Acute kidney injury and mortality 1 year after major non-cardiac surgery.

BACKGROUND: Even mild and transient acute kidney injury (AKI), defined by increases in serum creatinine level, has been associated with adverse outcomes after major surgery. However, characteristic decreases in creatinine concentration during major illness could confound accurate assessment of postoperative AKI. METHODS: In a single-hospital, retrospective cohort study of non-cardiac surgery, the association between postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria, and 1-year survival was modelled using a multivariable Cox proportional hazards analysis. Factors associated with development of AKI were examined by means of multivariable logistic regression. Temporal changes in serum creatinine during and after the surgical admission in patients with and without AKI were compared. RESULTS: Some 1869 patients were included in the study, of whom 128 (6·8 per cent) sustained AKI (101 stage 1, 27 stage 2-3). Seventeen of the 128 patients with AKI (13·3 per cent) died in hospital compared with 16 of 1741 (0·9 per cent) without AKI (P < 0·001). By 1 year, 34 patients with AKI (26·6 per cent) had died compared with 106 (6·1 per cent) without AKI (P < 0·001). Over the 8-365 days after surgery, AKI was associated with an adjusted hazard ratio for death of 2·96 (95 per cent c.i. 1·86 to 4·71; P < 0·001). Among hospital survivors without AKI, the creatinine level fell consistently (median difference at discharge versus baseline -7 (i.q.r. -15 to 0) µmol/l), but not in those with AKI (0 (-16 to 26) µmol/l) (P < 0·001). CONCLUSION: Although the majority of postoperative AKI was mild, there was a strong association with risk of death in the year after surgery. Underlying decreases in serum creatinine concentration after major surgery could lead to underestimation of AKI severity and overestimation of recovery.

Evaluating feasibility of an automated 3-dimensional scanner using Raman spectroscopy for intraoperative breast margin assessment.

Breast conserving surgery is the preferred treatment for women diagnosed with early stage invasive breast cancer. To ensure successful breast conserving surgeries, efficient tumour margin resection is required for minimizing tumour recurrence. Currently surgeons rely on touch preparation cytology or frozen section analysis to assess tumour margin status intraoperatively. These techniques have suboptimal accuracy and are time-consuming. Tumour margin status is eventually confirmed using postoperative histopathology that takes several days. Thus, there is a need for a real-time, accurate, automated guidance tool that can be used during tumour resection intraoperatively to assure complete tumour removal in a single procedure. In this paper, we evaluate feasibility of a 3-dimensional scanner that relies on Raman Spectroscopy to assess the entire margins of a resected specimen within clinically feasible time. We initially tested this device on a phantom sample that simulated positive tumour margins. This device first scans the margins of the sample and then depicts the margin status in relation to an automatically reconstructed image of the phantom sample. The device was further investigated on breast tissues excised from prophylactic mastectomy specimens. Our findings demonstrate immense potential of this device for automated breast tumour margin assessment to minimise repeat invasive surgeries.

Incidence and associations of acute kidney injury after major abdominal surgery.

PURPOSE: Acute kidney injury (AKI) is a recognised risk factor for adverse outcomes in critical illness and hospitalised patients in general. To understand the incidence and associations of AKI as a peri-operative complication of major abdominal surgery, we conducted a systematic literature review and meta-analysis. METHODS: Using a systematic strategy, we searched the electronic reference databases for articles describing post-operative renal outcomes using consensus criteria for AKI diagnosis (RIFLE, AKIN or KDIGO) in the setting of major abdominal surgery. Pooled incidence of AKI and, where reported, pooled relative risk of death after post-operative AKI were estimated using random effects models. RESULTS: From 4287 screened titles, 19 articles met our inclusion criteria describing AKI outcomes in 82,514 patients undergoing abdominal surgery. Pooled incidence of AKI was 13.4% (95% CI 10.9-16.4%). In eight studies that reported the short-term mortality, relative risk of death in the presence of post-operative AKI was 12.6 fold (95% CI, 6.8-23.4). Where reported, length of stay was greater and non-renal post-operative complications were also more frequent in patients experiencing AKI. CONCLUSIONS: Using modern consensus definitions, AKI is a common complication of major abdominal surgery that is associated with adverse patient outcomes including death. While a causative role for AKI cannot be concluded from this analysis, as an important signal of peri-operative harm, AKI should be regarded as an important surgical outcome measure and potential target for clinical interventions.

