The art of assessment in psychology: ethics, expertise, and validity.

Psychological assessment is a hybrid, both art and science. The empirical foundations of testing are indispensable in providing reliable and valid data. At the level of the integrated assessment, however, science gives way to art. Standards of reliability and validity account for the individual instrument; they do not account for the integration of data into a comprehensive assessment. This article examines the current climate of psychological assessment, selectively reviewing the literature of the past decade. Ethics, expertise, and validity are the components under discussion. Psychologists can and do take precautions to ensure that the "art" of their work holds as much merit as the science.

Converting gallbladder absorption to secretion: the role of intracellular calcium.

BACKGROUND: Experimental cholelithiasis is associated with elevated biliary calcium concentration and altered gallbladder absorption. Recent studies showed that extracellular calcium ([Ca2+]ec) plays a role in regulating gallbladder ion transport. The extent to which intracellular calcium ([Ca2+]ic) mediates the changes in gallbladder ion transport is not clear. We hypothesize that [Ca2+]ic is an important regulator of gallbladder ion transport. METHODS: Prairie dog gallbladders were mounted in Ussing chambers, standard electrophysiologic parameters were recorded, and unidirectional Na+, Cl- and H2O fluxes were measured before and after mucosal exposure of 10-5 mol/L calcium ionophore A23187 was performed. RESULTS: A23187 caused an increase in transepithelial short-circuit current and potential difference and a decrease in transepithelial resistance. A23187 inhibited mucosa to serosa Cl- flux and stimulated serosa to mucosa Na+ flux, resulting in increased net Cl- secretion and decreased net Na+ absorption. A23187 converted H2O from absorption to secretion. Transepithelial short-circuit current effect of A23187 was delayed by indomethacin pretreatment and was completely blunted by low bathing Ca2+. CONCLUSIONS: This is the first demonstration that increased [Ca2+]ic converts the gallbladder from its normal absorptive state to a secretory one. Furthermore [Ca2+]ic appears to regulate ion transport through mechanisms that are partially prostaglandin-dependent. Studies are necessitated to define possible links between gallbladder secretion of Cl- and H2O and mucus hypersecretion, a well-described phenomenon associated with cholesterol gallstone formation.

Protein kinase C regulates prairie dog gallbladder ion transport.

BACKGROUND: Gallstone formation is characterized by increased biliary calcium (Ca2+) level and altered gallbladder absorption. Recent studies suggest that luminal Ca2+ regulates gallbladder ion transport via intracellular calcium ([Ca2+]ic). Ca2+-calmodulin and protein kinase C (PKC) are two major systems through which [Ca2+]ic carries out second-messenger functions in many cell types. We have previously shown that Ca2+-calmodulin regulates basal gallbladder ion transport in prairie dog. The present study tests the hypothesis that PKC is also essential in regulation of gallbladder ion transport in this model. METHODS: The role of PKC in regulation of gallbladder ion transport was determined by studying the effects of phorbol esters, synthetic analogues of diacylglycerol, which directly activates PKC. Gallbladders were mounted in Ussing chambers, and standard electrophysiologic parameters were recorded after exposing tissues to either 10(-5) mol/L of 4-alpha-phorbol 12,13-didecanoate (PDD), 4-beta-phorbol 12-myristate 13-acetate, 4-beta-phorbol 12,13-dibutyrate (PDB), or 10(-4) mol/L serotonin. Unidirectional Na+, Cl-, and H2O fluxes were measured before and after treatment with only inactive PDD and most active PDB. RESULTS: Mucosal and serosal exposure of tissues to either 4-beta-phorbol 12-myristate 13-acetate or PDB resulted in a decrease in short-circuit current and transepithelial potential difference without any change in tissue resistance. Serotonin induced similar changes in gallbladder electrical properties. PDB caused an inhibition of mucosal to serosal fluxes of Na+, Cl-, and H2O, with a decrease in net Na+ absorption, an increase in net Cl- secretion, and a conversion of net H2O absorption to net H2O secretion. Serosal-to-mucosal fluxes of Na+, Cl-, and H2O did not change. Inactive PDD had no effect on either electrophysiologic parameters or ion and water fluxes. Pretreatment of tissues with PKC antagonist 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine blocked the phorbol ester-induced inhibition of ion transport. CONCLUSION: PKC regulates gallbladder ion transport in the prairie dog by inhibiting Na+ absorption and stimulating Cl- secretion.

