROUND: Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder. AIMS: To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings. METHOD: People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants. RESULTS: Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified. CONCLUSIONS: This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Nasogastric tube feeding under physical restraint on paediatric wards: ethical, legal and practical considerations regarding this lifesaving intervention.

Eating disorders have the highest mortality rate of any psychiatric condition. Since the COVID-19 pandemic, the number of patients who have required medical stabilisation on paediatric wards has increased significantly. Likewise, the number of patients who have required medical stabilisation against their will as a lifesaving intervention has increased. This paper highlights a fictional case study aiming to explore the legal, ethical and practical considerations a trainee should be aware of. By the end of this article, readers will be more aware of this complex issue and how it might be managed, as well as the impact it can have on the patient, their family and ward staff.

Nasogastric tube feeding under restraint: practical guidance for children's nurses.

The number of children and young people admitted to children's wards with an eating disorder has increased significantly since the start of the coronavirus disease 2019 (COVID-19) pandemic. In the most extreme cases, those with severe malnutrition may need to be fed via a nasogastric tube without their consent. Children's nurses working on hospital wards may therefore care for children and young people who need to receive nasogastric tube feeding under physical restraint. This article offers an overview of eating disorders and their detrimental effects as well as practical advice for children's nurses, supporting them to provide safe, compassionate and person-centred care to their patients.

Attitudes toward veganism in eating disorder professionals.

AIMS AND METHOD: Veganism has increased in popularity in the past decade and, despite being a characteristic protected by law, is often viewed negatively by the general population. Little is known about the attitudes of healthcare professionals despite the potential influence on practice and eating disorder patient care. This is one of the first studies to investigate attitudes toward veganism within specialist eating disorder, general mental health and other professionals. RESULTS: A one-way ANOVA indicated all professionals held positive views toward veganism. General mental health professionals held statistically more positive veganism attitudes than specialist eating disorder and other professionals. CLINICAL IMPLICATIONS: As one of the first studies to suggest eating disorder professionals are not biased against veganism, it has important clinical practice implications, particularly when exploring motivations for adopting a vegan diet (health, weight loss, environmental or animal welfare concerns) in patients with eating disorders. Implications for further research are provided.

Veganism and eating disorders: assessment and management considerations.

The number of people following a vegan diet in the UK is increasing. Eating disorder clinicians are anecdotally reporting that more of their patients with anorexia nervosa are wanting to follow a vegan diet. The relationship between veganism and eating disorders is unclear. A fictitious scenario is used to explore these issues. An approach is described that clinicians may follow to help patients to understand the potential relationship between their eating disorder and veganism. The human rights issues this involves are also explored. It is hoped that this article will make readers more aware of this complex issue and the impact it can have on engagement with services and on treatment options.

Tumor Doubling Time Using CT Volumetric Segmentation in Metastatic Adrenocortical Carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy with an overall unfavorable prognosis. Clinicians treating patients with ACC have noted accelerated growth in metastatic liver lesions that requires rapid intervention compared to other metastatic locations. This study measured and compared the growth rates of metastatic ACC lesions in the lungs, liver, and lymph nodes using volumetric segmentation. A total of 12 patients with metastatic ACC (six male; six female) were selected based on their medical history. Computer tomography (CT) exams were retrospectively reviewed and a sampling of ≤5 metastatic lesions per organ were selected for evaluation. Lesions in the liver, lung, and lymph nodes were measured and evaluated by volumetric segmentation. Statistical analyses were performed to compare the volumetric growth rates of the lesions in each organ system. In this cohort, 5/12 had liver lesions, 7/12 had lung lesions, and 5/12 had lymph node lesions. A total of 92 lesions were evaluated and segmented for lesion volumetry. The volume doubling time per organ system was 27 days in the liver, 90 days in the lungs, and 95 days in the lymph nodes. In this series of 12 patients with metastatic ACC, liver lesions showed a faster growth rate than lung or lymph node lesions.

A path towards citizenship: The effects of early college high schools on criminal convictions and voting.