The role of evolutionarily conserved sequences in alternative splicing at the 3' end of Drosophila melanogaster myosin heavy chain RNA.

Exon 18 of the muscle myosin heavy chain gene (Mhc) of Drosophila melanogaster is excluded from larval transcripts but included in most adult transcripts. To identify cis-acting elements regulating this alternative RNA splicing, we sequenced the 3' end of Mhc from the distantly related species D. virilis. Three noncoding regions are conserved: (1) the nonconsensus splice junctions at either end of exon 18; (2) exon 18 itself; and (3) a 30-nucleotide, pyrimidine-rich sequence located about 40 nt upstream of the 3' splice site of exon 18. We generated transgenic flies expressing Mhc mini-genes designed to test the function of these regions. Improvement of both splice sites of adult-specific exon 18 toward the consensus sequence switches the splicing pattern to include exon 18 in all larval transcripts. Thus nonconsensus splice junctions are critical to stage-specific exclusion of this exon. Deletion of nearly all of exon 18 does not affect stage-specific utilization. However, splicing of transcripts lacking the conserved pyrimidine sequence is severely disrupted in adults. Disruption is not rescued by insertion of a different polypyrimidine tract, suggesting that the conserved pyrimidine-rich sequence interacts with tissue-specific splicing factors to activate utilization of the poor splice sites of exon 18 in adult muscle.

Risk factors for bulimia nervosa. A community-based case-control study.

BACKGROUND: Many apparently disparate risk factors have been implicated as causes of eating disorders. This study was designed to test the hypothesis that 2 broad classes of risk factors exist for bulimia nervosa: those that increase the risk for development of a psychiatric disorder in general and those that increase the risk of dieting. It was predicted that the latter are especially common among persons with bulimia nervosa. METHODS: A case-control design was used involving 2 integrated comparisons. First, 102 subjects with bulimia nervosa were compared with 204 healthy control subjects without an eating disorder. Second, the same 102 subjects with bulimia nervosa were compared with 102 subjects with other psychiatric disorders. To reduce sampling bias, the subjects were recruited directly from the community. A broad range of putative risk factors was assessed. RESULTS: The subjects with bulimia nervosa and the healthy control subjects differed in their rates of exposure to most of the putative risk factors. Far fewer differences were evident between the subjects with bulimia nervosa and the control subjects with other psychiatric disorders, although exposure to factors that were likely to increase the risk of dieting and to negative self-evaluation and certain parental problems (including alcohol use disorder) were substantially more common among those with bulimia nervosa. CONCLUSIONS: The findings support the hypothesis that bulimia nervosa is the result of exposure to general risk factors for psychiatric disorder and risk factors for dieting. An unexpected finding was the particularly high rates of premorbid negative self-evaluation and certain parental problems among those with bulimia nervosa.

Three psychological treatments for bulimia nervosa. A comparative trial.

The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated. Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy, a simplified behavioral version of this treatment, or interpersonal psychotherapy. Assessment was by interview and self-report questionnaire, and many aspects of functioning were evaluated. All three treatments resulted in an improvement in the measures of the psychopathology. Cognitive behavior therapy was more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive behavior therapy was more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy.

A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments.

