Addressing child undernutrition in Tanzania with the ASTUTE program.

BACKGROUND: Optimal infant and young child feeding practices (IYCFP) reduce childhood stunting and are associated with additional health benefits. In Tanzania, IYCFP are far from optimal where 32% of children under the age of 5 years are stunted. The purpose of this study was to examine whether behavior change communication focused on reducing child undernutrition was associated with improved IYCFP in Tanzania. METHODS: A cross-sectional survey was administered to approximately 10,000 households with children under the age of 2 at baseline and endline. Bivariate analyses and logistic regression was used to examine the relationship between exposure to behavior change communication and timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). RESULTS: Mothers who heard a radio spot about IYCFP were more likely than mothers who had not heard a radio spot about IYCFP to begin complementary foods at six months. Their children were also more likely to achieve MMF, MDD, and MAD with odds ratios of 2.227 (p = 0.0061), 1.222 (p = 0.0454), 1.618 (p = < .0001), and 1.511 (p = 0.0002), respectively. Mothers who saw a TV spot about IYCFP were more likely to have greater odds of knowing when to begin complementary feeding, feeding their child a minimally diverse diet (4 food groups or more), and serving a minimum acceptable diet with odds ratios of 1.335 (p = 0.0081), 1.360 (p = 0.0003), and 1.268 (p = 0.0156), respectively. CONCLUSION: Exposure to behavior change communication in Tanzania was generally associated with some increased knowledge of optimal IYCFP as well as practicing IYCF behaviors. Behavior change communication planners and implementers may want to consider conducting similar campaigns as an important component of behavior change to reduce undernutrition and poor health outcomes in developing settings.

Sequences of emotions in patients with borderline personality disorder.

OBJECTIVE: To investigate sequences of emotions (temporal dependence of emotions) to identify specific patterns of borderline personality disorder (BPD). METHOD: The perceived emotions of 50 BPD patients and 50 healthy controls (HC) were monitored by using a hand-held computer system for a 24-h period in a daily life setting. Participants were prompted four times per hour to assess their current perceived emotions. Differences between BPD patients and HC in terms of activation, persistence and down-regulation of emotions were analyzed. RESULTS: Healthy controls in contrast to BPD patients more often activated joy and interest. BPD patients more often experienced persistence of anxiety and sadness. BPD patients more frequently switched from anxiety to sadness, from anxiety to anger and from sadness to anxiety. Anger was predominantly preceded by anxiety. CONCLUSION: Persistence of sadness and anxiety, as well as emotional oscillating between anxiety, sadness and anger are important aspects of the emotional dysregulation in BPD patients.

A longitudinal study of changes in respiratory status in young adults, 1993-2001.

SETTING: There is little information regarding the prognosis of respiratory symptoms in early adulthood or the effects of potential risk factors. OBJECTIVE: To observe changing respiratory morbidity in a group of young adults over a period of 6-8 years. DESIGN: Subjects responding to three or more consecutive postal respiratory surveys carried out between 1993 and 2001 were included in the study. In addition to asthma (defined by a validated scoring system), two symptoms were examined: wheeze and being woken by cough. Five outcomes were defined: persistent, remission, new onset, never and intermittent. RESULTS: Of 2693 subjects who responded to at least one survey, about one third were eligible for inclusion: 10.2% reported wheeze at each survey (persistent) and 3.6% had persistent asthma. Persistent wheeze was seen in almost half (46.7%) of those reporting the symptom at their first survey. The corresponding figure for asthma was 32%. New onset wheeze was found in 16.2% of subjects without wheeze at baseline (asthma 9.7%). Smoking was significantly associated with new onset wheeze (OR 1.97, 95% CI 1.30-3.00) and asthma (OR 2.14, 95% CI 1.26-3.50), but not with persistent symptoms. CONCLUSION: These findings highlight the importance of policies to reduce smoking prevalence in young adults, and will help in the planning of future health care.

Experimental demonstration, using polarized Raman and infrared spectroscopy, that both conventional and de Vries smectic-A phases may exist in smectic liquid crystals with a first-order A-C* transition.

