Faculty Bibliography

The type of dietary fat strongly affects the incidence of gallstones in the hamster model of cholesterol cholelithiasis. The present study was designed to determine whether dietary fats could affect gallstone formation by altering the microstructure (vesicular/micellar ratio) of cholesterol in bile. Golden Syrian hamsters from Sasco (Omaha, NE) or Charles River (Wilmington, MA) were fed nutritionally adequate semipurified diets to which were added: (i) 4.0% butterfat without added cholesterol; (ii) 1.2% palmitic acid plus 0.3% cholesterol; or (iii) 4.0% safflower oil plus 0.3% cholesterol. Gallstone incidence and the percentage of cholesterol in vesicles and micelles were determined after two- or six-week feeding periods. Three out of ten Sasco hamsters fed the 1.2% palmitic acid diet for two weeks had cholesterol stones, while none of the eight Charles River animals had stones. In the Sasco hamsters, a significant proportion of the biliary cholesterol was found in void volume vesicles (28.8%) and small vesicles (17.1%); Charles River hamsters had negligible proportions (1.1%) of cholesterol in void volume vesicles and 15.4% in small vesicles. Cholesterol gallstones were most abundant in Sasco hamsters fed 1.2% palmitic acid for six weeks (nine out of ten animals); the mean cholesterol saturation index of the bile was 1.27. A significant proportion of the biliary cholesterol was eluted in the void volume vesicles (21.4%) and in small vesicles (15.0%). Five of the eight identically treated Charles River hamsters had cholesterol stones; the cholesterol saturation index averaged 1.36, and the biliary cholesterol was present in void volume vesicles (31.3%) and small vesicles (14.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

This paper reports the chemical synthesis of a new bile acid analogue, namely sodium 3 alpha,7 alpha-dihydroxy-25,26-bishomo-5 beta-cholane-26-sulfonate (bishomoCDC-sul) from chenodeoxycholic acid and describes its metabolism in the hamster. The structure of the new compound was confirmed by proton and carbon-13 nuclear magnetic resonance spectroscopy. After intravenous infusion of [3H]-labeled sulfonate into bile fistula hamsters, it was extracted by the liver and secreted into the bile; more than 65% of the radioactivity was recovered in the bile within 1 h. Following intraduodenal administration of the [3H]sulfonate and [14C]chenodeoxycholyltaurine, both compounds were excreted into the bile more slowly; only 41 and 43% of the radioactivity, respectively, were recovered in the bile during the four-hour experimental period. In contrast, when the labeled compounds were injected into the terminal ileum, both the sulfonate and chenodeoxycholyltaurine were rapidly absorbed and secreted into the bile; 84 and 97%, respectively, of the radioactivity were recovered during a four-hour period. Chromatographic analysis demonstrated that in these short-term experiments most (> 95%) of the sulfonate was secreted into the bile without biotransformation regardless of the route of administration. When infused intravenously at increasing doses, bishomoCDC-sul induced cholestasis at an infusion rate of 1 mumol/min/kg. These results suggest that sodium 3 alpha,7 alpha-dihydroxy-25,26-bishomo-5 beta-cholane-26-sulfonate was absorbed from the terminal ileum by active transport, extracted by the liver, and secreted into the bile in a manner similar to that of the natural bile acids.

BACKGROUND: Measuring critical-appraisal skills is a key step in assessing physicians' abilities to engage in self-directed learning. The authors developed an instrument to evaluate the abilities of residents to critically appraise a journal article. METHOD: In 1991, 62 residents in the categorical internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Critical-appraisal skill was determined by calculating the resident's deviations from a "gold standard" critique developed through a modified Delphi technique, using a panel of five physicians. Spearman correlation coefficients were used to compare the residents' actual and self-perceived abilities. RESULTS: Twenty-eight residents returned the questionnaire, for a response rate of 45%. The composite score for the residents' objective assessments was 63% of the gold standard, and was not significantly correlated with post-graduate year, prior journal club experience, or self-assessed critical-appraisal skill. CONCLUSION: After further validation in other settings, the assessment instrument in this study may be used to objectively assess critical-reading skills. It may also provide feedback and measure outcomes for interventions designed to improve critical reading.

BACKGROUND AND OBJECTIVES: Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home-based, and institutional long-term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse-managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time-limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed. SETTING: The program is housed in renovated space devoted to the care of older people. The academic and clinical offices of the University of Pennsylvania's nursing and medical gerontologic and geriatric faculty are in the same building. PARTICIPANTS: We have targeted those persons older than age 65 who have complex health problems and are living at home. Individuals must need multiple services, including at least one rehabilitation therapy, and they must be unsuitable-for inpatient rehabilitation. DESCRIPTION OF THE POPULATION: In its first 8 months of operation, the program received 97 referrals and admitted 53 clients. Clients were, on average, 78 years of age. Over three-fourths (77%) were women and 58% were black. The average stay in the program was 6 weeks. FIM scores, which improved a mean of 2.4 points, were found to lack sensitivity to the functional improvements achieved by clients. CONCLUSION: Under existing Medicare and third party reimbursement policies, it is feasible to establish a nurse-managed comprehensive outpatient rehabilitation program designed to meet the needs of frail older persons. Preliminary data support the beneficial effects of the program as well as the economic feasibility of this approach.

BACKGROUND: When inpatients who are on psychiatry services develop hyponatremia, medical consultation is usually required for evaluation and management, thus halting or delaying psychiatric treatment. Risk factors for the development of hyponatremia in this population have not been studied. METHODS: A case-control study of psychiatric inpatients in a tertiary care facility was performed. Sixty-four patients who had a serum sodium level of less than 130 mmol/L were identified; three control subjects were chosen from the inpatient psychiatry service for each case. Risk factors investigated included medications, psychiatric diagnoses, basic demographic variables, and medical comorbidities. RESULTS: Univariate and logistic regression analyses revealed that, in addition to diuretic use (adjusted odds ratio, 8.2; 95% confidence intervals, 2.2 to 30.8), use of fluoxetine (adjusted odds ratio, 21.4; 95% confidence interval, 5.3 to 86.9), tricyclic antidepressants (adjusted odds ratio, 4.9; 95% confidence interval, 1.6 to 15.2), and calcium antagonists (adjusted odds ratio, 4.0; 95% confidence interval, 1.1 to 14.2) were all associated with the development of hyponatremia. Important comorbidities included elevated creatinine levels, chronic obstructive pulmonary disease, hypertension, systolic blood pressure, and diabetes. Although age was significantly associated with hyponatremia in univariate analyses, it was not significant in multivariate analyses. CONCLUSIONS: Among psychiatric patients, hyponatremia is often associated with factors other than psychogenic polydipsia, including medications and medical comorbidities. Although elderly psychiatric inpatients seem to develop hyponatremia more often than younger patients, once drugs and comorbidities are taken into account, age does not appear to be a significant risk factor for hyponatremia in this population.

The publication of Derek Humphry's Final Exist in 1991 caused a large uproar. Although designed as a suicide manual for terminally ill persons, there has been considerable fear that the book's methods might be used by others, such as nonterminal elderly individuals who have made a "rational" decision to end their lives. This piece, a short story about an elderly couple that commits double suicide, explores rational suicide by using fiction, as opposed to a standard bioethical approach. Fiction does not provide answers, but rather highlights the ambiguities surrounding elder suicide, and reminds us to evaluate this issue in the context of individual life experiences.