Perspectives on health care delivery systems for American Indian families.

The national effort to improve services to children with special health care needs presents unique challenges for the delivery of services to American Indian families. This study took place in New Mexico. American Indian families whose children have special needs and health care providers were interviewed. Their responses about obstacles to health care for their children and suggestions for improving services were examined. Generally, both groups identified similar obstacles, although important differences between groups were noted. The findings point to the need for understanding cultural barriers and the unique concerns of low income families living in rural areas. This has important implications for planning changes in the health care system for American Indian children with special needs.

Narcissism and adaptation to indignity.

Having initially briefly reviewed and then compared and contrasted the contributions of Kernberg and Kohut to the theory and treatment of narcissistic problems, the attempt was then made to evaluate critically their merits and possible short-comings. It was felt that in pushing back the frontiers of pathology to earlier and earlier developmental phases there has been an associated tendency to postulate "essentially preverbal unconscious communication' between therapist and patient where empathy tends to minimize or replace free association and other secondary process communication as the analytic therapeutic tool. The view was put forward that both Kernberg and Kohut emphasized the countertransference dangers involved in treating patients with narcissistic problems at the expense of recognizing the communicative, adaptive aspects of the feelings evoked and provoked by such patients. There was the question raised whether new self psychologies were required or merely the modification of existing theories. This was especially relevant to proposed changes in viewing the place of drives and the Oedipus complex. Finally, an attempt was made to show that along with object-related developmental conflicts and traumas, life presents us all with a series of indignities related to narcissistic traumas that we must cope with from infancy to senescence, and not least among these traumas are those related to being an analytic patient.

Splanchnic metabolism of free fatty acids and production of triglycerides of very low density lipoproteins in normotriglyceridemic and hypertriglyceridemic humans.

Transport of free fatty acids from the blood into the splanchnic region and their conversion to triglycerides of very low density lipoproteins, together with estimates of splanchnic oxidation of free fatty acids to ketones and to carbon dioxide and water, have been made in the postabsorptive state in seven normolipemic subjects, six with primary endogenous hyperlipemia and one each with primary dysbetalipoproteinemia and mixed hyperlipemia. Net systemic transport of free fatty acids into the blood was the same in normolipemic and hyperlipemic groups, but a greater fraction was taken up in the splanchnic region in the latter. Transport into the blood in very low density lipoproteins of triglyceride fatty acids derived from free fatty acids was proportional and bore the same relationship to splanchnic uptake of free fatty acids in the two groups. In normolipemic subjects, near equilibration of specific activities after 4 hr infusion of palmitate-1-(14)C showed that almost all triglyceride fatty acids of very low density lipoproteins and acetoacetate were derived from free fatty acids taken up in the splanchnic region. In the hyperlipemic subjects, equilibration of free fatty acidcarbon with acetoacetate was almost complete, but not with triglyceride fatty acids, owing at least in part to increased pool size. Comparison of the rate of equilibration of triglyceride fatty acids-(14)C with rate of inflow transport from the splanchnic region, together with other data, indicated that most of the circulating triglyceride fatty acids of very low density lipoproteins in hyperlipemic subjects were also derived from free fatty acids. Although mean inflow transport of triglyceride fatty acids was greater in the hyperlipemic subjects, it correlated poorly with their concentration and it appeared that efficiency of mechanisms for extrahepatic removal must be a major determinant of the concentration of triglycerides in blood plasma of the normolipemic as well as the hyperlipemic subjects. Estimates of splanchnic respiratory quotient supported the concept that oxidation of free fatty acids accounts for almost all of splanchnic oxygen consumption in the postabsorptive state. Splanchnic oxygen consumption was greater in the hyperlipemics, but fractional oxidation of free fatty acids to ketones was higher in normolipemic subjects. Calculations of splanchnic balance indicate that a larger fraction of free fatty acids was stored in lipids of splanchnic tissues in the hyperlipemics. No differences were found between the two groups in net splanchnic transport of glucose, lactate, or glycerol.