Building on a growing literature showing that early college high schools substantially improve educational outcomes, we investigate possible spillover impacts of this intervention on civic outcomes in North Carolina, which has early colleges in most of its 100 counties. We present both lottery and observational impacts on voting and criminal convictions. Our results suggest a modest increase in voting during early adulthood of about 4-5 percent, though lottery estimates do not rule out a null effect. For criminal convictions, lottery estimates are imprecise due to very low conviction rates, but observational evidence suggests a moderate decrease in convictions. We additionally identify stronger impacts on voting and conviction outcomes for key student subgroups, particularly black males and economically-disadvantaged white students. These results suggest that scaling up the early college program can improve youth civic outcomes and help to close key civic and political participation gaps.

Pulmonary Function in Patients With Multiple Endocrine Neoplasia 2B.

CONTEXT: Multiple endocrine neoplasia type 2B (MEN2B) is a rare cancer predisposition syndrome resulting from an autosomal-dominant germline mutation of the RET proto-oncogene. No prior studies have investigated pulmonary function in patients with MEN2B. OBJECTIVE: This study characterized the pulmonary function of patients with MEN2B. DESIGN: This is a retrospective analysis of pulmonary function tests (PFTs) and chest imaging of patients enrolled in the Natural History Study of Children and Adults with MEN2A or MEN2B at the National Institutes of Health. RESULTS: Thirty-six patients with MEN2B (18 males, 18 females) were selected based on the availability of PFTs; 27 patients underwent at least 2 PFTs and imaging studies. Diffusion abnormalities were observed in 94% (33/35) of the patients, with 63% (22/35) having moderate to severe defects. A declining trend in diffusion capacity was seen over time, with an estimated slope of -2.9% per year (P = 0.0001). Restrictive and obstructive abnormalities were observed in 57% (20/35) and 39% (14/36), respectively. Computed tomography imaging revealed pulmonary thin-walled cavities (lung cysts) in 28% (9/32) of patients and metastatic lung disease in 34% (11/32) of patients; patients with metastatic lung lesions also tended to have thin-walled cavities (P = 0.035). CONCLUSIONS: This study characterized pulmonary function within a MEN2B cohort. Diffusion, restrictive, and obstructive abnormalities were evident, and lung cysts were present in 28% of patients. Further research is required to determine the mechanism of the atypical pulmonary features observed in this cohort.

Adrenocortical carcinoma masquerading as pheochromocytoma: a histopathologic dilemma.

SUMMARY: Adrenocortical carcinoma (ACC) is an aggressive cancer that originates in the cortex of the adrenal gland and generally has a poor prognosis. ACC is rare but can be more commonly seen in those with cancer predisposition syndromes (e.g. Li-Fraumeni and Lynch Syndrome). The diagnosis of ACC is sometimes uncertain and it requires the use of precise molecular pathology; the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. We describe a case of a 57-year-old woman with Lynch Syndrome and metastatic ACC who was initially diagnosed as having pheochromocytoma. The tumor was first identified at 51 years of age by ultrasound followed by a CT scan. She underwent a left adrenalectomy, and the histopathology identified pheochromocytoma. Two years later, she had tumor recurrence with imaging studies showing multiple lung nodules. Following a wedge resection by video-assisted thoracoscopic surgery (VATS), histopathology was read as metastatic pheochromocytoma at one institution and metastatic ACC at another institution. She later presented to the National Institutes of Health (NIH) where the diagnosis of ACC was confirmed. Following her ACC diagnosis, she was treated with mitotane and pembrolizumab which were stopped due to side effects and progression of disease. She is currently receiving etoposide, doxorubicin, and cisplatin (EDP). This case highlights the importance of using a multi-disciplinary approach in patient care. Thorough evaluation of the tumor's pathology and analysis of the patient's genetic profile are necessary to obtain the correct diagnosis for the patient and can significantly influence the course of treatment. LEARNING POINTS: Making the diagnosis of ACC can be difficult as the differential diagnosis includes pheochromocytoma, adrenal adenoma, renal carcinoma, or hepatocellular carcinoma. Patients with Lynch Syndrome should undergo surveillance for ACC as there is evidence of an association between Lynch Syndrome and ACC. Conducting a complete tumor immunoprofile and obtaining a second opinion is very important in cases of suspected ACC in order to confirm the proper diagnosis. A multi-disciplinary approach including genetic testing and a thorough evaluation of the tumor's pathology is imperative to ensuring that the patient receives an accurate diagnosis and the appropriate treatment.

