Cerebral blood flow velocity in patients with subclinical portal-systemic encephalopathy.

UNLABELLED: Alterations in cerebral blood flow (CBF) are implicated in the etiology of portal-systemic encephalopathy. We hypothesized that CO2 reactivity of the cerebral circulation may be impaired in subjects with chronic liver disease (CLD) who also had subclinical portal-systemic encephalopathy (SPSE). We compared the relationship between PETCO2 and cerebral blood flow velocity in 10 patients with CLD with those of 10 healthy control subjects. Middle cerebral artery mean blood flow velocity (MCAMFV) was measured using transcranial Doppler during rest, hyperventilation, and hypoventilation. The degree of SPSE was quantified by using psychometric testing. Patients with CLD had poorer psychometric test scores compared with control subjects. Patients with CLD had lower PETCO2, MCAMFV, and blood pressure values and higher heart rates, differing from control subjects in all ventilation states. However, CO2 reactivity, the rate of change in MCAMFV to changes in ventilation (expressed as percent change in CBF velocity per mm Hg change in PETCO2) was similar for both groups (4.6% +/- 0.6% vs 4.2% +/- 0.5% for patients with CLD versus control subjects, P = 0.15). IMPLICATIONS: Psychometric test scores in patients with chronic liver disease revealed subclinical impairment compared with control subjects. Transcranial Doppler measurements of middle cerebral artery blood flow with varying PETCO2 were conducted, but the CO2 response of patients with liver disease was within the range of control subjects.

Developing leaders in public health: the role of executive training programs.

The growing complexity of the nation's health care system is creating new challenges and opportunities for public health officials, and a renewed concern for leadership training among these officials. A focus group conducted with public health officials at local, state, and national levels reveals perceptions about the predominant trends effecting public health practice, the leadership skills required for effective public health practice, and the strategies that are needed for providing appropriate leadership training to public health executives. Officials indicate that public health practice is undergoing substantial changes in response to the growth of managed care and integrated delivery systems, changes in public health funding sources and levels, and efforts to privatize the delivery of public health services. The skills identified as critical for effective leadership in this environment include the ability to guide organizational behavior and cultivate interorganizational relationships; apply scientific knowledge to public health problems, and build and sustain community coalitions. In light of these skills, public health officials identify four essential components of an optimally effective executive training program in public health leadership: exposure to the core scientific disciplines within public health; exposure to organization theory and management science; training in community development and empowerment; and training in ethics and social justice. All of the officials agree with the need for distance learning programs for executives in public health leadership, and most officials also support the need for doctoral-level training in public health practice.

Incidence of alcohol abuse in the parents of medical students.

An anonymous self-report survey of the medical students at the University of Colorado Health Sciences Center assessed how many of the students' parents were alcohol abusers. The results indicated that 27% of the student body were children of alcohol abusers, a rate twice that of the general population. This finding has implications for teaching strategies, student substance abuse, prevention efforts during the medical-school years, and provision of appropriate programs through student health services.

Measurement of amino acid compositions of glycoprotein systems by gas-phase hydrolysis and reversed-phase high-performance liquid chromatography.

Interest in glycoproteins and their compositions has increased in recent years. Work described in this report illustrates the use of an amino acid analysis protocol involving gas-phase hydrolysis and reversed-phase high-performance liquid chromatography of glycoprotein systems at microgram levels. In other amino acid analysis protocols the problem of losses of amino acids of glycoproteins has been documented. These losses were due to various reactions, referred to as browning or Maillard reactions, which yielded a residue from which amino acids were not recoverable. In our work, three glycoprotein systems are examined: ovalbumin, sICAM-1, and bovine serum albumin--which is naturally unglycosylated, but is spiked with about 30% saccharides. In all three cases, the compositional agreement between the molar ratio of amino acids determined empirically and that predicted is greater than 90%. Thus it is shown that the adverse effects of Maillard-type reactions are avoided, and the presence of carbohydrates causes negligible interferences with amino acid analysis performed under the conditions described herein.

Taking care of culturally different and non-English speaking patients.

Many physicians evaluate and care for non-English speaking patients and patients from different cultures. If not carefully considered, cultural factors, including language, often interfere with optimal diagnosis and treatment of these patients. In addition to improved clinical care, increased awareness and assessment of these issues will often enhance patient and family satisfaction and cooperation with therapeutic recommendations. A number of cultural examples are given to illustrate various points, which of course cannot be comprehensive, but which should alert the physician for areas to focus upon. The knowledge and skills to perform a sociocultural differential diagnosis and to initiate treatments in these areas are especially important for consultation-liaison psychiatrists.

Geriatric psychiatry patients' care by primary care physicians.

Primary care physicians were surveyed regarding their perceptions from recall of psychiatric disorders in, and their use of treatment approaches for, their geriatric patients. Affective disorders, organic mental syndrome, and generalized anxiety disorders were the three most common problems reported, and they were felt to be among the three most common problems by 89%, 56%, and 39% of the physicians, respectively. The three most common disorders for which they sought psychiatric consultation or referral were affective disorders, "psychosis," and organic mental syndrome, by 61%, 22%, and 18% of the respondents. The use of various psychiatric treatments and various sources of consultation and referral are analyzed and reported by age, primary care specialty, and practice setting of responding physicians.

The Mezzich MMPI regression formula revisited.

In a sample of depressed psychiatric inpatients, the Mezzich regression formula, based on five MMPI scales, correlated moderately with clinicians' judgments and yielded few false negative diagnoses in identifying patients with unipolar Major Depressive Disorder, but was less effective in eliminating false positives.