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SUMMARYPrevious studies relating systolic time intervals and measures of cardiac performance have suggested that the time intervals may be useful indices of myocardial contractility. To explore this possibility, systolic times and left ventricular (LV) performance and contractility were measured nearly simultaneously in 14 normal subjects and 56 patients with cardiac disease. Preejection period (PEP) and the ratio of PEP to LV ejection time (LVET) changed significantly with acute inotropic influences (exercise and isoproterenol), were normal in patients with right or left ventricular overloads in whom cardiac index and ejection fraction were depressed but contractile element velocity at peak dP/dt and the Frank-Levinson contractility index were normal, and were significantly abnormal in patients with either clinically evident or occult LV decompensation in whom the measures of contractility were reduced. Correlations of PEP and PEP/LVET with measures of both performance and contractility were insignificant for patients with valvular disease, shunts, or cor pulmonale and significant but weak for the entire series. However, in subjects with either normal left ventricles or cardiac disease confined to the left ventricle, PEP and PEP/LVET exhibited good correlations with measures of pump function and excellent correlations with measures of contractility. These results indicate that the systolic times are a valid measure of contractility which should prove useful in comparing patients with cardiac pathology confined to the LV myocardium and in following patients with extramyocardial hemodynamic lesions of constant severity.

Current techniques do not provide a reproducible, reliable, or valid basis for assessing clinical skills. The need for large-scale direct observation and standardized assessment procedures has precluded development of better techniques. A project using standardized patients presenting with common clinical problems evaluated the skills of 336 internal medicine residents at 14 New England residency programs in 1289 standardized patient and resident encounters. Results indicated that reproducible assessment of the clinical skills could be achieved in approximately 1 day of testing time using standardized patients. Resident performance improved with years of training, and senior residents and those from programs with stronger reputations performed better and were more homogeneous in ability. Low correlations between standardized-patient-based measures of clinical skills and other evaluation techniques suggested that standardized patients provided unique information. Reactions of residents and faculty to standardized-patient-based evaluations were favorable.

Systematic and effective procedures for developing standardized-patient-based test materials and for training standardized patients have been developed. This technique is best used for measuring data gathering and interviewing skills. Correlations with commonly used evaluation methods were generally low; this may be because standardized patients measure different skills. Local use of this technique by residency programs and the development of regional consortia sharing resources, costs, and expertise are advocated.

A B S T R A C T Since many patients with cardiomyopathy have a history of chronic ethanolism often associated with malnutrition, we have evaluated left ventricular (LV) function in alcoholics with fatty liver, who had no clinical evidence of cardiac or nutritional disease.During an afterload test of LV function the pressor response to angiotensin evoked a threefold rise of enddiastolic pressure in the alcoholic group which was substantially greater than the 4 mm Hg rise in control subjects. The stroke volume and stroke work response in the noncardiac alcoholic was significantly less than in controls. Diminished LV function was corroborated in the noncardiac alcoholic at rest, using a contractility index.To evaluate the dose-response relationship of ethanol in the production of cardiac malfunction, two groups of noncardiac alcoholic subjects were studied acutely at low and moderate dose levels. After 6 oz, ventricular function, myocardial blood flow, and metabolism were not significantly affected. After 12 oz, there was a progressive rise of end-diastolic pressure and decrease of stroke output at a mean blood alcohol level of 150 mg/ 100 ml, reverting toward control by 4 hr. The coronary effluent transiently evidenced leakage of cell constituents, despite an increase of coronary blood flow, suggesting a direct but reversible cardiac injury. Myocardial extraction of triglyceride was enhanced, whereas FFA uptake was reduced. A possible role of myocardial triglyceride accumulation in heart muscle was considered in pathogenesis.Chronic ingestion of 16 oz of Scotch daily by an alcoholic subject while on a normal diet-produced, after 12 wk, a progressive increase of heart rate and size,