Nuances in ophthalmic plastic surgery. A dermatologic surgeon's perspective. Presented several nuances in the performance of cosmetic upper, lower, and lateral eyelid surgery. To provide slight modifications in the performance of cosmetic upper and lower eyelid surgery that may be timesaving and outcome-enhancing. Lateral eyelid tightening is discussed. The expected outcomes and best candidates for surgery are also described. Methods vary with the individual procedure. However, expertise in the traditional methods of cosmetic eyelid surgery is integral to success with the modified techniques. Results vary with the individual procedure, the surgeon's expectations, and the surgeon's interpretation of the patient's expectations, as well as other factors. Modifications of traditional cosmetic eyelid surgical procedures may benefit the patient following careful planning and technique execution.


Complications of blepharoplasty and their management. BACKGROUND. Blepharoplasty is the most frequently performed cosmetic procedure on the face. Although complications are rare, their consequences can be devastating both the for patient and the surgeon. OBJECTIVE. The complications of blepharoplasty and their management are reviewed.


[Body temperature, internal energy and the probability of the existence of warm-blooded animals and man]. Based on statistical peculiarities of the existence of two-leveled thermodynamic systems, it was shown that the probability of existence for warm-blooded organisms is determined by body temperature, energy of metabolism, and thermodynamic potentials of critical increase and decrease in the body temperature. It was established that the dynamics of human death rate from the birth to extreme old age is conditioned by age-related changes in the energy of metabolism. It was shown that maintenance of the metabolic level in aging is very important for the life prolongation.


[The effect of chemotherapy on the total unsaturation and composition of plasma phospholipids and erythrocytes in patients with disseminated breast cancer]. The total unsaturation and composition of blood phospholipids were studied in patients with disseminated breast cancer prior to and after chemotherapy. It was shown that the level of double bonds in blood lipids was quite definitely related to the effect of treatment and may have an independent prognostic significance. A correlation was established between the survival of patients and the character of changes in the level of double bonds after chemotherapy. The treatment did not influence the relative content of different fractions and the oxidizability of plasma phospholipids and erythrocytes.


[A symmetrical approach to the analysis of cardiocyte electrical and contractile activity]. Based on the systemic symmetrical approach, experimentally determined parameters of action potential and contractile response of frog myocardial strip were analyzed prior to and after the administration of several physiologically active drugs (caffeine, neoepinephrine, nembutal, ouabain) into the perfusate. It was shown that the satisfactory functional state of preparation was characterized by an interrelation between parameters in the form of a harmonic proportion with relatively constant coefficient. When the functional state of subject is affected by a physiologically active substance, the interrelation between the parameters is considerably changed. Based on the analysis of the data of literature, it was found that the interrelation between temporary parameters of action potential in various structures from human heart has the form of a harmonic proportion with a constant coefficient close to the invariant of "Gold Wurf" proportion. The similarity is underlined of principles of cardiac function temporary arrangement at levels of cell, organ and organism.


Protein C and S deficiency in severe infectious purpura of children: a collaborative study of 40 cases. We studied, in 40 children (mean age: 52 months) with severe infectious purpura, the relationships between protein C (PC) and protein S (PS) levels, and shock, disseminated intravascular coagulation (DIC) and outcome. We determined, on admission, PC antigen (ELISA) and activity (chromogenic test), and total PS (ELISA). Results were expressed as % of normal adult values. Statistical analysis was performed with SAS. Thirty children were in shock, 20 had DIC. All children with DIC, and 10 without DIC were in shock. Of 20 children who were in shock and had DIC, 7 died and 3 had an amputation. PC antigen was significantly decreased in shock children (p less than 0.05), in children with DIC (p less than 0.0005), and in non-survivors (p less than 0.05). PC activity was significantly decreased in shock children (p less than 0.05), in children with DIC (p less than 0.0005), and in non-survivors (p less than 0.005). Total PS was not decreased in shock children, but was significantly decreased in children with DIC (p less than 0.005), and in non-survivors (p less than 0.005). We conclude that PC and PS levels were decreased in our children, and that PC levels were significantly decreased in the presence of shock, DIC, and fatal outcome. PC and antithrombin III (AT III) supplementation, should be evaluated in children with severe infectious purpura with shock and DIC.


[The bilateral asymmetry of the number of bristles in Drosophila occurring under the influence of methotrexate]. The data are analyzed on the bilateral asymmetry of the number of dorsal and scutellar chaeta observed under the action of methotrexate in Drosophila of wild strain. It was shown that the incidence of asymmetric specimens induced by methotrexate was abruptly increased as compared to the control. The asymmetry was found to have a statistically significant trend to left side both of the control and the variants of treatment. There was no sex difference revealed between targets of the asymmetry.


Oxygen consumption after cardiac surgery--a comparison between calculation by Fick's principle and measurement by indirect calorimetry. Oxygen consumption calculated by Fick's principle (cVO2) was compared to oxygen consumption measured (mVO2) by indirect calorimetry (Deltatrac Metabolic Computer) in 10 patients in the post-operative period after cardiac surgery. For 50 pairs of measurements the mean difference (mVO2-cVO2) was 34 +/- 27 ml/min.m2. The limits of agreement were -20 ml/min.m2 to 88 ml/min.m2. These results showed that cVO2 and mVO2 were not interchangeable in this study.


Uncertain relevance of gastric colonization in the seriously ill. We have studied the temporal relationship for the same micro-organisms between gastric colonization and both nasopharyngeal colonization and major clinical infections in 100 consecutive, long-stay, intensive care patients. 67% of patients developed positive gastric cultures, mainly with aerobic Gram-negative bacilli and C. albicans; 33% developed positive nasopharyngeal cultures with similar organisms, but in only 8% was the same organism previously cultured from the stomach; 48% of patients developed infections, mainly respiratory, but commonly with different organisms. The presence of a positive gastric culture was not associated with gastric pH, bleeding, severity of illness, or mortality. The results fail to confirm that an ascending migration of organisms from the stomach is.frequent or that there is a relationship between gastric colonization and clinical infections. Firm therapeutic recommendation in these areas may be premature.


Role of selective digestive decontamination (SDD) in the prevention of nosocomial pneumonia (NP): is gastric decontamination necessary? In the course of a prospective selective digestive decontamination (SDD) trial to prevent nosocomial pneumonia (NP) during mechanical ventilation (MV), we carried out serial cultures of gastric aspirate to assess the importance of gastric colonization for potential respiratory pathogens and its relationship to the simultaneous gastric pH, to whether the patients were receiving Sucralfate or Ranitidine and to the nutritional biochemical parameters. If NP developed, a bronchial sample was taken by fibreoptic bronchoscopy to determine the causal organisms and its relationship to the previous gastric isolated. Results show: 1) Increase in aerobic Gram negative bacilli colonization during hospitalization. 2) Direct relationship between colonization level and gastric pH. 3) Greater pH in ranitidine vs sucralfate group. 4) Low incidence of NP (11%), the majority of these (66%) being early. 5) No bacteriological correlation between gastric colonization and aetiological agents of NP. 6) Close relationship between pharyngeal colonization and causative germs of pulmonary infection (40%).


Reestimation of the effects of inorganic phosphates on the equilibrium between oxygen and hemoglobin. In a previous paper, published in this journal, we showed that the data obtained in patients with severe ketoacidosis suggest that inorganic phosphates (K2HPO4) can increase their P50 and therefore enhance tissue oxygenation without concomitant alteration of the 2,3 diphosphoglycerate (DPG). In order to test the hypothesis that K2HPO4 could influence the oxyhemoglobin dissociation curve (ODC) by a mecanism which was not DPG mediated we have measured the total ODC on whole blood with and without addition of 13-80 mmol/l of inorganic phosphates. On average, the level of DPG remained unchanged when the P50 with K2HPO4 was significantly higher (p greater than 0.001) (P50 = 29.9 +/- 3.7 mmHg) than when phosphates were not administered (P50 = 25.5 +/- 2.8 mmHg). The relationship between P50 (mmHg) and K2HPO4 (= X mmol/l) was delta P50 = -2.97 10(-3)(X)2 +0.26(X)-0.42 (r = 0.78). Seeing that phosphates have an immediate action on the ODC, we calculated in our ketoacidosis patients, the relationship between the P50, the inorganic phosphates (P(i) in mg%) and the DPG in mumol/gHb. Both factors exert a highly significant effect (p less than 0.001) on the P50, according to the following equation: P50 = 0.35 DPG +0.26 P(i) + 18.92 (r = 0.73). Our data are important in two points. First it is useful to add inorganic phosphates to the treatment of patients with severe ketoacidosis in order to enhance their tissue oxygenation. Second they recall that the ODC is not only determined by the classical effects of temperature, pH and DPG but also by inorganic anions, like phosphates as described by Benesh and Benesh in their pioneering work.


[The technology for isolating the avian myeloblastosis virus in high titers from leukosis-free chicks]. In order to enhance the outcome of high-quality reverse transcriptase enzyme, an efficient biotechnology was developed of accumulating and isolating the avian myeloblastosis virus (AMV) in high titres from blood plasma of leukosis-free chickens. When commercial chickens are infected in most sensitive one-day age, the virus titre does not exceed the value of 10(12) particles per 1 ml of plasma. We used 3-4-day old leukosis free chickens and achieved a stable average titre of the virus of 5.10(12) particles/ml due to adaptation of the virus to such chickens and their selection for a high sensitivity to AMV.