BACKGROUND: Little is known about the longer-term outcome of bulimia nervosa and the distal effects of treatment. METHODS: Prospective follow-up of subjects from two randomized controlled trials, involving a comparison of cognitive behavior therapy, behavior therapy, and focal interpersonal therapy. RESULTS: Ninety percent (89/99) underwent reassessment by interview (mean [+/- SD] length of follow-up, 5.8 +/- 2.0 years). Almost half (46%) had a DSM-IV eating disorder; 19%, bulimia nervosa; 3%, anorexia nervosa; and 24%, eating disorder not otherwise specified. There was a low rate of other psychiatric disorders. Premorbid and paternal obesity predicted a poor outcome. While the three treatments did not differ with respect to the proportion of subjects with anorexia nervosa or bulimia nervosa at follow-up, they did differ once all forms of DSM-IV eating disorder were considered together. Those who had received cognitive behavior therapy or focal interpersonal therapy were doing markedly better than those who had received behavior therapy. CONCLUSIONS: The longer-term outcome of bulimia nervosa depends on the nature of the treatment received. Patients who receive a treatment such as behavior therapy, which only has a short-lived effect, tend to do badly, whereas those who receive treatments such as cognitive behavior therapy or focal interpersonal therapy have a better prognosis.

Risk factors for binge eating disorder: a community-based, case-control study.

BACKGROUND: Many risk factors have been implicated for eating disorders, although little is known about those for binge eating disorder. METHODS: A community-based, case-control design was used to compare 52 women with binge eating disorder, 104 without an eating disorder, 102 with other psychiatric disorders, and 102 with bulimia nervosa. RESULTS: The main risk factors identified from the comparison of subjects with binge eating disorder with healthy control subjects were certain adverse childhood experiences, parental depression, vulnerability to obesity, and repeated exposure to negative comments about shape, weight, and eating. Compared with the subjects with other psychiatric disorders, those with binge eating disorder reported more childhood obesity and more exposure to negative comments about shape, weight, and eating. Certain childhood traits and pronounced vulnerability to obesity distinguished the subjects with bulimia nervosa from those with binge eating disorder. CONCLUSIONS: Binge eating disorder appears to be associated with exposure to risk factors for psychiatric disorder and for obesity. When compared with the wide range of risk factors for bulimia nervosa, the risk factors for binge eating disorder are weaker and more circumscribed. Pre-morbid perfectionism, negative self-evaluation, and vulnerability to obesity appear especially to characterize those in whom bulimia nervosa subsequently develops.

Bias and bulimia nervosa: how typical are clinic cases?

OBJECTIVE: Since patients being treated for bulimia nervosa constitute only a minority of persons with the disorder, the cases seen in clinics may be subject to sampling bias. The aim of this study was to investigate sampling bias as it affects secondary referrals for bulimia nervosa. METHOD: The personal and family characteristics of a consecutive series of 60 women with secondary referrals for bulimia nervosa (clinic subjects) were compare with those of 83 subjects with bulimia who were recruited directly from the community. Most of the data were collected by interview. RESULTS: The demographic characteristics of the two groups were similar. The clinic subjects had a more severe eating disorder and much greater impairment of social functioning. There was no difference between the groups in duration of the eating disorder or level of general psychiatric disturbance. The community subjects were heavier and had stronger family histories of obesity. CONCLUSIONS: There is sampling bias among secondary referrals for bulimia nervosa. The relative absence of persons prone to obesity among secondary subjects is important, since there is evidence that vulnerability to obesity is a poor prognostic feature as well as being a risk factor for the development of bulimia nervosa. The greater social impairment among the clinic subjects is suggestive of greater personality disturbance in this group. Caution is warranted when generalizing from clinic cases to the disorder as a whole.

Evaluation of the 'Best Start' breast-feeding education program.