Pancreatitis associated with adult choledochal cysts.

We reviewed the records of 32 adult patients with choledochal cysts (CDC) to determine the characteristics of the associated pancreatic disease. Eighteen patients (56%) had 30 documented episodes of pancreatitis with epigastric pain and elevated serum amylase levels. Three patients developed a prolonged course with a pancreatic phlegmon and one patient died secondary to a pancreatic abscess after endoscopic retrograde cholangiopancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender or race of the patient. There was an association with the size of the CDC: 90% of patients with CDC > or = 5 cm developed pancreatitis compared with only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERCP was performed in 14 patients and demonstrated an abnormal pancreaticobiliary duct junction in eight (57%). All eight patients with an abnormal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.006). Patients undergoing surgical bypass rather than resection also tended to have higher rates of pancreatitis (80 vs. 50%). One patient with a Type I CDC and chronic pancreatitis was treated with surgical resection of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal "common channel" within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecognized high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC.(ABSTRACT TRUNCATED AT 250 WORDS)

Open cholecystectomy. A contemporary analysis of 42,474 patients.

OBJECTIVE: This study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. SUMMARY BACKGROUND AND DATA: Although cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. METHODS: A population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1, 1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. RESULTS: A total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. CONCLUSIONS: These data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic cholecystectomy needs to be defined in the context of current and contemporary data regarding open cholecystectomy.

Biliary complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has rapidly become the preferred treatment for symptomatic gallstones. Although this procedure has certain advantages over open cholecystectomy, concern has been expressed regarding the potential for bile duct injuries. In an effort to understand the scope of this problem, a retrospective review was performed of all patients referred to UCLA after having sustained biliary injuries during laparoscopic cholecystectomy. Over a 14-month period, 10 patients were referred to UCLA with 12 major bile duct injuries. One patient had a false positive cholangiogram leading to an unnecessary biliary-enteric bypass and subsequent dehiscence, resulting in a biliary fistula. Six patients were referred on an acute basis, whereas four patients underwent attempted biliary reconstruction at outside facilities and were ultimately referred with either a biliary stricture or a fistula. Review of cholangiograms suggested that bile duct anomalies were present in five patients. There did not appear to be a relationship between the use of either electrocautery or laser and bile duct injuries. To date eight patients have been successfully managed via Roux-en-Y hepaticojejunostomies, with a mortality rate of 0%. Although the exact frequency cannot be ascertained from the current study, our data demonstrate that major biliary complications do occur during laparoscopic cholecystectomy. Most of these injuries, however, can be safely and successfully treated with surgical biliary reconstruction. Early diagnosis and treatment with liberal use of intraoperative cholangiography and a low threshold for conversion to open laparotomy appears to be associated with a more favorable outcome.

Early and long-term effects of colectomy and endorectal pullthrough on bile acid profile.

OBJECTIVE: Although total colectomy with mucosal proctectomy and endorectal pullthrough affects two sites critical to the enterohepatic circulation of bile acids, little information is available regarding the manner in which normal digestive physiology is altered by these procedures. This study defines the early and long-term effects of colectomy and endorectal pullthrough on bile acid profile and the long-term effects on biliary lipid metabolism. SUMMARY BACKGROUND DATA: Specific changes in bile acid absorption have been reported in patients after ileal resection. Recent studies from our laboratory indicate that in the early postoperative period, colectomy with endorectal pullthrough causes a significant decrease in gallbladder bile concentrations of total bile acids, cholesterol, phospholipids, and calcium. The observation by several authors that the pouch undergoes morphologic and perhaps functional adaptation suggest that these changes may be transient and perhaps reversible. METHODS: These studies were done in an awake, unanesthetized canine model that allows periodic sampling of gallbladder bile without creation of an external biliary fistula and its associated sequelae. Animals were ultimately randomly assigned to either laparotomy and gallbladder cannulation (N = 6), or gallbladder cannulation with total colectomy and ileorectal anastomosis (N = 7), or biliary cannulation, colectomy, mucosal proctectomy and endorectal pullthrough with ileal reservoir (N = 5). RESULTS: Six weeks after operation, colectomy and ileorectal anastomosis were associated with a significant alteration in the relative composition of bile acids in gallbladder bile. These early changes were manifested by a significant (p < 0.05) increase in taurocholic acid and a concomitant decrease in taurodeoxycholic acid. These changes became even more pronounced in the ileorectal anastomosis group 12 weeks after colectomy and ileorectostomy. Although similar changes in the relative concentrations of individual bile acids occurred in the 6-week endorectal animals, bile acid profile was restored to normal by 12 weeks. CONCLUSIONS: Colectomy with ileorectal anastomosis leads to early and significant changes in bile acid profile, which persist and become even more pronounced with time. In contrast, the construction of an ileal reservoir after colectomy facilitates restoration of a normal bile acid profile. We propose that these alterations in bile acid metabolism result from adaptation of the ileal reservoir as its mucosa assumes functional characteristics of normal colon.