Tidal volume, breathing frequency, and oxygen consumption at different pressure support levels in the early stage of weaning in patients without chronic obstructive pulmonary disease. The objective of this study was to evaluate the influence of different PSV levels on VT, F, VO2 in the early weaning phase of patients without chronic obstructive pulmonary disease. These parameters were tested for the predictive power for the success of the weaning. Patients on SIMV were studied during the first weaning attempt with PSV. Depending on their ventilatory support demands after 24 h they were divided into responders (patients breathing on CPAP) and nonresponders (patients being on a more invasive ventilatory mode). 14 ICU patients without pre-existing pulmonary disease being ventilated for at least 3 days entered the study. 2 of them could be studied a second time after failing the first weaning attempt. Beside the level of ventilatory support no other changes (drugs, nutrition) were allowed. VO2, VT, F were measured by a computer controlled, metabolic unit connected to the expiratory port of a Siemens Servo Ventilator. In addition, airway pressures, arterial pressure and heart rate were recorded. The measurements were performed at PSV of 5, 10 and 20 cmH2O. Arterial blood-gases were drawn at the end of each 60 min lasting PS period. Responders and nonresponders could be separated by the response of VO2, VT and F to a change in PS 10 to PS 20 cmH2O. Patients who significantly increased VT and significantly decreased F did not fulfil our weaning criteria. Our responders did not show a significant change in these two parameters, but a significant increase in VO2 at PS 20 cmH2O could be observed.(ABSTRACT TRUNCATED AT 250 WORDS)


Fat emulsions containing medium chain triglycerides in patients with sepsis syndrome: effects on pulmonary hemodynamics and gas exchange. Fat emulsions containing medium chain triglycerides (MCT) have recently been introduced into clinical practice as a component of total parenteral nutrition. Since several authors reported increased pulmonary artery pressure and impaired gas exchange during intravenous (i.v.) fat use, in particular in septic patients, we studied the pulmonary hemodynamic and gas exchange effects of i.v. fat containing MCT and long chain triglycerides (LCT) in patients with sepsis syndrome. As the effects of fat emulsions have been attributed to increased formation of prostanoids, the production of thromboxane A2 and prostacyclin was investigated by the determination of urinary thromboxane B2 and 6-keto-prostaglandin F2 alpha, respectively. The i.v. fat use did not induce any alterations in pulmonary hemodynamics and gas exchange, the distribution of ventilation and perfusion nor urinary prostaglandin content. We conclude that fat emulsions containing MCT induce little alterations in pulmonary hemodynamics and gas exchange. This result is probably due to reduced prostaglandin formation because fat emulsions containing MCT provide less prostaglandin precursors than pure LCT emulsions.


High volume hemofiltration improves right ventricular function in endotoxin-induced shock in the pig. This study assessed the influence of continuous high volume hemofiltration on right ventricular function of pigs with endotoxin induced shock. Eighteen anesthetized and ventilated pigs were studied for 240 min after the start of infusion of 0.5 mg/kg endotoxin over 30 min. Right ventricular ejection fraction (RVEF) was measured by rapid response thermodilution technique. After endotoxin infusion, the pigs were randomly divided into 3 groups: group 1 as a control group, receiving endotoxin only, group 2 to observe the effects of zero balance high volume veno-venous hemofiltration with removal of ultrafiltrate at a rate of 6000 ml/h, and group 3 to evaluate the effect of the extracorporeal circuit itself on RVEF. The decline of RVEF in group 2 was less than in group 1 (0.04 +/- 0.02 vs 0.21 +/- 0.03 (mean +/- SEM); p less than 0.001). The decline of RVEF in group 3 (0.24 +/- 0.02) was more pronounced than that in group 1 (p less than 0.05). The differences in the course of RVEF between group 1 and group 2 could not be explained by differences in heart rate, preload or afterload. Cardiac output and mean arterial pressure were significantly higher in group 2 than in group 1 (p less than 0.01). It is concluded that in this model, high volume hemofiltration improves RVEF and cardiac performance by removal of vasoactive mediators, responsible for myocardial depression.


Treatment of severe tetanus by intrathecal injections of baclofen without artificial ventilation. A study was conducted to evaluate repeated intrathecal injections of baclofen, without artificial ventilation, in the treatment of severe tetanus. Ten patients, 5 men and 5 women, with a mean age of 34 +/- 7 years, were included in the study. The dose of baclofen injected was 1000 micrograms between the ages of 16 and 55 years, 800 micrograms over the age of 55 years and 500 micrograms under the age of 16 years. The efficacy was assessed on the basis of the resolution of contractures and paroxysms and the initial dose was reinjected prior to the reappearance of these symptoms. Treatment was discontinued in the case of central nervous system depression or inefficacy. The first injection was effective in 9 cases for 24-48 h. The haemodynamic safety was always good. Five patients developed central depression with coma and respiratory depression, requiring artificial ventilation in 3 cases and reversed by flumazenil in 2 cases. Five patients were treated exclusively with baclofen with 4 cures. Five patients had to be ventilated with only one cure. This study confirms earlier studies concerning the efficacy of intrathecal baclofen in tetanus. However, the frequency of episodes of respiratory depression prevents the recommendation of repeated injections when respiratory intensive care facilities are not available.


Diagnosis of gallbladder perforation in acute acalculous cholecystitis in critically ill patients. In the presence of ascites ultrasound is not appropriate to distinguish between gallbladder perforation and acute acalculous cholecystitis. However, the correct and early diagnosis of gallbladder perforation is important for the treatment and prognosis. We report 4 critically ill patients with ascites. All patients had evidence of gallbladder perforation by ultrasound and underwent cholecystectomy: 2 patients had gallbladder perforation, but 2 had acalculous cholecystitis without perforation. Markedly elevated serum alkaline phosphatase was the only discriminating finding indicating gallbladder perforation.


Severe acute myocardial infarction during a staphylococcal septicemia with meningoencephalitis. A possible contraindication to thrombolytic treatment. We report the first case of lethal intracranial haemorrhage complicating a treatment by rt-PA in a patient presenting with a simultaneous staphylococcal septicemia with meningoencephalitis and an acute myocardial infarction with cardiogenic shock. The presence of microvascular lesions in the central nervous system seems to be important risk factor for intracranial haemorrhage and we recommend extreme caution in the use of thrombolytic treatment in septicemic patients with acute myocardial infarction, particularly when neurological symptoms are present.


Transient non-cardiogenic pulmonary edema following massive ingestion of ethylene glycol butyl ether. A case of acute poisoning with ethylene glycol butyl ether (EGBE) is reported in a chronic alcohol abuser. On admission the 53-year-old patient was comatose with metabolic acidosis, shock, and noncardiogenic pulmonary edema confirmed by haemodynamic study. Following supportive treatment and haemodialysis the outcome was favorable. The relationship between respiratory failure and EGBE is examined.


Who was Morton Prince?

Who was Morton Prince? Morton Prince, a Boston neurologist, founded the Journal of Abnormal Psychology in 1906 as an outlet especially for those who took a psychogenic view of neurotic disorders. Through experiments with hypnotism, he added appreciably to knowledge of subconscious and coconscious mental processes; The Dissociation of a Personality (Prince, 1905) still ranks as a classic. He early saw that studying normal people in the depth and detail with which one studied patients could make significant contributions to our whole understanding of human nature. Before his death he established and briefly directed the Harvard Psychological Clinic, devising the research environment out of which presently sprang major contributions to the study of personality.


Relation between self-reported affect and drug urges and cravings in continuing and withdrawing smokers. In 2 experiments we investigated the effects of withdrawal and stress on the affective correlates of urges to smoke. In both, habitual cigarette smokers were divided into continuing and withdrawing smoker groups. In the 1st study, 44 adults reported current mood, urge, and expectations over a 24-hr period. In the 2nd, a controlled laboratory study, urge, affect, and physiological data were obtained from continuing and withdrawing groups (N = 64) exposed to high- or low-stress conditions. Urges among withdrawing smokers were positively associated with negative affect and negatively associated with positive affect; continuing smokers reported urges that were directly associated with positive affect and unrelated to negative affect. Stress and withdrawal produced urge self-reports that were related to negative affect. Moreover, subjects who smoked after exposure to withdrawal and stress reported greater pleasure and arousal than did other subjects.


Delay of gratification in psychopathic and nonpsychopathic offenders. Delay of gratification is a prototypical measure of self-control that merits systematic investigation in psychopaths. White male prisoners were provided with repeated opportunities to select an immediate response with uncertain reward or a delayed response with a higher rate of reward under one of three incentive conditions. Psychopaths' performance depended on their level of trait anxiety and incentive condition: Whereas low-anxious psychopaths were relatively unwilling to delay when omission of expected rewards also incurred monetary punishments, they displayed relatively superior performance when the task involved rewards only. Findings complement those for passive avoidance learning in psychopaths and suggest that inhibitory self-control in low-anxious psychopaths is somewhat impaired under conditions involving a combination of monetary rewards and punishments.


Depressed patients with dysfunctional families: description and course of illness. Sixty-eight depressed patients were subdivided according to their family's level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels of neuroticism. A 12-month follow-up of these patients indicated that depressed patients with dysfunctional families had a significantly poorer course of illness, as manifested by higher levels of depression, lower levels of overall adjustment, and a lower proportion of recovered patients. Thus, impaired family functioning appears to be an important prognostic factor in major depression.


Sequential analysis of marital interactions involving alcoholic, depressed, and nondistressed men. This study was based on the investigators' earlier work on alcoholism and the family and involved a comprehensive assessment of sequential patterns associated with the marital interactions of alcoholic, depressed, and nondistressed men. A total of 131 couples were assessed in a laboratory-based discussion of personally relevant problems. Videotaped observations were conducted during drinking and nondrinking sessions and were subsequently coded according to the Marital Interaction Coding System. Depressed couples were most distinguishable in terms of unique antecedent-consequent patterns, whereas alcoholic and nondistressed control couples were similar to one another and different from depressed couples. Results are discussed in regard to the extant literature on interpersonal theories of depression and alcoholism and in regard to future research needs.