OBJECTIVE: To compare the frequency of breast-feeding before and after the "Best Start" breast-feeding educational program was implemented. DESIGN: Preintervention-postintervention trial. SETTING: A women's health center and children's hospital serving a low-income population. PATIENTS: Ninety mother-infant pairs of whom the infants were born between January 2 and February 28, 1993, compared with 90 mother-infant pairs of whom the infants were born between January 2 and February 28, 1994. INTERVENTION: Best Start, a breast-feeding education program, was presented to health professionals and clerical staff of the Women's Health Center. At the first prenatal visit, a woman is asked, "What do you know about breast-feeding?" instead of "Are you going to breast-feed or bottle-feed this baby?" The program elicits and acknowledges the mother's concerns and then educates her about the benefits of breast-feeding. This is repeated at each prenatal visit. OUTCOME MEASURES: Sociodemographic data and breast-feeding rates of preintervention groups were compared with those of postintervention groups. Both hospital and out-patient records were reviewed. RESULTS: In 1993, 13 (15%) of 86 mothers breast-fed at hospital discharge compared with 25 (31%) of 81 in 1994 (P < .03). At the 2-week clinic visit, 11 (13%) of 86 were still breast-feeding in 1993 compared with 17 (21%) of 81 in 1994 (P > .20). The impact on mothers aged 19 years or less was particularly marked, with a tripling of the breast-feeding rate at hospital discharge from 11% (2/18) in 1993 to 37% (10/27) in 1994. CONCLUSION: This simple, low-cost educational intervention with a change in the manner of presentation significantly improved the breast-feeding rates of this low-income population.

Parental leave: comparing children's hospitals with Fortune 500 companies.

OBJECTIVE: To identify parental leave policies and availability of support systems for new parents employed by children's hospitals and compare these benefits with those offered by Fortune 500 companies. DESIGN: Telephone or facsimile survey of all (n=118) children's hospitals and pediatric medical centers in the National Association of Children's Hospitals and Related Institutions 1995 Directory of Members, and 118 geographically matched Fortune 500 companies. Policies for maternity and paternity leave, adoption benefits, and support services for new parents were compared. RESULTS: Ninety-four children's hospitals (80%) and 82 Fortune 500 companies (69%) responded to the survey. No difference in duration of maternity (P>.30) or paternity (P=.12) leave was found. Sixty-two companies (77%) classified maternity leave as short-term disability while 47 hospitals (50%) classified it as sick time (P<.005). Classifying maternity leave as short-term disability generally gives better benefits to employees with short duration of service, whereas classifying maternity leave as sick time usually favors employees with longer employment. Companies provided more financial support for adoption expenses (P<.05), but there was no difference in duration of paid or unpaid leave for adoption (P=.14). Hospitals provided more on-site day care (69% vs 42%; P<.001) and better support systems for breast-feeding mothers (49% vs 24%; P<.002). CONCLUSIONS: Children's hospitals do not offer better parental leave benefits than Fortune 500 companies; however, they offer better support systems for parents returning to work after the birth of a child.

Relaxation training and breast milk secretory IgA.

OBJECTIVE: To evaluate the hypothesis that breast-feeding women who participate in relaxation training will have increased secretory IgA (sIgA) levels in their breast milk compared with women not receiving training. DESIGN: Nonrandomized control trial of a convenience sample. SETTING: Women were recruited from the postpartum floor of a university teaching hospital. The intervention took place in the women's homes. PARTICIPANTS: Women in the first 48 hours after delivery who were planning to breast-feed their healthy newborn infants for at least 8 weeks were approached for enrollment. Women were excluded if they had previous experience with relaxation training. At 4 to 6 weeks postpartum, we enrolled 38 women still breast-feeding their infants. INTERVENTIONS: Women were allocated into 3 groups. Women in group 1 were taught relaxation and had breast milk samples collected before and after the teaching. Women in group 2 had conversation with similar breast milk sample collection, and women in group 3 had 1 breast milk sample collected. Women in group 1 were encouraged to practice the relaxation once or twice a day for 2 weeks, and a second visit was made to all mothers with repeated breast milk collections. Women who were still breast-feeding at 6 to 8 weeks after study end had a final breast milk sample collected. Breast milk was analyzed for secretory IgA levels. Stress was assayed using the Symptom Checklist-90-R and open-ended questions. RESULTS: There was no difference in sIgA levels among the 3 groups at any time. Women who reported stress present between visit 1 and visit 2 increased their sIgA levels at the final sample collection (+0.16 g/L) compared with women who reported no stress (-0.09 g/L; P= .03). The ratings of success in relaxation in women in group 1 were related to the following sIgA levels in sample 4: poor relaxation, 0.67 g/L; fair relaxation, 0.41 g/L; good relaxation, 0.35 g/L; and very good, 0.30 g/L (P= .006). CONCLUSIONS: Self-reported stress appears to increase breast milk sIgA levels. Success at relaxation was inversely related to sIgA levels in the group learning relaxation.