Two models exist for the orientational distribution of the long molecular axes in smectic-A liquid crystals: the conventional unimodal distribution and the "cone-shaped" de Vries distribution. The de Vries hypothesis provides a plausible picture of how, at a molecular level, a first-order Sm-A to Sm-C* transition may occur, especially if there is little or no concomitant shrinkage of the layer spacing. This work investigates two materials with such transitions: C7 and TSiKN65. The azimuthal distribution of in-layer directors is probed using IR and polarized Raman spectroscopy, which allows us to obtain orientational order parameters. In C7, we observe a discontinuous change in the order parameter, the magnitude of which is small compared with the corresponding change in the in-layer director tilt angle Theta . Assuming that the smectic-A liquid crystal is of the de Vries type, we calculate the Theta required to reproduce the apparent order parameter app, obtained from IR, by using the true order parameter , obtained from polarized Raman scattering. The results indicate that, for C7, the tilt angle so calculated is much smaller than that in the Sm-C* angle and hence de Vries behavior may not be the appropriate explanation in this case. Conversely, we find that TSiKN65 shows a different behavior to C7, which can be explained in terms of the de Vries concept. Thus, we conclude that either type of distribution may exist in Sm-A phases which undergo a first-order transition to the Sm-C* phase. We also discuss the changes in the smectic layer spacing and the orientational order parameters across the Sm-A-Sm-C* phase transition, together with changes in birefringence with applied electric field.

Improved detection of allele loss in renal cell carcinomas after removal of leukocytes by immunologic selection.

We used immunologic selection to remove contaminating leukocytes from primary renal cell carcinomas and to improve detection of chromosome 3p allele loss. Leukocytes were removed from disaggregated renal cell carcinomas by a double-antibody, magnetic bead separation technique. Before immunologic selection, the preparations contained 26% +/- 15% (SD) tumor cells (n = 7); after immunologic selection, the preparations contained 76% +/- 12% tumor cells. The recovery of tumor cells in the purified preparations was about 10%. Detection of allele deletion was facilitated by immunologic selection. This method may be useful in allele deletion analysis of other human solid tumors that are contaminated with host leukocytes and, with appropriate modification, may be applied to tumors that are contaminated with other cell types.

Genetic changes in human adrenocortical carcinomas.

Recent studies have suggested that loss of heterozygosity at loci on the short arm of human chromosome 11 (11p) may be important in the pathogenesis of benign and malignant adrenal cortical tumors. To test this concept, adrenocortical carcinomas from nine patients and benign adrenal cortical lesions from eight patients were tested for loss of alleles at loci on human chromosomes 11, 13, and 17. All patients with adrenocortical carcinoma whose normal somatic tissues were heterozygous for a locus on chromosome 17p had lost alleles in the tumor. Four of six patients with adrenocortical carcinoma who were heterozygous for one or more alleles on chromosome 11p in normal tissues had lost 11p alleles in the tumor. Three of six patients with adrenocortical carcinoma showed loss of 13q alleles in the tumor. Loss of alleles on chromosomes 11p, 13q, and 17p was observed in primary tumors and metastases but not in adrenocortical adenomas or hyperplastic lesions of the adrenal cortex. One patient with adrenocortical carcinoma had a somatic mutation in the HRAS1 gene in the normal adrenal gland. The consistency of the genetic changes on chromosomes 11p, 13q, and 17p suggests that they are important in the pathogenesis of adrenocortical carcinoma.

Specific genetic change in tumors associated with von Hippel-Lindau disease.

Previous reports showed that the loss of DNA sequences on the short arm of chromosome 3 (3p) is consistently found in sporadic renal cell carcinomas. To evaluate the significance of this genetic change, we looked for the loss of 3p alleles in hereditary renal cell carcinomas and other tumors from patients with von Hippel-Lindau disease. Specific loss of alleles from chromosome 3p was detected with polymorphic DNA markers in 11 renal cell carcinomas, one pheochromocytoma, two spinal hemangioblastomas and one cerebellar hemangioblastoma from von Hippel-Lindau patients. Multiple renal cell carcinomas in individuals with von Hippel-Lindau disease showed loss of the same chromosome 3p alleles, which demonstrated that the same chromosome was deleted in each tumor. Analysis of haplotypes indicated that the loss of chromosome 3p alleles was from the chromosome bearing the balancing, wild-type allele of the VHL gene. These results are consistent with the concept that the VHL gene is a recessive oncogene. Renal cell carcinoma, pheochromocytoma, and spinal and cerebellar hemangioblastomas develop in predisposed family members when somatic mutational events lead to loss of chromosome 3p sequences bearing the wild-type allele of the VHL gene.

Regional DNA hypermethylation at D17S5 precedes 17p structural changes in the progression of renal tumors.