Expert judgments of hypnosis from subjective state reports. Suggestibility was assessed in 60 college students after a traditional hypnotic induction, an alert induction, progressive relaxation training, or instruction in goal-directed imagery. Responsiveness to suggestion did not differ between groups. Subjects also generated open-ended reports of their states of awareness and of their experience of 3 hypnotic suggestions. A sample of these reports from 24 moderately to highly suggestible subjects were evaluated by 18 experts in the field of hypnosis. Expert ratings of subjects' open-ended reports indicated that (a) traditional hypnotic inductions produce a state of consciousness that is indistinguishable from nonhypnotic relaxation training, (b) the subjective experience of hypnotic suggestions after imagination training is indistinguishable from that after hypnotic inductions, and (c) suggestibility is unrelated to state of consciousness as assessed by experts.


Transient positive and negative experiences accompanying stage hypnosis. Frequency of positive and negative experiences accompanying stage hypnosis was assessed in follow-up interviews with 22 participants of university-sponsored performances. Most subjects described their experience positively (relaxing, interesting, exciting, satisfying, illuminating, and pleasurable), but some described it negatively (confusing, silly, annoying, and frightening). Five subjects (22.7%) reported partial or complete amnesia; all were highly responsive to the stage hypnosis suggestions. One subject was completely unable to breach amnesia and felt annoyed and frightened. Five subjects (22.7%) believed the hypnotist had control over their behavior. Participants (n = 15) tested subsequently on the Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer & Hilgard, 1962) were mostly moderately to highly hypnotizable (M = 7.07), and the scores correlated significantly (r = .68) with the percentage of passed stage hypnosis suggestions.


Relationship between dietary restraint, energy intake, physical activity, and body weight: a prospective analysis. Dietary, activity, and body weight differences in high- and low-restrained eaters and the independent impact of dietary restraint on body weight change were evaluated in 287 adults (141 men, 146 women) followed over a 1-year period. Analyses of measures of energy intake, physical activity, and dietary restraint indicated that high-restrained eaters did not differ in physical activity compared to low-restrained eaters at baseline but were ingesting significantly fewer kcal/lb and a higher percentage of the diet from fat. Body mass was significantly greater in both high-restrained men and high-restrained women than in their low-restrained counterparts. Regression modeling procedures revealed that weight and body mass at baseline were related to weight gain in men. In contrast, weight gain in women was predicted by baseline weight and higher restraint scores. These results indicate that dietary restraint is associated with weight gain in women but not in men.


Comparison of bulimics, obese binge eaters, social phobics, and individuals with panic disorder on comorbidity across DSM-III-R anxiety disorders. Eighty-two women, presenting as normal-weight bulimics, obese binge eaters, social phobics, and individuals with panic disorder, were compared on anxiety, depression, and substance abuse. All were administered the Anxiety Disorder Interview Schedule-Revised and completed the Michigan Alcohol Screening Test, Drug Abuse Screening Test, and Self-Consciousness Scale. A striking proportion of eating disorder subjects were comorbid for one or more anxiety disorders, the most frequent diagnoses being generalized anxiety disorder and social phobia. The results suggest that the place of anxiety in bulimia nervosa goes beyond that discussed within the context of the anxiety reduction model. Conflicting comorbidity findings among this and prior investigations are noted, however, and discussed in terms of the issue of differential diagnosis between eating and anxiety disorders.


Attentional cues in chronic schizophrenia: abnormal disengagement of attention. Posner's (1980) reaction time (RT) paradigm was used to examine the engagement and disengagement operations of visual selective attention in patients with schizophrenia. In the 1st experiment, 14 medicated, chronic schizophrenic subjects (diagnosed by criteria of the Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association, 1987) and 15 age-matched normal control subjects made a speeded response to a target preceded by a valid, an invalid, or no cue. Control subjects showed the expected advantage and disadvantage in RT for valid and invalid cues, which suggests intact engagement and disengagement operations. For schizophrenic patients, valid cues also enhanced RT, but invalid cues did not slow RT. Similar results were found in the 2nd experiment. The failure of unpredictable, invalid cues to inhibit RT in chronic schizophrenia may be related to an abnormality in the disengagement operation of selective attention.


Influence of rapport on hypnotically induced pseudomemory. Three studies examined the influence of rapport on pseudomemory. Study 1 tested eight groups of 22 subjects in a 2 (level of susceptibility: high, low) x 2 (state instruction: hypnosis, waking) x 2 (rapport: present, reduced) design, rapport being inhibited by the hypnotist criticizing subjects' performance. Pseudomemory was tested by a second experimenter who also criticized subjects. Study 2 varied level of susceptibility and rapport for 88 hypnotically instructed subjects where criticism was offered only by the second experimenter. Study 3 analyzed effects among 44 highly susceptible hypnotic subjects where the second experimenter refrained from criticizing subjects. Data indicated a significant association between rapport with the hypnotist and pseudomemory in cued recall, strength of pseudomemory being appreciably lowered when negative hypnotist rapport was reinforced by the person testing pseudomemory.


Importance of shared genes and shared environments for symptoms of depression in older adults. The Center for Epidemiologic Studies-Depression scale was administered to 68 identical and 161 fraternal twin pairs reared apart and 114 identical and 138 fraternal pairs reared together to ascertain relative genetic and environmental contributions to individual differences in self-reported depressive symptoms. Intraclass correlations and model fitting indicated that genetic influences explained 16% of the variance in total depression scores and 19% for the Psychomotor Retardation and Somatic Complaints subscale, but heritability was minimal for the Depressed Mood and Well-Being subscales. Influence of family rearing context played a substantial role in explaining twin similarity, whereas unique life experiences accounted for the greatest proportion of variance. Significant age group differences were observed, with heritability greater in twins of 60 years of age or older than in twins under 60, especially for Psychomotor Retardation.


Monaural and binaural story recall by schizophrenic subjects. P. Green and other investigators have reported that schizophrenic Ss have poorer recall of stories presented to both ears than to the single best ear (binaural deficit) and poorer recall of stories presented to the left ear than to the right ear (monaural asymmetry) than do normal control Ss. These studies are plagued by potential methodological problems, including differences in overall accuracy, which artifactually affect the difference scores, and scoring methods that are vulnerable to systematic bias. In this study, scores of schizophrenic, bipolar, and normal control Ss on the Auditory Comprehension Test were compared. Scoring bias was avoided by the use of blind scoring and a revised scoring manual, and artifactual effects of accuracy were considered in interpreting the results. Contrary to previous findings, the groups did not differ on either monaural asymmetry or binaural deficit.


Dissociative experiences, psychopathology and adjustment, and child and adolescent maltreatment in female college students. Thirty-three female college students who scored in the upper 15% on the Dissociative Experiences Scale (DES) were compared with 33 female students who scored below the mean on the DES on measures of psychopathology (Symptom Checklist-90), college adjustment (Student Adaptation to College Questionnaire), and child and adolescent maltreatment. Compared with controls, high-DES subjects reported more psychopathology, poorer college adjustment, and a greater extent of psychological, physical, and sexual maltreatment. On the basis of the Dissociative Disorders Interview Schedule, 2 high-DES subjects but none of the control subjects met criteria for a dissociative disorder (i.e., multiple personality and psychogenic amnesia). Despite the sensitivity of the DES, 8 subjects who scored in the upper 2% of the population on the DES failed to meet criteria for a dissociative disorder.


Covariation detection in treated and untreated spider phobics. Twenty treated and 18 untreated spider phobics were exposed to a series of 72 slides. Three different categories of slides were used: phobia-relevant slides (spiders), alternative fear-relevant slides (weapons), and neutral slides (flowers). Slides were randomly paired with either a shock, a tone, or nothing at all. Despite the absence of a systematic correlation between slides and outcomes, untreated phobics strongly overestimated the covariation between spider slides and shock. Treated phobics did not show a covariation bias, suggesting that such bias can be modulated by behavioral treatment. In addition, untreated subjects were more confident about their contingency estimates than were treated subjects. The present results fit with earlier studies.


Discrepancy between self- and observer ratings of performance in social phobics. Twenty-eight subjects meeting Diagnostic and Statistical Manual of Mental Disorders (rev. 3rd ed.; American Psychiatric Association, 1987) criteria for social phobia and without a comorbid affective disorder and 33 nonclinical controls were asked to present a brief, impromptu speech to a small audience. Speakers themselves, as well as members of the audience, rated each speaker on a public speaking questionnaire that included both specific items (e.g., voice shook) and global items (e.g., appeared confident). For global items, no significant difference was indicated between the two groups on observers' ratings of public speaking performance. However, social phobics rated their own performance worse than did nonclinical controls, and there was a significantly greater discrepancy between self and other ratings for social phobics than controls. Fear of negative evaluation was the only significant predictor of the self-other discrepancy on global items.


Medication status of participants in psychopathology research: selective review of current reporting practices. The majority of Ss included in studies of psychopathology are typically receiving psychoactive medication. In view of concerns regarding the confounding effects of psychoactive medication, it appears that researchers should provide information regarding at least the drug status of the Ss studied. A review of the articles on adult psychopathology that appeared in the Journal of Abnormal Psychology during a 5-year period, however, revealed that nearly 50% of reports on Ss presumably receiving psychoactive medications failed to specify the medication status of those Ss. Few studies (15%) provided adequate information regarding the types and dosages of psychoactive drugs received by the Ss. It is argued that researchers should provide a full report of the psychoactive drugs received by research participants and, when participants are unmedicated, to indicate the reasons for drug-free status.