Neurobehavioral symptoms and family functioning in traumatically brain-injured adults.

Traumatic brain injury (TBI) often results in a myriad of symptoms across physical, cognitive, and neurobehavioral domains. Despite inherent limitations associated with physical or cognitive impairments, the extant literature suggests that neurobehavioral symptoms tend to be the most distressing symptoms for the family and are more strongly related to poor outcome for the patient. The Neuropsychology Behavior and Affect Profile (NBAP) along with the General Functioning subscale of the Family Assessment Device (FAD-GF) and the Perceived Stress Scale were administered to 153 family members of persons who had sustained a TBI. The results provide new normative data and statistical support for the NBAP as a promising measure of neurobehavioral symptomatology following TBI. The correlation of.54 (p <.01) between FAD-GF and Full Scale NBAP scores provides powerful support for the hypothesis that family dysfunction is related to the presence of neurobehavioral symptoms in the patient. NBAP domains of Depression, Inappropriateness, Pragnosia, and Indifference appear most strongly related to family functioning and also bear a significant relationship to caregiver stress level and patient unemployment, whereas injury severity had little impact on either family functioning or neurobehavioral symptoms. The findings reinforce the significance of neurobehavioral symptoms and fortify their proposed link to family dysfunction post-TBI.

Factors influencing consumer demand for U.S. pork exported to the Republic of Korea (South Korea).

The potential market for single-ribbed bellies and Boston butts in South Korea was characterized and quantitative selection criteria were identified for use by U.S. packers when selecting pork for export. South Korean retail meat market managers and traders/wholesalers in Seoul and Pusan were interviewed and asked to identify the quality attributes that are considered when making pork-purchasing decisions. In addition, pork labeling characteristics and meat display case measurements and space allocations were recorded in each retail store. Data from box labels were recorded in retail storage coolers to characterize pork products currently being merchandized in South Korea. Sample retail packages of belly and butt slices were collected and sent to a commercial laboratory for analysis of iodine values, ether-extractable fat content, total aerobic plate count (APC), total coliform count (TCC), and generic Escherichia coli count (ECC). No quality attributes of U.S. products exceeded the expectations of retailers. Quality attributes of U.S. pork products that exceeded the expectations of traders included presence of foreign material, marbling, tenderness, juiciness, flavor, and overall eating satisfaction. Traders/wholesalers assigned negative ratings for overall workmanship and adherence to purchase criteria for U.S. pork products. Retail APC for South Korean belly samples were higher (P < 0.05) than APC for U.S. belly samples. Retail TCC and ECC for butts and belly samples and APC for butt samples did not differ by country of origin. Retail prices for South Korean bellies were higher (P < 0.05) than prices for retail U.S. and Danish bellies. Pork butt prices did not differ (P > 0.05) by country of origin. Beef, pork, and poultry products comprised 66.8, 27.8, and 5.4%, respectively, of the total meat display case frontage. U.S. beef products occupied, on average, 18% of the total beef display area, whereas U.S. pork products comprised 2.6% of the total pork display case area.

Quantification of pork belly and boston butt quality attribute preferences of South Korean customers.