In a preceding paper for brain tumors, we demonstrate a tight association between regional hypermethylation at locus D17S5 of chromosome 17p and allelic loss of this chromosome. Because 17p allelic losses occur at the earliest stages of brain tumors, the exact temporal relationship between this event and the hypermethylation could not be elucidated. In renal cancers, two linked structural changes on chromosome 17p, allelic loss and p53 gene mutations, generally occur late in progression. We now show that D17S5 hypermethylation is tightly coupled to both of these genetic changes in late stage renal tumors. However, the methylation change is the only one of the 17p abnormalities which occurs at a high incidence in early-stage renal cancers (hypermethylation, 50%; 17p allelic loss, 13%; p53 mutations, 0%). Our results firmly suggest that D17S5 regional hypermethylation precedes the appearance of the consistent 17p genetic changes in renal cancers, suggesting that this event either marks, or may even cause, chromatin changes which predispose to genetic instability.

The efficacy of mesna (2-mercaptoethane sodium sulfonate) as a uroprotectant in patients with hemorrhagic cystitis receiving further oxazaphosphorine chemotherapy.

We examined the possibility of continuing oxazaphosphorine therapy in patients with previously documented cyclophosphamide- or ifosfamide-induced hematuria by concomitant use of the uroprotective agent, mesna. Twenty-six patients with oxazaphosphorine-induced hematuria received additional cyclophosphamide or ifosfamide with mesna. Twelve, who had previously experienced hematuria with ifosfamide, received a median of 3.5 more cycles of ifosfamide/mesna. One patient developed further hematuria (grade 1). Of seven patients who experienced acute hematuria with cyclophosphamide, one experienced further hematuria after an additional course of cyclophosphamide with mesna, but none of the other six patients developed further hematuria when administered either cyclophosphamide/mesna (two) or ifosfamide/mesna (four). Seven patients who had chronic cyclophosphamide-induced hematuria had further oxazaphosphorine with mesna without worsening of their hematuria. Mesna is an effective uroprotective agent that prevents recurrent acute hemorrhagic cystitis, or worsening of chronic hemorrhagic cystitis, in patients receiving further oxazaphosphorine after previous ifosfamide- or cyclophosphamide-induced hematuria.

Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients.

BACKGROUND: A randomized clinical trial was conducted to evaluate whether the superior performance of dialectical behavior therapy (DBT), a psychosocial treatment for borderline personality disorder, compared with treatment-as-usual in the community, is maintained during a 1-year posttreatment follow-up. METHODS: We analyzed 39 women who met criteria for borderline personality disorder, defined by Gunderson's Diagnostic Interview for Borderline Personality Disorder and DSM-III-R criteria, and who had a history of parasuicidal behavior. Subjects were randomly assigned either to 1 year of DBT, a cognitive behavioral therapy that combines individual psychotherapy with group behavioral skills training, or to treatment-as-usual, which may or may not have included individual psychotherapy. Efficacy was measured on parasuicidal behavior (Parasuicide History Interview), psychiatric inpatient days (Treatment History Interview), anger (State-Trait Anger Scale), global functioning (Global Assessment Scale), and social adjustment (Social Adjustment Scale--Interview and Social Adjustment Scale--Self-Report). Subjects were assessed at 6 and 12 months into the follow-up year. RESULTS: Comparison of the two conditions revealed that throughout the follow-up year, DBT subjects had significantly higher Global Assessment Scale scores. During the initial 6 months of the follow-up, DBT subjects had significantly less parasuicidal behavior, less anger, and better self-reported social adjustment. During the final 6 months, DBT subjects had significantly fewer psychiatric inpatient days and better interviewer-rated social adjustment. CONCLUSION: In general, the superiority of DBT over treatment-as-usual, found in previous studies at the completion of 1 year of treatment, was retained during a 1-year follow-up.

Cognitive-behavioral treatment of chronically parasuicidal borderline patients.

A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.

Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients.

OBJECTIVE: This study reports the efficacy of a cognitive behavioral outpatient treatment on interpersonal outcome variables for patients diagnosed with borderline personality disorder. METHOD: In a 1-year clinical trial, 26 female patients with borderline personality disorder were randomly assigned to either dialectical behavior therapy or a treatment-as-usual comparison condition. All subjects met criteria of DSM-III-R and Diagnostic Interview for Borderline Patients for borderline personality disorder and were chronically suicidal. RESULTS: In both the intent-to-treat and treatment completion groups, dialectical behavior therapy subjects had significantly better scores on measures of anger, interviewer-rated global social adjustment, and the Global Assessment Scale and tended to rate themselves better on overall social adjustment than treatment-as-usual subjects. CONCLUSIONS: These results suggest that dialectical behavior therapy is a promising psychosocial intervention for improving interpersonal functioning among severely dysfunctional patients with borderline personality disorder.