The Gulf War: reaction and action in institutions for the aged in Israel. In order to learn how geriatric centres were coping during the Gulf War (1991), questionnaires were distributed to 116 unit head nurses in 16 institutions in Israel. Additional information was obtained from the directors of nursing and national supervisors in a meeting 3 1/2 months after the cease-fire. Questions focused on organization of work, behaviour of staff, patients and their families, main problems, solutions and recommendations. Data showed a very high level of commitment by staff, flexibility, initiative and creativity in meeting the emotional, physical and safety needs of the aged. Stress level was highest in the 'Scud' areas and among the aged who are mentally alert. Families visited less but increased contact by telephone. Management was supportive with guidance, transport, child care facilities, etc. They also provided beds and food for spouses of the aged residents. Major problems related to safety measures (sealing rooms, moving patients during attacks), physical exhaustion and emotional stress of staff, and reorganization of care programmes. Recommendations included development of a master plan for non-conventional attacks, preparation of buildings with structural improvements, recruitment and training of volunteers, clarification of roles of staff and education for them.


The young pioneers: first baccalaureate nursing students in the People's Republic of China. Nursing in the People's Republic of China, like elsewhere, has undergone monumental changes during the 20th century. This paper focuses on one of those changes by examining the professional socialization process of the first class from the first baccalaureate in nursing (BSN) programme in China since 1952. These data from this first BSN class are part of a larger study on professional socialization in which data were collected from four of the recently established 11 BSN programmes in China. To put these data into a historical context, some highlights of Chinese nursing history are noted. These will help us to understand the present-day situation in this the world's most populous nation.


Diagnostic reasoning among second-year nursing students. This paper reports on a study investigating the relationship of nursing students' approaches to learning and processing of information, science content knowledge, ability in interpreting and organizing clinical data (nursing assessment), and logical reasoning ability with the accuracy and quality of the nursing diagnosis made in a simulated diagnostic reasoning task. One hundred and sixty-nine second-year pre-service nursing students participated in the study. Results of path analyses indicated a set of pathways from surface approach to low-quality nursing diagnosis that reflected less competent diagnostic reasoning; and a second set from deep/achieving approach through content knowledge and logical reasoning to higher-quality nursing diagnosis that reflected more competent diagnostic reasoning. The implications of these findings for nurse education are discussed.


The Case Management Model: an innovative approach to the delivery of patient care. Because of trends in the health care environment, hospitals are restructuring to innovative patient care delivery systems. The Case Management Model, with its emphasis on quality patient care and cost containment, is gaining widespread recognition throughout Canada and the United States. In this paper, the Case Management Model is described in relation to nursing practice.


Good nursing practice as perceived by clients: a starting point for the development of professional nursing. This paper presents clients' experiences of health care and nursing services in the Finnish primary health care and hospital system. These are described to find evaluation criteria for good nursing care and to point out challenges for development of the nursing profession.


Witnessing family violence: the children's experience. A phenomenological study was conducted in order to describe the experience of children as they accompany their mothers who are leaving abusive relationships. Thirteen children were interviewed. The children describe their experience as having three components: living with violence, living in transition and living with Mom. Themes within these components are identified, and implications for nursing practice are discussed.


The role of the nurse in high-quality patient care: a review of the literature. A review of the literature reveals a range of the nurse's subroles within the service of nursing. Competence in psychomotor, cognitive and affective skills is required for performance within each of these subroles to achieve the delivery of high-quality nursing care.


Cardiovascular disease prevention: knowledge and attitudes of graduate nursing students. Graduate nursing students were surveyed to determine the knowledge and attitudes of cardiovascular disease prevention. Questionnaires were self-administered to first-year graduate nursing students (n = 50) in a school of nursing prior to and following a physiology course with cardiovascular disease prevention content. In general, the results demonstrated that the respondents were least knowledgeable regarding the prevalence of smoking, the gender differences in high-density lipoprotein (HDL)-cholesterol levels, the influence of body weight on lipids and the recommended percentages of calories from dietary fat. A significant improvement in knowledge was noted after the course. Positive attitudes regarding the importance of cardiovascular disease prevention and the partnership between patients and clinicians necessary to manage risk were identified. These attitudes did not change significantly following the course. These results indicate that graduate education which emphasizes cardiovascular disease prevention increases knowledge. Coupled with positive attitudes and healthy personal lifestyle behaviours, knowledge of cardiovascular disease prevention may enhance the ability of nurses to integrate preventive standards into clinical practice and ultimately decrease the risk of cardiovascular disease.


Characteristics of effective nursing interventions in the management of challenging behaviour. A combination of semi-structured interviews and participant observation were used in order to investigate the interventions used by psychiatric nurses when faced with challenging behaviour. The study described 10 such categories of effective interventions: confirming messages, personal control, staff honesty, providing face-saving alternatives, setting limits, use of structure, facilitating expression, monitoring, timing and calming, and non-verbal skills. The report concludes by suggesting that these categories can be used to provide a structure for the analysis of critical incidents from a nursing perspective.


Participation of informal caregivers in the hospital care of elderly patients and their evaluations of the care given: pilot study in three different hospitals. This action research is an ongoing study which will last from 1991 to 1993. The main purpose of the study is to increase the participation of informal caregivers in the hospital care of elderly patients without decreasing the quality of care. The data reported here are from a pilot study. This study had three aims: (a) to test reliability and validity of the measure used, (b) to investigate the current participation of informal caregivers in the hospital care of elderly patients (aged over 75), and (c) to evaluate and compare the quality of care from both the patients' and the informal caregivers' point of view in three different hospitals. The measure of quality of care was developed on the basis of need theories, mainly those of Maslow and Alderfer. Patients and caregivers were also asked to rate the participation of the caregivers in the hospital care of elderly patients. Participation consisted of 18 activities of daily living. The pilot test with 18 elderly hospital patients and seven family members or significant others showed differences between the two groups in perception of care received. Statistically significant differences (P < 0.001) were found in the following categories: mainly social needs, psychic and spiritual needs and totals. The results supported earlier findings that elderly patients are satisfied with and do not criticize their care. The younger generation (i.e. their children) is more demanding and has precise perceptions about the care given. Relatives could be used more in planning, evaluation and even implementation of care; however, their current participation in patient hospital care is minimal.


Confidence as a factor in chronic illness care. Confidence is generally regarded as a positive quality which enhances personal coping and success. For those who are chronically ill and face a life of uncertainty, confidence becomes especially important. In a recent qualitative study examining chronically ill patients' perceptions of nursing care, confidence was found to be the grand essence which tied together all the informants' experiences with good nursing care. The informants entered the hospital with the expectation that the nurses would and could look after them. Observing and receiving good nursing care reinforced this confidence. In addition to this, the informants referred to confidence that was developed by the interest and value the nurses placed on the patient as an individual. Showing an interest in the patient as an individual gave the patient confidence in self-worth and in personal coping ability. These two sources of confidence combined to give the informants confidence in their futures. In the nursing literature the exploration of the concept of confidence is minimal. This paper discusses confidence as a factor in the care of the chronically ill using data from the study for illustration.


Skin problems beneath the breasts of in-patients: the knowledge, opinions and practice of nurses. A survey of knowledge and nursing practice in relation to sub-mammary skin problems was conducted among ward sisters and primary nurses in one district health authority. Respondents identified a number of characteristics as predisposing factors, with obesity and poor hygiene being mentioned most frequently. A very wide selection of nursing interventions was recommended, with nurses who mentioned pharmacologically active topical preparations reporting a significantly greater number of recurrences among patients than those who relied on less sophisticated regimes. Nurses expressed a variety of opinions about the effect that this condition has on patients, ranging from no effect at all to pain and discomfort. These findings highlight the lack of a coherent strategy for treating this problem and support the continuation of a research programme examining sub-mammary skin problems and the nursing response to them.


Abbreviated instrument to measure hope: development and psychometric evaluation. The purpose of this research was to develop and evaluate psychometrically an abbreviated instrument to assess hope in adults in clinical settings. The Herth Hope Index (HHI), a 12-item adapted version of the Herth Hope Scale (HHS), was tested with a convenience sample of 172 ill adults. Alpha coefficient was 0.97 with a 2-week test-retest reliability of 0.91. Criterion-related validity was established by correlating the HHI with the parent HHS (r = 0.92), the Existential Well-Being Scale (r = 0.84) and the Nowotny Hope Scale (r = 0.81). Divergent validity with the Hopelessness Scale was established (r = -0.73). Construct validity was supported through the factorial isolation of three factors: (a) temporality and future; (b) positive readiness and expectancy; (c) interconnectedness. These three factors accounted for 41% of the total variance in the measure.


Nurses' attitudes toward patients with AIDS and AIDS-related risk factors. Three variables were experimentally manipulated by simulation measurement using six vignettes in a completely randomized, partial hierarchical, experimental design: medical diagnosis (AIDS v. non-AIDS), sexual orientation (heterosexual v. homosexual) and intravenous drug-use history (IVDU v. non-IVDU). Following each vignette, the same Prejudicial Evaluation Scale (PES) and Social Interaction Scale (SIS) were used to measure nurses' attitudes toward patients and their willingness to interact with patients. Vignette questionnaires were randomly assigned to 360 acute-care nurses. Although sexual orientation was found not to influence PES and SIS scores, an AIDS medical diagnosis and a history of intravenous drug use were found to increase nurses' negative attitudes toward patients significantly and reduce their willingness to interact with patients. Study findings did not vary according to nurses' age, academic preparation or previous practice experience with patients with AIDS.