HIV and serious mental illness: reducing the risk.

Persons with SMI residing in community mental health center group homes received an educational intervention program on HIV/AIDS. As with virtually all such approaches provided for this population, the intervention was generalized from programs used with other populations, for example, users of intravenous drugs, gay men, and adolescents. Assessment of pre- and postintervention knowledge indicated no increase in accurate information. Further, consumers were initially uncertain regarding their risk for HIV infection; this attitude, too, remained unchanged. The research design employed did not compare persons with SMI with a normative sample receiving the same information, and assessed with the same instruments, limiting hypotheses about the generalizability of existing interventions. However, the data seems to suggest its potential inefficacy. Several findings are germane to effective educational intervention techniques.

Prostaglandin E2 stimulates ion transport in prairie dog gallbladder.

The effects of prostaglandins, and specifically prostaglandin E2, on gallbladder ion transport were examined in the prairie dog. Gallbladders were mounted in an Ussing chamber and baseline short-circuit current, potential difference, and tissue resistance were measured. Addition of arachidonic acid (10(-4) M, mucosal surface) produced sustained elevations in short-circuit current and potential difference (P < 0.05), with mild reductions in resistance. In a second set of tissues, indomethacin exposure (10(-6) M) resulted in a significant (P < 0.02) decrease in short-circuit current and potential difference, with an increase in resistance. Subsequent addition of prostaglandin E2 (10(-7) M, serosal surface) fully reversed these changes and led to a significant increase in short-circuit current and potential difference (P < 0.001) with a return of resistance to baseline values. These findings suggest that endogenous prostaglandins mediate gallbladder ion transport.

Lovastatin and gallstone dissolution: a preliminary study.

BACKGROUND: Lovastatin, an agent that reduces both serum and biliary cholesterol in humans, also inhibits cholesterol gallstone formation in an animal model. The present study was designed to assess the efficacy of lovastatin in gallstone dissolution. METHODS: All prairie dogs were fed a 1.2% cholesterol-enriched diet during the entire study. Gallbladders from five animals were examined at 3 weeks, and four of five gallbladders contained gallstones. Remaining animals were maintained on the 1.2% cholesterol-enriched diet and randomized to receive either water (n = 7); lovastatin, 8 mg (n = 7); ursodeoxycholic acid, 50 mg (UR, n = 7); or both drugs (lovastatin and UR, n = 7) twice daily by way of orogastric tube for 4 additional weeks. Response to therapy was determined by blinded examination of gallbladders. RESULTS: All three treatment groups had significant reductions in serum cholesterol, hepatic bile cholesterol, and hepatic cholesterol saturation index as compared to controls (water). Lovastatin induced a 28% response rate to dissolution therapy, which was equal to that achieved with UR, and the combination of lovastatin and UR produced a 56% response rate. CONCLUSIONS: This preliminary study suggests that lovastatin, alone or in combination with UR, may be useful in dissolving gallstones in humans.

The effects of extracellular calcium on prairie dog gallbladder ion transport.