Behavioral treatments of suicidal behaviors. Definitional obfuscation and treatment outcomes.

This chapter focuses on a review of randomized clinical trials of both psychosocial and behavioral interventions designed to directly reduce rates of suicide and parasuicidal behavior, including suicide attempts. It begins with an overview of the definitional difficulties in this field and then proceeds to an overview of treatment issues and a comprehensive review of treatment studies aiming to reduce suicidal behavior among suicidal individuals. Twenty studies are discussed. Eighteen studies randomly assigned subjects to the experimental and control condition; the other two studies assigned subjects in an alternating sequential fashion. Analyses showed that four psychosocial intervention studies and one pharmacotherapy study have reported efficacious results when compared to treatments-as-usual or placebo controls. From another perspective, when outpatient psychosocial interventions were examined, the strongest predictor of whether the experimental treatment would be more effective than the control was whether high-risk suicidal individuals were included. Psychosocial interventions appear to be most effective with the more high-risk individuals.

Postoperative complications in patients receiving suramin therapy.

BACKGROUND: Suramin is an antiparasitic agent that is currently being evaluated for antineoplastic activity. Documented toxicities of suramin include adrenal and renal insufficiency, coagulation factor abnormalities, immunosuppression, and polyneuropathy. These adverse effects have potential for contributing to postoperative morbidity in surgical patients. Because no experience with suramin has been reported in the surgical literature, this 5-year retrospective review of postoperative complications in patients receiving suramin was performed. METHODS: From a review of 171 charts, 14 patients were identified who had undergone a major surgical procedure either while receiving intravenous suramin or within 1 year after its administration. Primary diagnoses included prostate cancer (six), lymphoma (four), ovarian cancer (two), colon cancer (one), and glioblastoma (one). All patients received replacement dose hydrocortisone at the initiation of suramin therapy and thereafter. RESULTS: Eighteen major surgical procedures were performed with 18 complications occurring in five patients. The predominant complications encountered were hemorrhage (five), impaired wound healing (three), and bowel dysmotility (two). A highly significant relationship existed between the incidence of complications and interval from completion of suramin therapy to the time of operation (p < 0.0005), with 17 of the 18 morbidities occurring within the first month. The length of operation (p < 0.05) and amount of blood transfused during the procedure were related to postoperative morbidity (p < 0.05). No other factors evaluated were correlated to complications. CONCLUSIONS: This experience suggests the avoidance of elective procedures during the first month after suramin therapy and a heightened awareness of the potential for bleeding and wound healing problems in patients receiving suramin who do require an emergent procedure.

Birt-Hogg-Dubé syndrome: a novel marker of kidney neoplasia.

BACKGROUND: Birt-Hogg-Dubé syndrome (BHD) is a dominantly inherited predisposition for development of fibrofolliculomas, trichodiscomas, and acrochordons. Concurrent internal tumors, such as colonic polyps and renal carcinoma, have been described in patients with BHD. OBJECTIVE: To evaluate kindreds with familial renal tumors for cutaneous manifestations of BHD. DESIGN: One hundred fifty-two patients from 49 families underwent complete oral and skin examination. Skin lesions were identified by their clinical appearance, and the diagnosis was confirmed by results of histologic examination. Individuals underwent screening for familial renal neoplasms. SETTING: A tertiary referral research hospital. PATIENTS: Individuals with familial renal tumors and their asymptomatic at-risk relatives. MAIN OUTCOME MEASURE: We determined whether any form of renal cancer is associated BHD. RESULTS: We identified 3 extended kindreds in whom renal neoplasms and BHD appeared to segregate together. Two kindreds had renal oncocytomas and a third had a variant of papillary renal cell carcinoma. Thirteen patients exhibited BHD. Seven individuals, including a set of identical twins, had renal neoplasms and BHD. An additional 4 patients (3 deceased and not examined) in these families had renal neoplasms but not BHD. Birt-Hogg-Dubé syndrome without renal neoplasms was present in 6 individuals. Thirteen patients with fibrofolliculomas and trichodiscomas presented clinically with multiple smooth skin-colored to grayish-white papules located on the face, auricles, neck, and upper trunk. Oral papules were present in 9 of 28 and achrochordons in 11 of 28 patients. Features of BHD not previously appreciated included deforming lipomas in 5, collagenomas in 4, and pulmonary cysts in 4 of 28 patients. Families with BHD did not display germline mutations in the von Hippel-Lindau gene or in the tyrosine kinase domain of the MET proto-oncogene. CONCLUSIONS: Birt-Hogg-Dubé syndrome may be associated with familial renal tumors. Birt-Hogg-Dubé and renal tumors segregate together in an autosomal dominant fashion. Patients with BHD and their relatives are at risk for development of renal tumors. Therefore, patients with BHD and their relatives should undergo abdominal computed tomography and renal ultrasound screening for renal tumors.

