[How is it with tuberculosis in the world?]

Tuberculosis is well entrenched in the world and the number of cases is projected to continue to rise, especially in low-income countries. Eradication of the disease will be difficult in poor countries where, for the most part, the population is increasing, HIV infection is spreading, and control measures are inadequate or lacking. The problem is worsened by the increasing prevalence in many countries of strains of drug-resistant Mycobacterium tuberculosis.

The influence of gonadal steroids on pre-pro melanin-concentrating hormone mRNA in female rats

Melanin-concentrating hormone (MCH) may have a regulatory role in the control of luteinizing hormone (LH) release. We have investigated if gonadal steroids induce changes in the expression of pre-pro MCH (ppMCH) that are associated with changes in the pattern of LH release. Using quantitative in-situ hybridization histochemistry we have determined the effect of administration of either oestradiol benzoate (5 microg/rat) or oestradiol benzoate followed 44 or 48 h later by progesterone (0.5 mg/rat) to ovariectomized rats on the expression of ppMCH in the medial and lateral zona incerta and the lateral hypothalamus. The prevalence of ppMCH transcripts in the intact female rat at 12.00 and 19.00 h on proestrus and the first day of dioestrus was also examined. Oestrogen reduced the intensity of hybridization signal for ppMCH mRNA and this was associated with both a decrease in the number of cells in which the message was detected in the medial zona incerta and a negative feedback effect on LH release in ovariectomized rats. Progesterone administration to oestradiol benzoate-primed rats did not alter the reduced expression in the medial zona incerta in spite of its positive feedback effect on LH release. We suggest that progesterone may act only on post-translational events. Expression in the MCH cell bodies of the lateral zona incerta were not affected but there was a transient decrease 4 h after progesterone treatment in the oestradiol benzoate-primed rats in expression in the lateral hypothalamus. No changes in ppMCH mRNA were seen in intact animals on proestrus or the first day of dioestrus indicating that gonadal steroids are not important in the modulation of ppMCH gene expression during the oestrous cycle. In other steroid-dependent physiological situations, however, oestrogen may influence the expression of ppMCH in a subpopulation of cell bodies in the medial zona incerta.

The cost-effectiveness of losartan versus captopril in patients with symptomatic heart failure

The Losartan Heart Failure ELITE Study recently found that in patients with symptomatic heart failure and a left ventricular ejection fraction of </=0.40, losartan compared to captopril improved survival with better tolerability. The objective of this study was to perform an economic evaluation of losartan versus captopril based on the results of the Losartan Heart Failure ELITE Study. The Losartan Heart Failure ELITE Study was a multinational, double-blind, randomized 48-week study comparing the safety and efficacy of losartan to captopril in angiotensin-converting enzyme-inhibitor-naive patients >/=65 years with symptomatic heart failure. Data on health care resource utilization were collected as part of the trial. We conducted a cost-effectiveness analysis to estimate the lifetime benefits of treatment and the associated costs. We observed no differences between treatments in the number of hospitalizations, hospital days, and emergency room visits per patient over the trial period. We estimated the total cost of losartan to be USD 54 (95% CI: USD -1,717, USD 1,755) less per patient than captopril over this time frame. We also estimated that over the projected remaining lifetime of the study population, losartan compared to captopril would increase survival by 0.20 years (undiscounted) at an average cost of USD 769 (discounted) more per patient. This cost increase translated into a cost-effectiveness ratio of USD 4,047 per year of life gained for losartan relative to captopril. In patients with symptomatic heart failure, losartan compared to captopril increased survival with better tolerability at a cost well within the range accepted as cost-effective.

The effects of exogenous growth hormone on follicular steroid secretion and ovulation rate in sheep

Growth hormone (GH) has diverse actions in many tissues, including the follicle. This paper summarizes three experiments that examined the effects of GH and insulin-like growth factor (IGF)-I on the ovary. Ewes given oGH and pregnant mane serum gonadotrophin were compared with control and pregnant mane serum gonadotrophin-treated ewes. Ewes, with synchronized cycles, were given varying doses of pregnant mane serum gonadotrophin and/or oGH to determine if oGH is able to augment ovulation rate (Experiment 1). Experiments 2 and 3 used the ovarian autotransplant model. Ewes were infused via the ovarian artery with oGH (Experiment 2) or insulin-like growth factor I (IGF-I) (Experiment 3). Both were administered for 12 hr on Day 10. In Experiment 2, ewes were given intravenous gonadotropin releasing hormone (150 ng i.v.) at -2.5 and 10.5 hr relative to infusion. Ovarian and jugular venous blood was collected every 15 min from -30 to 150 min relative to gonadotropin releasing hormone. In Experiment 3, luteolysis was induced at the end of infusion. Ovarian and jugular venous blood was collected every 3 hr from before and until 84 hr after the infusion. Estradiol and androstenedione were assayed in ovarian venous plasma and GH in jugular venous plasma. In Experiment 1, treatment with oGH increased the jugular venous concentration of GH. However, in Experiment 2 treatment with oGH via the ovarian artery did not increase jugular venous GH but did increase ovarian venous GH. Treatment with oGH had no effect on ovulation rate (Experiment 1) or the secretion of androstenedione and estradiol (Experiment 2). Infusion of IGF-I (Experiment 3) increased the secretion of estradiol during the follicular phase. These data show that short-term treatment of sheep with GH had no in vivo effects on the follicle and that IGF-I was a potent stimulator of follicular steroidogenesis in vivo.