Recent studies suggest that experimentally induced gallstone formation is associated with altered gallbladder absorptive function. Moreover, elevated biliary levels of calcium have been implicated in the pathogenesis of cholesterol gallstones. Nonetheless, the relationship between gallbladder ion transport and biliary calcium remains obscure. We tested the hypothesis that extracellular calcium modulates gallbladder ion transport. Prairie dog gallbladders were mounted in an Ussing chamber, and short-circuit current (Isc), transepithelial potential difference (Vms), and tissue resistance (Rt) were measured. Tissues were randomly exposed to physiologic salt solutions containing the following concentrations of calcium: 0.01, 1.3, 5, and 10 mmol/L. Exposure of gallbladder epithelium to increasing calcium concentrations resulted in concomitant increases in Isc and Vms (p < 0.001), without altering Rt. Regression analysis demonstrated a curvilinear correlation between calcium and Isc (Y = 167 + 22.5x - 1.4 x 26; p < 0.001). We conclude that extracellular calcium may be a modulator of gallbladder ion transport.

How to reduce the risk of HIV infection for the seriously mentally ill.

1. The professional literature increasingly indicates the need to educate persons with serious mental illness regarding HIV/AIDS. 2. Community-based organizations currently responding to the AIDS epidemic are poorly equipped to respond to the special needs of persons with serious mental illness. 3. Persons with serious mental illness are concerned by HIV/AIDS. Some, however, will incorporate education into their pathology via delusional systems or misunderstandings. 4. Effective programs for this population can be developed following community health nursing principles.

Cholecystectomy. The impact of socioeconomic change.

The impact of our evolving health care system on a commonly performed surgical procedure, cholecystectomy, was assessed in a county-subsidized and private university hospital setting. Although condition on admission, use of resources, and outcome were unchanged in the private setting between 1980 and 1988, significant differences were noted among the largely uninsured patients at the county facility during this same time interval. There was a significant increase in the acuity of illness among patients undergoing cholecystectomy at the county hospital in 1988 as compared with 1980. These data suggest that alterations in reimbursement strategies and allocation of resources are significantly impacting on patient care, particularly in nonprivate health care facilities.

Demographic, clinical, and personality variables associated with male prostitution by choice.

This research compared demographic, clinical and personality variables in a sample of 15 male prostitutes and 15 nonprostitutes from the same cohort. Unlike previous samples of male prostitutes, these young men specifically reported that they were involved by choice, primarily to earn extra money. Significant findings included heavier drug and alcohol use, more limited vocational success and aspirations, and greater alcohol use among family members of male prostitutes. Male prostitutes were also more likely to identify themselves as drug or alcohol addicted. No significant differences were found in personality characteristics between the two groups, although there was limited support for the hypothesis that male prostitutes are more antisocial.

Altered Na+ and Cl- flux during diet-induced mixed gallstone formation in the prairie dog.

Recent studies suggest that altered gallbladder absorptive function may be an important and previously unrecognized factor in the pathogenesis of experimentally induced gallstones. The present study was designed to define the specific changes in gallbladder epithelial ion transport that occur during mixed gallstone formation. Fifteen prairie dogs were fed either control or corn-alfalfa chow for six months. No control animals developed gallstones or crystals. Three of eight corn-alfalfa-fed animals had large black stones, and the remaining five had crystals ("pregallstone" group). Corn-alfalfa-fed animals had significant increases in gallbladder bile cholesterol, phospholipids, and calcium as compared to controls. Gallbladders were removed and mounted in a Ussing chamber for electrophysiologic and ion flux studies. Gallbladders from animals fed corn-alfalfa demonstrated significant decreases in short-circuit current and potential difference as compared to controls (P less than 0.05). 22Na and 36Cl were used to determine unidirectional ion fluxes. While net ion fluxes were similar in pregallstone animals and controls, stone-forming animals exhibited a significant decrease in net Na+ flux and a significant reversal in the direction of net Cl- flux (from secretion to absorption) as compared to controls (P less than 0.05). These data indicate that mixed gallstone formation is associated with alterations in gallbladder ion transport. The role of these changes in the pathogenesis of mixed gallstones remains to be determined.

The natural history of carcinoma of the bile duct in patients less than forty-five years of age.