Patients' experience of technology at the bedside: intravenous infusion control devices. Within health care systems, rapid and pervasive technological development is occurring with significant ramifications for both nurses and patients. In order to determine the patient's perception of the experience of clinical equipment at the bedside, an exploratory study of 150 hospitalized patients was undertaken. For this study an item of electronic clinical 'hardware', the infusion control device, used increasingly by nurses, was selected as an exemplar of bedside nursing technology. A positive patient response to the equipment and its management was found. The majority of respondents understood the reasons for the equipment's use, were not disturbed greatly by the alarms, had few concerns about the equipment and would welcome further use. A majority felt that the care they received was more patient centred than technology centred. Several recommendations for nursing practice follow from these findings.


A view of the phenomenon of caring in nursing practice. Care is regularly used as a suffix to nursing, in such well-known phrases as 'total nursing care' and 'holistic nursing care'. While most care is provided by lay persons, there is little nursing research which focuses on the meaning of care, particularly in relation to the United Kingdom. This small-scale study investigates the meaning of care from the experience of six practising staff nurses in a British hospital and leads to a view of this phenomenon. Phenomenology was the chosen methodology, which facilitated the emergence of an essential structure of caring which incorporated four major categories described as 'being supportive', 'communicating', 'pressure' and 'caring ability'. It is suggested that, through gaining perspectives to enhance our understanding of the meaning of care, it will ultimately develop our understanding of nursing itself.


Health promotion in primary care: taking account of the patient's point of view. Some of the difficulties of putting health promotion into practice are considered. It is argued that, in a health promotion intervention aimed at lifestyle change, three questions need to be considered concerning the image, the meaning and the implementation of the programme.


'Scripts' for dying at home--displayed in nurses', patients' and relatives' talk. Perceptions and expectations reflecting what constitutes a 'good' death that seem to exist in Western societies are explored and compared with those presented by five symptom control team nurses at their home visits to 54 terminally ill cancer patients. These perceptions and expectations are termed 'scripts' for dying and are derived from the nurses', patients' and relatives' audio-recorded conversations over a 3-month period. The elements of the 'scripts' used were identified as: (a) control of physical symptoms, (b) acceptance of cancer and its prognosis, (c) preservation of hope and 'will to live', (d) mobility and 'fighting back', (e) enjoyment of life, (f) a peaceful death at home. How these components are determined from the conversations are presented and the responses of the patients to the nurses' 'scripts' are analysed. The dilemmas created by putting the 'scripts' into action for nurses, patients and relatives are discussed.


Defining risk from the perspective of nurses in clinical roles. Although the nursing literature suggests that nurses generally avoid risk, their willingness and ability to take risk are fundamental to their professional advancement, job satisfaction and patient advocacy. The definition of risk as it pertains in clinical practice, however, may not be synonymous with risk as defined in other fields. This study defines risk in nursing from the perspective of three registered nurses in clinical roles. Grounded theory methodology indicated that 11 risk categories comprised six core concepts. The latter formed the basis for the following: risk in clinical nursing practice is defined by uncomfortable and typically unavoidable role-related situations characterized by high unpredictability and negative or hostile overtones, dependency on others, exceedingly high performance expectations from self and others, unpleasant emotions, and health threats that extend beyond working hours. Findings of this study refute the notion that nurses avoid risks. Risk, ever present in the nurse's clinical practice and environment, requires strategies to minimize its negative impact.


Familial inflammatory bowel disease in a paediatric population. Familial aspects of inflammatory bowel disease (IBD) were assessed as part of an age and sex matched case control study of 91 children with IBD and 131 controls. The prevalence of IBD in family members of the children was studied, the affected side (mother's side or father's side) of the family was documented and the type of inflammatory bowel disease was traced among relatives. Data were collected from children in out-patient clinics at a large urban tertiary-care facility. All family data were verified with the affected relatives and/or their physicians. The children with IBD (the cases) had significantly (P = 0.0000385) more IBD in their families than the controls. Among all children with IBD in their family, IBD was found significantly (P = 0.0073) more often on the mother's side of the family than on the father's side. Patterns of disease varied within families. A mixture of ulcerative colitis and Crohn's disease was found within families. The implications of the findings are discussed. Directions for prevention, screening, early intervention and further study are given.


Giving and receiving: an empirically derived theory on health visiting practice. The aim of this study was to uncover how experienced health visitors conceptualize and evaluate their health visiting work. The grounded theory approach to data collection and analysis was used to develop a beginning midrange substantive theory about health visiting practice. The beginning theory provides an explanation and understanding of how health visitors work with clients in the community during their day-to-day visiting practice. Data were gathered from 45 experienced health visitors from 13 health authorities in the north-west of England by means of the conversational interview. The basic psychosocial problem uncovered in the data was health visitors' need to provide a service and clients' need to fulfil personal needs and goals. The unifying theme of giving and receiving integrated the major categories into the key analytic framework in this study. This key psychosocial process was the pattern of interaction between health visitors and clients, in which both parties control the interactions by regulating what they offer and accept from each other. Each party both selectively 'gives' and 'receives' in order to manage the health visitor-client encounters. What gets offered and how the offer is received and acted on is a complex process involving many factors related to the health visitor, the client, and the context in which the interaction takes place.


Anxiety, accuracy and reflection: the limits of professional development. Reflection is a key concept in the development and maintenance of nursing expertise in theory and practice, yet commentators have rarely examined difficulties associated with it. This paper describes the role of reflection in nursing and relates it to information-processing accounts of human memory. The issues raised by the role of memory in mediating reflection are discussed, in the context of an examination of the importance of accuracy in reflection-on-practice. It is argued that anxiety is of particular importance in mediating accurate reflection. Whilst it is concluded that reflection is inherently flawed, a range of tactics to enhance it are explored, with particular emphasis on anxiety reduction and reduction of the burden of the memory task.


Mothers and daughters: a powerful spell. An unanticipated finding of a small exploratory study of the health of never-married women in old age is discussed. Focused conversational interviews yielded evidence of the potent effect the mother-daughter relationship had in a group of women who had lived for all their adult lives in the parental home. Usually mothers had outlived fathers, and when they finally died daughters lost someone to whom they had been very close and at the same time had to cope with living alone for the first time in their lives. Three case histories, illustrating both strong positive and negative aspects of mother-daughter relationships are reported, and the psychological and sociological literature is explored. Parallels are also drawn with biographical and autobiographical literature about this type of relationship, including that of Florence Nightingale and her mother. Finally, some implications for nurses are considered and the special support needs of these women at bereavement and in old age are highlighted.


Of sex and status: a study of the effects of gender and occupation on nurses' evaluations of nursing research. Despite wide recognition that nursing must increase its research base, there still appears not only to be a shortfall in published nursing research but also a marked failure to implement research findings into clinical practice. One possible explanation for these problems is that nursing research may not be valued by peer professionals. To investigate this possibility, a study was designed to test the hypothesis that nurses would underrate the quality of papers they believed to have been produced by a nurse as opposed to a doctor, even when the status of the authors was randomly assigned to the papers. Thirty-one nurses were asked to rate two comparable papers on a number of criteria. Half the sample was told that the first paper had been written by a nurse and the second by a doctor; for the remainder of the sample, the order of authorship was reversed. A series of related t-tests was performed on the sample's evaluations in order to ascertain whether the status of the author affected perceptions of quality. No difference was found in the sample's judgement of overall quality, clarity of expression, expertise on the topic in question or contribution to current knowledge. However, significant differences were found in attributed grasp of research design and statistical analysis, with the nurse being judged as inferior on both (t = 1.71, d.f. = 30, P < 0.05; t = 1.72, d.f. = 30, P < 0.05 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)


Nursing models in a special hospital: cybernetics, hyperreality and beyond. Two emerging themes that resulted from research carried out in a special hospital on the use of nursing models are identified. The first theme to emerge was the tendency of the subjects to perceive the models as concrete entities thus undergoing a process of reification. The second theme identified was the adherence to the models outside the contextual nature of the setting which limited their effectiveness. A theoretical framework in which to locate the results of the study is explored using cybernetic learning theory and the notion of hyperreality, using the works of Jean Baudrillard. A method for innovation and changing practice in the special hospital setting is suggested.


Method slurring: the grounded theory/phenomenology example. Increasingly, qualitative research methods are being embraced by nurse researchers because these approaches allow exploration of human experience. Failure to explicate qualitative methodologies is resulting in a body of nursing research that is either mislabelled or is classified broadly as qualitative and subject to charges that qualitative research lacks rigour. In this paper, the authors discuss the importance of specificity in methodology and distinguish between phenomenology and grounded theory, two frequently misused terms in the description of qualitative methodology.


Nursing science in The Netherlands: the Utrecht contribution. The two goals of a 5-year nursing science project at the State University of Utrecht were the establishment of graduate nursing science studies and a nursing research programme. The project formally started on 1 January 1987 and is now nearing completion. This paper builds on a paper previously published in the Journal of Advanced Nursing. It first describes the history of nursing science in The Netherlands and sets out to demonstrate how the Utrecht goals were achieved.


Staff turnover among hospital nurses.

Staff turnover among hospital nurses. Nursing staff turnover remains a financial concern to public as well as private institutions, and it has an impact on staff morale and working practices. Evidence suggests that staff turnover could also have a detrimental effect on patient care. Numerous studies have examined the reasons why staff leave their jobs, but these have often produced conflicting findings and have frequently relied upon bivariate correlation or multiple regression techniques. The availability of analytical techniques such as structural modelling provides an opportunity to examine several aspects of turnover behaviour simultaneously, and overcome some of the methodological difficulties encountered by prior research. This study involved 221 female nurses working full-time in hospitals to examine aspects of the nursing turnover model. Using modelling techniques, this current study found job satisfaction and participation at work to be important variables in the turnover process. This is in keeping with other models of nursing turnover.