U.S. packers must have quantitative criteria for selection of pork bellies and Boston butts for export to South Korea. Pork bellies (IMPS 409A) and Boston butts (IMPS 409A, 406B, 407) were selected from normal production in a U.S. pork packing plant and transported to Seoul, South Korea, via seafreighter in refrigerated containers (frozen < -5 degrees C) or via air freight (fresh > 0 degrees C; frozen < -5 degrees C). Participants at the Seoul Food Show were surveyed about their preferences for specific quality attributes of these cuts. Bellies were selected to differ in seam fat content (low = < 20%, moderate = 20 to 40%, high = > 40% extractable fat), lean color (pale = L* > 50, medium = L* 48-50, dark = L* < 48), weight (3.36, 4.04, or 5.36 kg), state of refrigeration and packaging (frozen, poly-wrapped; chilled, poly-wrapped; frozen, vacuum-packaged; chilled, vacuum-packaged), shape (round, wavy, square), and belly thickness (3.81, 4.32, or 4.90 cm). Boston butts were selected to differ in USDA marbling score (Slight, Small, Modest, Moderate, and Slightly Abundant), seam fat content (low = < 10%, moderate = 10 to 20% fat, high = > 20% extractable fat), lean color (pale = L* > 44, medium = L* 40-42, dark = L* < 38), weight (2.91, 3.82, or 4.66 kg), state of refrigeration and packaging (frozen, poly-wrapped; chilled, poly-wrapped; frozen, vacuum-packaged; chilled, vacuum-packaged), and shape (square, oblong, round). In Seoul, pork subprimals were tempered (if frozen), sliced, and arrayed by quality attribute and category in a retail display case. Over 4 d of testing, attendees (n = 210) of the food show were asked to rate the displayed samples for each quality attribute on a standardized ballot. Mid-weight (3.82 kg) Boston butts that displayed Moderate or higher USDA marbling scores with moderate amounts of seam fat, Japanese lean color scores of 2 or 4, round geometric shape, and that were vacuum-packaged and transported to Korea in the freshly chilled state best characterized the quality attribute preferences of respondents. Pork bellies that exhibited moderate amounts of seam fat, Japanese lean color scores of 3, square shape, belly thickness of 3.94 cm, approximate weight of 4.04 kg, and that were vacuum-packaged and transported to Korea in the freshly chilled state best met the quality needs of South Korean customers.

CaEDTA vs CaEDTA plus BAL to treat children with elevated blood lead levels.

The effectiveness of CaEDTA alone vs CaEDTA plus BAL was compared retrospectively in a group of 72 children with lead levels between 2.41 mumol/L (50 micrograms/dL) and 2.90 mumol/L (60 micrograms/dL). The children who received both drugs had higher median zinc protoporphyrin (ZnP) concentrations at the initiation of therapy than children who received CaEDTA alone (160 micrograms/dL vs 96 micrograms/dL, p less than .01). There was a significantly increased incidence of vomiting and abnormal liver-function test results in the children who received both drugs. The children who received CaEDTA alone had a greater percent mean fall in lead level at one to three weeks postchelation (30.5% vs 18.1%, p less than .05). Children who received both CaEDTA and BAL had a greater percent decrease in ZnP at four to eight months postchelation, but there was no difference in percent decrease in lead levels. Children who received both drugs also had a greater number of repeat courses of chelation by six months. The addition of BAL to CaEDTA for treatment of children with lead levels of 2.41 mumol/L (50 micrograms/dL) to 2.90 mumol/L (60 micrograms/dL) produced greater toxicity and does not seem to prevent repeat chelations within six months.

Children with moderately elevated lead levels: is chelation with DMSA helpful?