Dialectical behavior therapy for binge eating disorder.

This study evaluated the use of dialectical behavior therapy (DBT) adapted for binge eating disorder (BED). Women with BED (N = 44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED.

Research on dialectical behavior therapy for patients with borderline personality disorder.

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. Evidence suggests that additional research is warranted to examine which components of DBT contribute to outcomes. Although preliminary, skills coaching seems to be a crucial ingredient in producing reductions in parasuicidal behavior, and specific strategies (e.g., validation, balance of change, and acceptance interventions) may play an important role in positive behavioral change. Several investigators are evaluating the efficacy of DBT. For example, Asberg et al at the Karolinska Institute in Sweden have begun a pilot study comparing DBT for women who have made multiple suicide attempts to transference focus psychotherapy, a psychodynamic therapy developed by Kernberg. They have planned a randomized clinical trial to compare DBT and transference focus psychotherapy with TAU in the community. van den Bosch has completed a randomized clinical trial for women who met criteria for BPD and substance abuse comparing DBT-S with TAU. Lynch is conducting a randomized clinical trial examining the efficacy of DBT skills training plus medication versus medication only for the treatment of moderate to severe depression in the elderly. Results from these studies should become available over the next several years, providing further empiric evidence by which to evaluate the efficacy of DBT. Additional development of DBT seems warranted to improve its efficacy, and additional investigation is needed to establish its effectiveness in public health settings. Analyses from existing data sets of factors that predict treatment response and elements of the treatment that contribute to outcome are needed. Also, longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains are needed. Because DBT has been adopted in a variety of clinical settings, effectiveness studies are needed. Given the difficulty of conducting treatment research with chronically suicidal individuals, perhaps the largest challenge to further treatment development is recruiting young investigators who are willing to conduct research in this area. Nevertheless, in the 6 years since the treatment manuals were published, DBT seems to be a step toward more effective treatment for severely multidisordered patients.

Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study.

Dialectical-Behavioral Therapy for Borderline Personality Disorder (DBT) developed by M. Linehan is specifically designed for the outpatient treatment of chronically suicidal patients with borderline personality disorder. Research on DBT therapy, its course and its results has focused to date on treatments in an outpatient setting. Hypothesizing that the course of therapy could be accelerated and improved by an inpatient setting at the beginning of outpatient DBT, we developed a treatment program of inpatient therapy for this patient group according to the guidelines of DBT. It consists of a three-month inpatient treatment prior to long-term outpatient therapy. In this pilot study 24 female patients were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect which prompts the development of a randomized controlled design.

Special feature: theory and treatment development and evaluation: reflections on Benjamin's "models for treatment".

To make the final point of this commentary clear at the outset, I could not agree with Dr. L. S. Benjamin's comments more, on the one hand, and could not disagree more, on the other hand. I will first review the points that I not only agree with but also think are extremely important. I will then beg to differ with some of her conclusions (at least as I interpret then), and with her analysis of the outcomes of the one cognitive-behavioral treatment of a personality disorder she reviewed in some detail.

Facial expression recognition ability among women with borderline personality disorder: implications for emotion regulation?

This study examined recognition of facial expressions of emotion among women diagnosed with borderline personality disorder (BPD; n = 21), compared to a group of women with histories of childhood sexual abuse with no current or prior diagnosis of BPD (n = 21) and a group of women with no history of sexual abuse or BPD (n = 20). Facial recognition was assessed by a slide set developed by Ekman and Matsumoto (Japanese and Caucasian Facial Expressions of Emotion and Neutral Faces, 1992), expanded and improved from previous slide sets, and utilized a coding system that allowed for free responses rather than the more typical fixed-response format. Results indicated that borderline individuals were primarily accurate perceivers of others' emotions and showed a tendency toward heightened sensitivity on recognition of fear, specifically. Results are discussed in terms of emotional appraisal ability and emotion dysregulation among individuals with BPD.