The emerging role of the nurse teacher in Project 2000 programmes in England: a literature review. This paper explores the literature on the role of the nurse teacher in the United Kingdom, in order to support a research study on the role of the nurse teacher as it emerges in Project 2000 programmes in England. Explicit within the reform of nurse education is a change in the role of the teacher. It is being influenced, first, by the creation of colleges of nursing and midwifery and their links to higher education, secondly, by the content and academic level of the course and, thirdly, by the supernumerary status of the student. Studies carried out on the activities nurse teachers undertake highlight the complex and multifaceted nature of the role. Excessive paper work, meetings and lack of autonomy are given as dissatisfying aspects of their work leaving only a small proportion of their time for classroom and clinical teaching. The literature suggests that the nurse teacher is required in Project 2000 to be a nurse, a teacher, a graduate in a specialist subject and clinically and academically credible. The study, which is mentioned briefly in this paper, will critically analyse the key components of the role of the nurse teacher as it emerges in the Project 2000 courses in England. The methodology and findings will be discussed in a later paper.


The social networks of bipolar affective disorder patients. The social interaction parameters of a carefully delineated group of bipolar patients were compared to those of a random New Zealand community sample. The bipolar subjects had significantly lower scores for perceived availability and adequacy of both intimate and diffuse social relationships. Their mean scores did not differ from those of the subgroup in the random community survey who were classified as showing psychiatric morbidity, most of whom were depressed. Social interaction scores were negatively correlated with the bipolar patients' age and duration of illness. Those bipolar subjects with a predominance of manic episodes had lower mean values for their social interaction indices than those with more depressions. The results may suggest that the longer the illness continues, the greater is the impoverishment of the sufferer's social interaction patterns. Overall, manic episodes appeared to have a more deleterious effect on social relationships than depressive episodes.


High-dose fluoxetine in the treatment of depressed patients not responsive to a standard dose of fluoxetine. In a four-week, open label study of major depression, 15 patients who had failed to respond to a trial of fluoxetine 20 mg/day of 8-12 weeks duration were then treated with fluoxetine 40 mg/day for one week and then, if tolerated, with either 60 or 80 mg/day. The mean HAM-D-17 and CGIS scores of these 15 patients decreased significantly at the end of 4 weeks on a higher dosage of fluoxetine (60 or 80 mg/day) with respect to the beginning of the four-week study. No significant side-effects were noted.


On the way to scholarship: from master's to doctorate. Progress in the discipline of nursing is predicated on the development of a community of scholars who have passion for substance. Nurse educators are challenged to develop programs and environments that stimulate and nurture scholarship. However, doctoral education that enhances scholarship encompasses more than coursework. Strategies for the development of scholarly doctoral education are discussed in this article.


Differentiated practice: the evolution of professional nursing. Differentiated practice identifies and uses three distinct nursing roles to create a comprehensive nursing care delivery system that meets client needs across the health care continuum. Clearly defined associate degree in nursing, bachelor's of science in nursing, and master's science in nursing competencies present career opportunities for professional nurses at the bedside providing, integrating, or managing client care as well as options in management, education, and regulation. An evolutionary paradigm shift required of all nurses is the awareness that each nurse is not the whole of nursing, but rather each nurse contributes to the whole of nursing. A nursing community comprised of differentiated roles that are mutually valued and well integrated will position nursing as a powerful force in meeting the diversity and complexity of health care needs in contemporary society.


A psychosocial profile of women with premenstrual dysphoria. Sixty women from the community were used in this study to identify a profile of women who experience premenstrual dysphoria. Women with prospectively confirmed premenstrual dysphoria (PMD +; N = 24) were compared to women with prospectively unconfirmed premenstrual dysphoria (PMD -; N = 15) and controls (PMD control; N = 21). Over one menstrual cycle daily records of physical, emotional and behavioural symptoms were completed on the Daily Ratings Form. Other self report measures obtained were the Premenstrual Assessment Form, Rotter's Internal External Locus of Control, the Locke-Wallace Marital Adjustment Scale, and the State-Trait Anxiety Inventory. A psychiatric history was obtained during an interview. Analyses showed that premenstrually, PMD + and PMD - groups could be significantly differentiated from controls on reports of premenstrual dysphoric changes and levels of state and trait anxiety. Postmenstrually, they could be significantly differentiated from controls firstly, by history of affective disorder and locus of control and secondly, by premenstrual dysphoric changes. There were no significant differences between the PMD+ and PMD- women on most of the self report measures either at pre or post menstrual assessments. The present findings suggest that the characteristic profile of PMD+ and PMD- women is one of being symptomatic premenstrually in relation to dysphoric changes and levels of state and trait anxiety. Postmenstrually these symptoms appear to be superimposed on a background of a history of affective disorder and an external locus of control orientation.


Folates and post partum depression.

Folates and post partum depression. Hypofolatemia can cause psychiatric disturbances of a depressive nature. Pregnancy and delivery are often associated with hypofolatemia. This study was conducted to determine if hypofolatemia at day 3 post partum is a risk factor for baby blues or post partum depression. To study this hypothesis, 131 post partum women were followed prospectively for the 3 months immediately following delivery. 19% were found to have 'baby blues', as defined by a score greater than 20 on Pitt's scale (Pitt, 1968, J. Psychiatry 114, 1325-1335) and 12% had post partum depression as defined by a score greater than 7 on QD2A scale (Pichot et al., 1984, Rev. Psycholog. App. 34, 229-250, 323-340), within the three months post partum. No relationship was observed between the serum or erythrocyte folate levels on the third day following delivery and the maternal post partum depression scores. A statistically significant correlation between post partum depression and previous psychiatric disturbance was, however, observed.


Success-failure on the National Council Licensure Examination for Registered Nurses by nurse candidates from an accelerated baccalaureate nursing program. Nine years of data from first-time nurse candidates taking the National Council Licensure Examination for Registered Nurses (NCLEX-RN) were examined to identify predictors of successful performance and determine probabilities of success. Using logistic regression, four statistical models at strategic time periods during an accelerated baccalaureate nursing program were tested to see when intervention might be initiated to influence student performance on the NCLEX-RN. By the end of the first semester the model could predict failure for 94 per cent of those who failed, but it was less consequential in correctly predicting success of those who passed. Significant variables placing nurse candidates at risk included their first-semester grade point average, sex, and whether they were foreign educated. By the end of the second semester, with each full letter grade increase in cumulative grade point average, nurse candidates had a 46 times better chance of passing the NCLEX-RN; American-educated nurse candidates had a 4.5 times better chance of passing than their foreign-educated counterparts. At the end of the final semester, with each full letter grade increase on the final cumulative grade point average, nurse candidates had a 97 times greater likelihood of performing successfully on the NCLEX-RN.


Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. 68 patients with affective disorders, and receiving lithium prophylaxis in a specialized lithium clinic were followed up for 8 years on average. Patients were selected for this study according to 2 criteria: They had been given lithium for at least 12 months, and they had attempted suicide at least once before onset of lithium prophylaxis. Outcome was analysed in terms of suicidal and parasuicidal behaviour. 55 patients took their lithium regularly, 13 discontinued or dropped the medication. One third of those patients having discontinued the medication died from suicide. Only one suicide occurred in patients with regular lithium intake and proven compliance during the last check before death. An impressive drop of parasuicides was observed in responders as well as in apparent non-responders. In total, 11 of 13 patients showed suicidal or parasuicidal behaviour 2 weeks-44 months after lithium discontinuation, which in about half of these cases took place on advice or with consent of the treating psychiatrist. It is concluded that lithium may have specific anti-suicidal properties, possibly related to its anti-aggressive effect, and that patients apparently not responding satisfactorily in terms of reduced number of episodes may still be protected against suicide or parasuicide.


Is the tyramine test for depressive illness useful in elderly patients? There were no significant differences in tyramine sulphate excretion following tyramine ingestion between elderly depressed, demented or control patient groups, in contrast with younger subjects where this test is a trait marker for unipolar endogenous depression. There are inherent problems in urine collection studies in the elderly and the results may have been influenced by the medication that elderly patients have to take for other disorders. This study suggests that the tyramine test is unlikely to be of clinical usefulness in the over 65 age group.


Are preceptors for orientation of new nurses effective? The intent of this secondary analysis of a large data set was to provide empirical data on the benefits of preceptorship programs for orientation. Do nurses with preceptors have more satisfaction, social integration, and professionalism; less turnover; and better performance? The subjects were newly employed nurses, 177 were assigned to preceptors, and 98 did not have preceptors. The subjects completed questionnaires at three time periods: during the first few weeks on the job and at 6 and 12 months after employment. Data were analyzed by student's t test and chi square analysis. On average, nurses with preceptors and less education and experience and were more involved with family. They worked on units with sicker patients. Nurses with preceptors were more satisfied with social and psychological rewards initially and had more of a feeling of self-regulation. Previously employed nurses with preceptors reported more social integration at 6 and 12 months. The study provides beginning evidence that preceptors are beneficial for nurses who have limited education and experience.


Natural law as a unifying ethic.

Natural law as a unifying ethic. Natural law asserts that there is an objective moral order that human intelligence can understand and that societies are bound in conscience to follow. In 1772, George Mason appealed to natural law in denouncing a slavery statute in Virginia. This same ethic was called on to convict Nazi war criminals of crimes against humanity in 1948. In the last decade, natural law has enjoyed a resurgence in the medical biomedical ethics literature. It has appeared less frequently in the nursing literature and has been summarily dismissed when it has appeared. Only one nurse ethicist used natural law in discussing ethical issues (organ transplantation). Although further development of this philosophy is required, this ethic shows great promise as a guide to decision making in nursing.