This study evaluates the effectiveness (use under routine circumstances) of DMSA (2,3 dimercaptosuccinic acid) and environmental remediation as compared with placebo and environmental remediation on children with blood lead (BPb) levels of 30-45 micrograms/dL (1.45-2.17 mumol/L). The endpoints were BPb at 1 month and 6 months after study entry. This double-blind placebo-controlled trial involved 39 children aged 2-5 years, who were randomized to one course of DMSA or placebo. The mean BPb levels of the two groups at study entry were similar, placebo group 33.0 micrograms/dL (1.59 mumol/L) and the DMSA group 34.9 micrograms/dL (1.68 mumol/L). At 1 month (the end of treatment) the mean BPb levels of the two groups were: placebo group 33.2 micrograms/dL (1.60 mumol/L) and the DMSA group 27.4 micrograms/dL (1.32 mumol/L), p = 0.16. At 6 months, the mean BPb levels were 25.1 micrograms/dL (1.21 mumol/L) for the placebo group and 28.8 micrograms/dL (1.39 mumol/L) for the DMSA-treated group, p = 0.06. Neither of these differences is statistically significant. All children with BPb, in the range studied here, should receive environmental evaluation and remediation; DMSA does not improve long-term blood lead levels.

Frequent breastfeeding and food refusal associated with failure to thrive. A manifestation of the vulnerable child syndrome.

This paper acquaints pediatricians and health care personnel with the triad of poor weight gain, frequent breastfeeding, and food refusal in infants during the second 6 months of life. The histories of six infants aged 8-11 months, with failure to thrive, food refusal, and frequent breastfeeding, are presented. All the mothers were facing significant stresses, which may have decreased their breast milk supply, and were leading them to use breastfeeding for their comfort and/or the comfort of their infant. The infants responded with continued frequent breastfeeding, refusal of complementary foods, and decreased weight gain. These infants fit the characteristics of the vulerable child syndrome. Treatment of these infants required evaluation and treatment of the mothers' psychosocial issues along with a behavioral feeding program. Even with this multidisciplinary approach, these infants showed very slow catch-up growth. Pediatricians and health care personnel should use and build on this information in the evaluation and treatment of infants with similar problems.

Infant feeding practices in complex emergencies: a case study approach.

The majority of deaths associated with complex emergencies are attributed to infants and children under the age of five years. Most of these deaths are related to preventable diseases such as malnutrition, diarrhea, and malaria. Infant feeding emergencies have emerged as a major factor in complex emergencies. This paper reviews the current information relative to infant feeding, and uses four case studies as educational tools for the management of infant feeding emergencies. Child mortality rates in refugee population have been linked directly to protein-energy malnutrition (PEM). Breast feeding has many advantages over all other forms of feeding for children up to the age of two years of age. These advantages are discussed in detail in this paper. In addition, the appropriate and inappropriate uses of breast-milk substitutes (BMS) are discussed. Breast feeding also may play a role in the spread of HIV infections from the mother to the infant. However, in the setting of complex emergencies in the developing world, the risk of an infant dying of malnutrition and infection when not breastfed is likely to be greater than is the risk of death due to HIV acquisition through breastfeeding. The physiology of lactation is reviewed with particular reference to the roles of prolactin, oxytocin, and the feedback inhibitor of lactation (FIL) hormone. No medications have been demonstrated to augment milk production that can be used in a practical sense in complex emergencies. Lastly, the principles promulgated by the WHO and UNHCR for the feeding of infants and children in emergencies and for milk powder distribution are summarized.

Psychological studies in nonionizing electromagnetic energy research.

Research on nonionizing electromagnetic (NIEM) energy has focused on potential hazards, and to a lesser degree beneficial applications, of radiofrequency (RF) fields and extremely low frequency (ELF) fields. The history of research on the potential biological effects of NIEM contains many psychological investigations. These psychological investigations were conducted primarily in the discipline of biopsychology and included interdisciplinary cooperation with engineering, physical sciences, and other disciplines not routinely associated with psychology. The current recommended exposure level for RF is based on behavioral observations of laboratory animals. Psychology has been and continues to be in the midst of controversy regarding the ability of low-frequency, low-level electromagnetic energy or electric and magnetic fields to affect living organisms.