Complete and Voluntary Starvation of 50 days

A 34-year-old obese male (96.8 kg; BMI, 30.2 kg m⁻¹) volitionally undertook a 50-day fast with the stated goal of losing body mass. During this time, only tea, coffee, water, and a daily multivitamin were consumed. Severe and linear loss of body mass is recorded during these 50 days (final 75.4 kg; BMI, 23.5 kg m⁻¹). A surprising resilience to effects of fasting on activity levels and physical function is noted. Plasma samples are suggestive of early impairment of liver function, and perturbations to cardiovascular dynamics are also noted. One month following resumption of feeding behavior, body weight was maintained (75.0 kg; BMI, 23.4 kg m⁻¹). Evidence-based decision-making with the fasting or hunger striking patient is limited by a lack of evidence. This case report suggests that total body mass, not mass lost, may be a key observation in clinical decision-making during fasting and starvation.

Housing at the neighbourhood level: a review of the initial approaches to neighbourhood development plans under the Localism Act 2011 in England

The Localism Act 2011 created an opportunity for local communities to form neighbourhood forums and to prepare their own neighbourhood development plans in urban and rural areas in England. Initial reactions suggested that, rather than leading to the development of more housing, these initiatives would confirm all the stereotypes of local residents blocking unwanted development in their defined neighbourhoods. However, neighbourhood plans need to be in general conformity with the core strategies of higher-tier plans and often make provision for more new homes than planned before 2011. This article discusses the role and purpose of neighbourhood plans, the evidence base on which they are founded and some of the legal challenges which have helped clarify procedures. It then identifies two types of plan based on the ways housing strategies and evidence of need are reflected in a sample of 10 plans which have been made to date. It concludes that the voluntary nature of localism to date tends to favour more rural and affluent areas and ends with an assessment of the impact of neighbourhood plans on the planning process. It suggests that the implications for spatial planning may be far-reaching.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.