Clinical correlates of response to DST. The Dexamethasone Suppression test in depression: a World Health Organisation collaborative study. From 9 centres 293 patients took part in the WHO-collaborative study on Dexamethasone-Suppression-Test (DST) in depression to examine the relationship of psychopathological and psychiatric history information to cortisol-levels and suppression/non-suppression status. Differences between the centres were large and significant on nearly all of the measures. The predictor analyses generally suffered from numerically weak correlations with many variables correlating to sex and age. Therefore analyses of the data were adjusted for centre-, sex-, and age-influences. The best predicting features of cortisol were 'fitful, restless sleep', 'change of bodyweight' and 'affective disorders in blood relatives'. The last 2 items together with 'hypersomnia' and 'ideas of insufficiency' were the best predictors of suppression/nonsuppression status. However, statistical evidence did not seem to be strong enough to describe a typical symptom profile of a depressive cortisol suppressor or nonsuppressor.


A statewide study of academic variables affecting performance of baccalaureate nursing graduates on licensure examination. The purpose of this study was to validate, using a statewide sample, findings from two previous smaller studies investigating the relationships between admission selection variables and subsequent achievement in baccalaureate nursing programs and performance on the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Subjects for this study were 1,069 graduates of nine Iowa basic baccalaureate nursing programs. The analyses included three major components. The first addressed the relationship between admission selection variables and subsequent achievement in the nursing programs and performance on a standardized nursing achievement test (AssessTest) and the NCLEX-RN. The second component investigated the extent to which achievement in nursing courses predicted performance on the NCLEX-RN. In the third component a path analysis was used to formulate a causal model describing the relationships among the variables in the study. The results of the study suggest that students' prenursing grade point average and American College Testing scores predict their performance on the NCLEX-RN. Knowledge of performance predictors can both facilitate admission selection and the use of educational resources to develop nursing competence and promote success in obtaining licensure to practice.


Puerperal psychoses: a clinical case study with follow-up. Thirty cases of post-partum psychotic disorders occurred between 1973 and 1987 and hospitalized at the Psychiatric Ward of Florence University were studied and followed up. A structured diagnostic interview was used, which explored DSM Ill-R diagnosis both for mood disorders and for psychotic features. The psychotic symptoms had started within 8 weeks of parturition in all cases. Only 36.7% of the patients showed no subsequent pathology after the puerperal symptoms. The diagnoses, both at the index episode and at the follow-up, revealed a great predominance of mood disorders and the absence of schizophrenia. The follow-up survey showed a greater proportion of bipolar disorders than it appeared at the puerperal onset of the disease. A high frequency of puerperal psychotic relapses has also occurred after subsequent deliveries during the follow-up period.


Single photon emission tomography with 99mTc-exametazime in major depression and the pattern of brain activity underlying the psychotic/neurotic continuum. Forty patients with a major depressive episode were investigated at rest using Single Photon Emission Tomography (SPET or SPECT) with 99mTc-exametazime, an intravenous ligand taken into brain in proportion to regional cerebral blood flow, thereby providing an estimate of regional metabolism. All patients were unipolar and were rated on the Newcastle scale and with the 17-item Hamilton scale. They also completed a range of neuropsychological tests. They were compared with 20 control subjects matched for age, gender, premorbid intelligence and education. The uptake of 99mTc-exametazime was expressed for a range of anatomically defined regions of interest relative to calcarine/occipital cortex. The depressed group showed reduced uptake in the majority of cortical and sub-cortical regions examined, most significantly in temporal, inferior frontal and parietal areas. Unexpectedly, there was a strong positive association between uptake and scores on the Newcastle scale, especially in cingulate areas and frontal cortex. After removing the variance attributable to the Newcastle ratings, however, there emerged the expected negative association between Hamilton scores and anterior tracer uptake. The associations between neuropsychological impairment and regional brain uptake of tracer in part reflected the pattern seen with the Newcastle scale: for example, impairment of memory function correlated with higher uptake into posterior cingulate areas. We propose that depressive illness may be characterised by two processes. One leads to an overall reduction in anterior neocortical function, perhaps related to symptom severity. The other mechanism is manifest as relatively increased function, most notably within cingulate and frontal areas of the cerebral cortex in association with psychotic symptoms. The findings offer new understanding of the brain states underlying depressive illness and a potential focus to subsequent neuropharmacological analysis.


Risk for affective disorder and alcohol and other drug abuse in the relatives of affectively ill adoptees. We investigated the risk for substance abuse in the biological relatives of adoptees with affective illness, controlling for potential confounds, and additionally assessed risk by probands' and relatives' gender. Our sample consisted of 67 index adoptees with affective illness, matched control adoptees, and their biological and adoptive relatives. Both affective illness and substance abuse were more common in the biological relatives of affectively ill adoptees than in controls' relatives. Affective illness was more common than substance abuse among female index biological relatives, with the opposite pattern observed among male relatives.


Depression and learning disabilities in children. Occurrence of learning disabilities was determined in 30 inpatient children aged 6-12 with major depressive disorder (MDD). Learning disabilities (LD) occurred seven times more often compared to community base rates (33% v 4.7%). While rates of comorbid diagnoses, severity of depression, and children's and parents' reports (DICA-C, DICA-P) did not differ between groups, teachers' reports (TRS, TRF) indicated increased classroom problems and poorer adaptive functioning in MDD/LD subjects (P < 0.0001).


Diagnostic specificity of the dependent and self-critical personality dimensions in major depression. Validational studies of self-critical and dependent personality dimensions as vulnerability factors for depression have been tested primarily with depressed samples, employing research designs devised to address state vs. trait and trait-situational congruity issues. In this study we examined the diagnostic specificity to depression of these two personality dimensions, comparing Self-Criticism and Dependency scores as measured by the Depressive Experiences Questionnaire (DEQ) in two samples of outpatients: (1) panic disorder with agoraphobia; and (2) non-psychotic, unipolar major depression. As hypothesized, the two groups differed on Self-Criticism, with the depressed group scoring higher, but no differences were found for Dependency. These findings were similar even when depressed mood was partialed out. These results complement a growing body of research associating Self-Criticism, as specifically measured by the DEQ, with depression.


Imipramine and weight gain during the long-term treatment of recurrent depression. The recently completed long-term maintenance trial of full-dose imipramine for recurrent unipolar disorder provided an opportunity to examine the extent to which such doses (200-300 mg daily) are associated with persistent and adverse side effects, particularly weight change. In 115 patients we monitored weight change during the three-year maintenance treatment phase to the point of trial completion, recurrence or termination. No differences were noted between individuals receiving active medication (average gain of 5.8 lbs. during an average treatment period of 725 days) versus those randomized to the 'no-drug' cells (average gain of 2.8 lbs. during an average treatment period of 422 days). Numerous other factors such as body mass index, previous weight gain and gender did not play a differential role in establishing why some individuals gained weight during long-term treatment of depression regardless of specific treatment.


Diagnostic accuracy in adolescents of several depression rating scales extracted from a general purpose behavior checklist. Receiver Operating Characteristics (ROC) analysis of six depression scales extracted from the Child Behavior Checklist (CBCL) and Youth Self-report (YSR) in a clinically referred sample of adolescents (N = 667) showed that their performance in discriminating between depressed and not depressed patients was comparable to other specifically designed depression rating scales (area under the ROC curves between 0.75 and 0.82). Performance was better for boys than for girls. These results suggest that specific depression self-report rating scales may be unnecessary in adolescents if CBCL or YSR data are available, and that self-reports are not more accurate than parent-reports in the identification of depression in this age group.


The effect of cholesterol screening on college students. This study was designed to determine the effect of cholesterol screening on college students' knowledge retention and self-reported behavior change. Students (N = 180, age M = 21.4 +/- 4.1 years) enrolled in a self-paced personal fitness course participated in a screening accompanied by two educational handouts and oral information from the technician. Six weeks later, subjects completed a questionnaire that revealed that 76% remembered their exact cholesterol level. Only 36%, however, remembered specifically why their cholesterol level was important, 22% remembered the three National Cholesterol Education Program (NCEP) categories and values, and only 36% could fully identify their correct NCEP follow-up. Chi-square analyses revealed no significant differences between expected and observed frequencies for gender or cholesterol category by cognitive information retention. Analyses did reveal more self-reported dietary and exercise changes for those testing above 200 mg/dL than for those below 200. Although college students may remember their cholesterol level after 6 weeks and may take some action if they are above the desirable level, the knowledge base established in a typical screening situation appears inadequate. Educational efforts accompanying most screenings should be improved, and some attention should be given to young adults who test at the high end of the desirable category.


Medical students' exposure to formaldehyde in a gross anatomy dissection laboratory. The authors studied 150 first-year medical students exposed to formaldehyde during the dissection of cadavers in a gross anatomy laboratory. As a reference group, they used 189 third- and fourth-year medical students matched for sex, ethnic group, and age. Environmental and personal samples were collected to determine the exposure to formaldehyde among the first-year students. The mean concentration of formaldehyde in parts per million (ppm) in the area was 0.50 ppm (range = 0.40-0.60 ppm) and the personal sample was 0.74 ppm (range = 0.41-1.20 ppm). No significant differences were noted in the pre- and post-exposure mean FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity) among the 22 randomly selected exposed male and female subjects. Significant differences, however, were observed in the exposed group for symptoms of decreased ability to smell, eye irritation, throat irritation, and dry mouth in comparison with the reference group. These symptoms were also significantly related to the time and place of occurrence. Medical schools should take more concrete measures to reduce students' exposure to formaldehyde. Meanwhile, although it is not now the practice in most medical schools, students should have ready access to goggles and respirators when working in dissection laboratories.