Pelagic tar balls collected in the North Atlantic Ocean and Caribbean Sea from 1988 to 2016 have natural and anthropogenic origins.

Tar balls are prevalent in oceans and the coastal environment; however, their origins are not well constrained on a global scale. To address this, we used gas chromatography to analyze the molecular composition of a unique set of 100 pelagic tar balls collected in the Western North Atlantic and Caribbean Sea between 1988 and 2016. Hierarchal cluster analysis (HCA) was employed to classify the samples into groups based on the relative proportions of resolved and unresolved hydrocarbon distributions. Additional analysis of polycyclic aromatic hydrocarbons revealed that 28% of samples originated from heavy fuel oils and therefore had anthropogenic origins consistent with the classifications based on HCA. Other samples examined could originate from anthropogenic or natural origins, such as natural seeps. This study provides a preliminary record of 100 classified pelagic tar ball samples and demonstrates an approach to determine their origin to the environment.

Nodularin from benthic freshwater periphyton and implications for trophic transfer.

In 2013 and 2015, the Pennsylvania Department of Environmental Protection conducted a survey of lotic habitats within the Susquehanna, Delaware, and Ohio River basins in Pennsylvania, USA, to screen for microcystins/nodularins (MCs/NODs) in algae communities and smallmouth bass (Micropterus dolomieu). Periphyton (68 from 41 sites), juvenile whole fish (153 from 19 sites) and adult fish liver (115 from 16 sites) samples were collected and screened using an Adda enzyme-linked immunosorbent assay (ELISA). Samples that were positive for MCs/NODs were further analyzed using LC-MS/MS, including 14 variants of microcystin and NOD-R and the MMPB technique. The ELISA was positive for 47% of the periphyton collections, with NOD-R confirmed (0.7-82.2 ng g-1 d.w.) in 20 samples. NOD-R was confirmed in 10 of 15 positive juvenile whole fish samples (0.8-16.7 ng g-1 w.w.) and in 2 of 8 liver samples (1.7 & 2.8 ng g-1 w.w.). The MMPB method resulted in total MCs/NODs measured in periphyton (2.2-1269 ng g-1 d.w.), juvenile whole fish (5.0-210 ng g-1 d.w.) and adult livers (8.5-29.5 ng g-1 d.w.). This work illustrates that NOD-R is present in freshwater benthic algae in the USA, which has broader implications for monitoring and trophic transfer.

Effect of Playground Environments on the Physical Activity of Children With Ambulatory Cerebral Palsy.

PURPOSE: To compare the effect of 2 different playground environments on the physical activity of children with ambulatory cerebral palsy during their playground play. METHODS: Five 7- to 8-year-old children with cerebral palsy (Gross Motor Functional Classification System [GMFCS] level II) participated. Using an alternating treatment, single-subject design, stride patterns were obtained using an activity monitor on an Americans with Disabilities Act (ADA)-compliant and noncompliant playground. Visual and statistical analysis of the stride data was used to analyze the effect of the playground environments. RESULTS: Four of the 5 participants increased the number of strides on an ADA-compliant playground. CONCLUSION: Children with cerebral palsy (GMFCS II) may benefit from an ADA-compliant playground to increase their physical activity.

The effect of prenatal natural disaster exposure on school outcomes.

This study looks at the impact of exposure to natural disasters during pregnancy on the educational outcomes of North Carolina children at the third grade level. A broad literature relates negative birth outcomes to poor educational performance, and a number of recent studies have examined the effect of prenatal exposure to natural disasters on birth outcomes. This study takes the next step by considering how prenatal exposure affects later outcomes. Combining North Carolina administrative data on births and school performance with disaster declarations from the U.S. Federal Emergency Management Agency (FEMA) allows for the identification of children who were exposed to disasters during prenatal development. These children are compared with other children born in the same county who were not exposed to disasters while in utero. Regression results suggest that children exposed to hurricanes prenatally have lower scores on third grade standardized tests in math and reading. Those exposed to flooding or tornadoes also have somewhat lower math scores. Additionally, results suggest that these negative effects are more concentrated among children in disadvantaged subgroups, especially children born to black mothers. However, no evidence exists that these effects are mediated by common measures of birth outcomes, including birth weight and gestational age.