Traditionally regarded as a disease of the elderly, the natural history of carcinoma of the bile duct in young patients has not been well defined. Of 186 patients (mean age of 62 years) treated at UCLA (1954 to 1988) for carcinoma of the bile duct, 26 were less than 45 years old. Younger patients had symptoms for an average of 4.5 +/- 0.8 months prior to diagnosis, as compared with 2.3 +/- 0.2 months for patients more than 45 years old (p less than 0.03). Of the younger patients, 96 per cent were managed surgically with either resection, surgical palliative bypass or laparotomy and tube drainage. Among the younger patients who underwent resections, 92 per cent were alive at one year, as compared with 60 per cent of patients who underwent palliative bypass procedures. Two patients who underwent tumor resections survived four years or longer. We conclude that carcinoma of the bile duct is not limited to the elderly and occurs in a significant number of young patients. In the younger population, carcinoma of the bile duct is characterized by delays in diagnosis. Early suspicion and aggressive management of young patients with obstructive jaundice are essential to ensure the best possible outcome for patients with this disease.

Self-concept in hearing and prelingual, profoundly deaf students. A comparison of teachers' perceptions.

A self-concept measure was administered to a group of 68 deaf students aged 8-19 years and a comparison group of 68 hearing students. Teachers for both of the groups completed observer reports of self-concept. Although tentative, the findings indicate that hearing teachers' perceptions of students' self-concepts are in closer agreement for hearing students than they are for deaf students. At the same time, the results show that deaf students do not appear markedly different from hearing students in their own reports of self-concept.

Lovastatin inhibits gallstone formation in the cholesterol-fed prairie dog.

The efficacy of lovastatin, an inhibitor of hepatic cholesterol synthesis in the prevention of cholesterol gallstone formation, was evaluated in the prairie dog model. Two groups of animals were maintained on either nonlithogenic or 1.2% cholesterol-enriched chow for 21 days. Seven of the animals in each group received lovastatin, and the remaining six received only distilled water. All of the cholesterol-fed/water-treated animals had crystals and 83% had gallstones, but none of the cholesterol-fed/lovastatin-treated animals had gallstones and only three had microscopic crystals. These data indicate that lovastatin inhibits cholesterol gallstone formation in a diet-induced model of gallstone disease.

Intracellular calcium modulates gallbladder ion transport.

Although experimentally induced cholesterol gallstone formation has been associated with altered gallbladder (GB) absorption and increased biliary Ca2+, the relationship between these events remains unclear. Recent studies suggest that extracellular Ca2+ ([Ca2+]ec) influences GB ion transport. Whether the effects of [Ca2+]ec are mediated by changes in intracellular Ca2+ ([Ca2+]ic) has not been determined. This study was designed to define the effects of altered [Ca2+]ic on GB ion transport. Prairie dog GBs were mounted in a Ussing chamber and short-circuit current (Isc), potential difference (Vms), and resistance (Rt) were recorded. Mucosal surfaces were exposed to either Dantrolene (Dt) or nickel (Ni2+). Dt "traps" [Ca2+]ic within intracellular organelles, thereby lowering cytosolic Ca2+; and Ni2+ prevents influx of [Ca2+]ec, presumably by binding Ca2+ channels. Although Dt reduced both Isc and Vms (P less than 0.01), these effects were transient. Transport recovery was probably due to increased [Ca2+]ec influx with restoration of [Ca2+]ic. Ni2+ resulted in sustained decreases in Isc and Vms (P less than 0.05) despite subsequent addition of 10 mM Ca2+. These findings are consistent with the prevention of [Ca2+]ec influx by Ni2+. We conclude that: (1) [Ca2+]ic may be a modulator of GB ion transport and (2) previously reported [Ca2+]ec effects on ion transport may be mediated through [Ca2+]ic concentration changes.

Systemic treatment of multiple personality: response to a chronic disorder.

Multiple Personality Disorder (MPD) is a more and more frequently diagnosed disorder. In this article, MPD is considered the result of a dissociative defense in response to severe trauma during the formative period of personality formation. As the child dissociates to defend against the trauma, the fragments of personality develop as separate entities. The traditional focus of therapy is integration, or fusion of the various fragments of personality. The current article does not dispute this therapeutic goal, but does offer an alternative treatment process. Borrowing from the theoretical concepts of the family therapy literature, the person with MPD is described as a system. Therapy, then, must attempt to maintain balance within the system as a short-term goal, as well as striving for integration as a long-term goal. This article delineates the systemic approach, first from a theoretical, then a practical perspective. The concepts of coconsciousness (or awareness by all aspects of the system) and coexistence (a state of mutual cooperation between various personalities) are described, and fitted within the systemic model. Practical aspects of life with MPD, including activities of daily living and relationships, are then outlined within this model.