The history of sections in the American College Health Association. The founders of the American College Health Association (ACHA) recognized the importance of regional groups (affiliates) and worked actively to foster their formation and continued existence. In 1932, D. F. Smiley, MD, described the concept of establishing ACHA regions and suggested combining institutional membership in both the national and regional organizations. Significant affiliate representation in the association's governance structure finally became a reality in 1987, when regional representatives became permanent members of the board of directors. Standing committees of the association were transformed into the present ACHA sections in 1957, and a new category for individual membership established for college health professionals interested in participating in educational activities of the new sections. In many ways, the changes in the association's governance that occurred in 1987 are reminiscent of the original structure of the 1920-1970 era, when the organization was much smaller and essentially an association of college health center directors.


The impact of influenza vaccination on respiratory illness at a boarding school. We studied the impact of influenza vaccine during an outbreak of influenza at a 989-student boarding school in January to March, 1989. By February 6, 120 (17%) of 690 students completing survey questionnaires had been ill with fever and respiratory symptoms. Eighty-seven students had received influenza vaccine in the previous 18 months; these students had an attack rate half that of the unvaccinated students (9% v 19%; vaccine efficacy = 50%, confidence interval = 0%-70%). We estimate that, if the entire student body had been vaccinated, influenza-like illness could have been prevented in 162 students (16% of the school), and that preventing this illness could have avoided at least 482 student-days of missed classes, or approximately one student-day for each 1.8 additional doses of vaccine given. This study suggests that, when feasible, a broad influenza immunization policy for healthy students at residential schools should substantially decrease the disruption of school activities caused by influenza.


Connotative meanings assigned to contraceptive options. Healthy People 2000: National Health Promotion and Disease Prevention Objectives states that the reduction of unintended pregnancies is one of the primary health objectives for college-aged people. In addition, the reduction in rates of sexually transmitted diseases, with special emphasis on reducing the incidence of HIV infection, is an important objective for this population. One way of addressing these objectives is through promoting use of effective contraception methods. Attitudes toward a particular contraceptive option may play an important role in acceptance of, and predisposition toward, using a given method. The authors used semantic differential scaling to study the connotative meanings college students assigned to 13 contraceptive methods. They asked 751 students (mean age = 19.6 years) to rate each method of contraception, using 7-point scales composed of 15 bipolar adjective pairs. Scale internal consistency was estimated using Cronbach's alpha, and ranges were from .68 for douching to .92 for oral contraceptives. Respondents' rank-ordered approval ratings of the 13 options were as follows: oral contraceptives; abstinence; the condom; the diaphragm; the contraceptive sponge; female sterilization; rhythm; male sterilization; douching, the IUD, and vaginal suppositories (tied); spermicidal foam; and withdrawal. These results indicated general approval for methods that are effective in preventing conception. Semantic interpretation of selected contraceptive options differed by gender and race, but not by age. Implications for contraception education and future research issues are discussed.


Gender-specific changes in students' sexual behaviors and attitudes at a southeastern university between 1973 and 1988. This study investigated the gender-specific, self-reported sexual behaviors and attitudes of never-married college students attending a southeastern university in 1973 and 1988. Data were collected by means of a mailed questionnaire that remained essentially unchanged for both years. The authors found that both men and women reported an increase in heterosexual relationships that included sexual intercourse and a decrease in nonsexual relationships with the other gender. The majority of the students perceived themselves as adequately informed about sexuality and satisfied with their relationships, although the proportion of men who reported being satisfied with their relationships declined over the 15 years. The students indicated that sexuality education should focus primarily on information about AIDS and on preparation for marriage.


Mechanism of benefit of combination thrombolytic therapy for acute myocardial infarction: a quantitative angiographic and hematologic study. The goal of this study was to lend insight into the mechanisms responsible for the beneficial effects of combination thrombolytic therapy. Combination thrombolytic therapy for acute myocardial infarction has been associated with less reocclusion and fewer in-hospital clinical events than has monotherapy. Infarct-related quantitative coronary dimensions and hemostatic protein levels were evaluated in 287 patients with acute myocardial infarction during the early (90-min) and convalescent (7-day) phases after administration of recombinant tissue-type plasminogen activator (rt-PA), urokinase or combination rt-PA and urokinase. Minimal lumen diameter was similar in the 90-min and 7-day phases after treatment with rt-PA, urokinase and combination rt-PA and urokinase (0.72 +/- 0.45 mm, 0.62 +/- 0.53 mm and 0.75 +/- 0.58 mm, respectively, at 90 min, p = 0.16; and 1.05 +/- 0.56 mm, 1.12 +/- 0.72 mm and 0.94 +/- 0.54 mm, respectively, at 7 days, p = 0.22). In-hospital clinical event and reocclusion rates were less frequent in patients receiving combination therapy than in those receiving monotherapy (25% vs. 38% and 32% for rt-PA and urokinase, respectively, p = 0.084; and 3% vs. 13% and 9% for rt-PA and urokinase, respectively, p = 0.03), but these events were unrelated to early or late coronary dimensions. Patients receiving combination therapy or urokinase monotherapy had significantly higher peak fibrin degradation products (1,307 +/- 860 and 1,285 +/- 898 micrograms/ml vs. 435 +/- 717 micrograms/ml, respectively, p < 0.0001) and lower nadir fibrinogen levels (0.85 +/- 1.00 and 0.75 +/- 0.53 g/liter vs. 1.90 +/- 0.86 g/liter, respectively, p < 0.0001) than did those receiving rt-PA monotherapy. Peak fibrinogen degradation products indirectly correlated (p = 0.004) and baseline (p = 0.026) and nadir (p = 0.089) fibrinogen levels directly correlated with reocclusion. Lower in-hospital clinical event and reocclusion rates observed with combination thrombolytic therapy may relate to systemic hematologic factors rather than to the residual lumen obstruction after thrombolysis.


Pathophysiology and prognostic significance of Holter-detected ST segment depression after myocardial infarction. The Tissue Plasminogen Activator: Toronto (TPAT) Study Group. We performed Holter monitoring on days 4 and 7 after acute myocardial infarction in 109 patients to assess whether ST segment shift would identify those with more severe coronary artery disease, left ventricular dysfunction and unfavorable prognosis. Silent myocardial ischemia is a frequent and prognostically significant event after acute myocardial infarction. However, the specific pathophysiologic mechanisms and the impact of thrombolytic therapy are uncertain. In addition to Holter monitoring, patients underwent exercise testing, radionuclide angiography on days 1 and 9 and quantitative coronary angiography on day 9. Thirty-five patients (32%) had ST segment depression and had similar recombinant tissue-type plasminogen activator (rt-PA) treatment assignment and a reduced cross-sectional area of the infarct-related artery (0.59 +/- 0.57 vs. 1.04 +/- 1.26 mm2, p < 0.05). Global left ventricular function improved from day 1 to day 9 in patients without (4% +/- 11%, p < 0.001) but not in those with (0% +/- 7%) ST segment depression. In-hospital event rates were similar; however, follow-up 18 +/- 11 months after hospital discharge revealed a greater frequency of death and recurrent myocardial infarction in patients with compared with those without ST segment depression (27% vs. 6%, p = 0.03). After acute myocardial infarction, approximately one third of patients have ST segment depression on Holter monitoring, independent of the use of thrombolytic therapy. The unfavorable prognosis observed in these patients may be related to greater lumen obstruction in the infarct-related artery and lack of improvement in left ventricular function.


Ischemic cardiomyopathy: endomyocardial biopsy and ventriculographic evaluation of patients with congestive heart failure, dilated cardiomyopathy and coronary artery disease. This study was designed to define clinical and pathophysiologic similarities and differences between patients with ischemic and idiopathic dilated cardiomyopathy. Significant coronary artery disease in patients with new onset congestive heart failure due to dilated cardiomyopathy has important prognostic and therapeutic implications. Clinical, histologic, ventriculographic and hemodynamic features of patients with dilated cardiomyopathy who underwent coronary angiography were reviewed. Patients with ischemic cardiomyopathy (n = 21) compared with those with idiopathic cardiomyopathy (n = 40) had similar presenting symptoms, durations of illness, and coronary risk factor profiles, with the exception of a greater prevalence of cigarette smoking (71% vs. 39%, p = 0.028) and male gender (100% vs. 70%, p = 0.014). Endomyocardial biopsy specimens from patients with ischemic cardiomyopathy demonstrated a greater prevalence of replacement fibrosis (48% vs. 8%, p = 0.001) and a lesser degree of histologically assessed myocyte hypertrophy (mean grade 0.5 +/- 0.7 vs. 1.3 +/- 1.3, p = 0.015). Although ventriculographically determined regional dyskinesia was present in both groups, there was a higher prevalence of two or more adjacent segments in the ischemic cardiomyopathy group (50% vs. 10%, p = 0.03). This ischemic group had hemodynamic variables associated with a worse prognosis: higher pulmonary artery wedge pressure (23 +/- 10 vs. 15 +/- 9 mm Hg, p = 0.006) and lower cardiac index (2.0 +/- 0.5 vs. 2.3 +/- 0.5 liters/min per m2, p = 0.044). Also, in this group, patients had a mean of 2.6 +/- 0.7 diseased vessels; 15 (71%) of 21 patients had triple-vessel disease and 18 (86%) of 21 had at least one occluded or suboccluded artery. 1) Patients with ischemic and idiopathic cardiomyopathy may be clinically indistinguishable unless coronary angiography is performed. 2) A greater prevalence of replacement fibrosis and a lesser degree of myocardial hypertrophy in patients with ischemic cardiomyopathy may account for the greater extent of hemodynamic decompensation observed at presentation.