Effects of preconceptual caffeine exposure on pregnancy and progeny viability

OBJECTIVE

A previous study demonstrated for the first time that a drug such as caffeine, administered prior to ovulation and genomic activation, causes a quantitative difference in growth-promoting energy utilization in a proportion of 5-day-old blastocysts. The objective of the present study was to investigate whether developmental changes induced by caffeine administered throughout the estrus cycle prior to fertilization are sustained throughout pregnancy and after birth.

METHODS

Caffeine was administered to rats throughout the estrus cycle prior to fertilization, with control and experimental groups subdivided into preimplantation and postimplantation categories. Preimplantation fertilization rate was assessed on day 4 of pregnancy by a pregnancy-induced elevation in maternal plasma progesterone concentration, or by flushing each uterine horn on day 5 of pregnancy to determine the presence or absence of a litter. Postimplantation fetuses were collected on gestational day 12 or allowed to go to term.

RESULTS

Preconceptual caffeine exposure significantly reduced maternal fertility by the failure of a proportion of the litters to implant, rather than curtailing preimplantation development or postimplantation losses. Postnatal mortality between weeks 0 and 1 was elevated and the weekly incremental growth rate of the pups from week 3 through week 7 was significantly reduced in the preconceptually caffeine-treated offspring. Experimental females reached puberty at the same age as the controls but at a significantly lower body weight. Gestation length, hirthweight, litter size, sex ratio, and anogenital distance (a measure of prenatal androgenization) were not affected by preconceptual caffeine treatment.

CONCLUSIONS

It was concluded that the reduced fertility rate in preconceptually caffeine-exposed rats was due to the failure of litters to implant rather than to a reduced fertilization rate, which was normal. It was further concluded that the growth rate over the neonatal and prepubertal periods of surviving pups in the caffeine-treated group was subnormal.

Risk factors for negative sputum acid-fast bacilli smears in pulmonary tuberculosis: results from Dakar, Senegal, a city with low HIV seroprevalence

SETTING

Two teaching hospitals in Dakar, Senegal, a West African country with a low prevalence of human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine whether patients with HIV-associated pulmonary tuberculosis have fewer acid-fast bacilli (AFB) in their sputum as assessed by routine microscopy, and to correlate the findings with systematically obtained clinical, radiographic and laboratory variables.

DESIGN

Prospective study from November 1995 to October 1996 of 450 consecutive patients diagnosed with pulmonary tuberculosis.

RESULTS

Tuberculosis was diagnosed in 380 patients (84.4%) by positive bacteriology, in 61 (13.6%) by a favorable response to anti-tuberculosis chemotherapy, and in nine (2.0%) by the presence of a miliary radiographic pattern. Forty (8.9%) patients were HIV-seropositive. AFB-negative smears were found in 14/40 (35.0%) of the HIV-seropositive patients with pulmonary tuberculosis compared with 71/410 (17.3%) of the seronegative patients (risk ratio [RR] = 2.02, 95% confidence interval [CI] 1.26-3.24, P = 0.01). Multivariate analysis revealed that AFB smear negativity was associated with absence of cavitation (P = 0.002), lack of cough (P = 0.005), the presence of HIV seropositivity (P = 0.02), a CD4+ cell count above 200/mm3 (P = 0.02), and age over 40 years (P = 0.03).

CONCLUSIONS

Compared with HIV-seronegative patients with pulmonary tuberculosis, seropositive patients in Dakar, Senegal, are more likely to have negative sputum-AFB smears. This phenomenon has now been observed in seven of eight sub-Saharan African countries with varying HIV seroprevalence from which reports are available.

Dissecting cost-effectiveness analysis for preventive interventions: a guide for decision makers

BACKGROUND

Decision makers usually limit their use of economic evaluations of preventive interventions to the cost-effectiveness ratio.

OBJECTIVE

To show decision makers how economic evaluations can be used to understand the cost-effectiveness of different options for altering health intervention strategies.

OBSERVATIONS

Cost-effectiveness analysis provides insights into many factors that contribute to the overall benefits, hazards, and costs of interventions. This article reviews how epidemiologic and intervention characteristics, costs, natural history, targeting, and current interventions influence the value of prevention strategies.

CONCLUSION

Understanding the factors that contribute to the overall costs and effectiveness of interventions should allow decision makers to better adapt interventions to their needs.

Tuberculosis and HIV infection: global perspectives

This paper reviews the epidemiological and clinical aspects of the interaction between Mycobacterium tuberculosis and HIV infection. The incidence of HIV-associated tuberculosis is increasing worldwide and is expected to increase further, especially in Africa and parts of Asia. HIV infection appears to increase the likelihood that tuberculous infection will occur after tubercle bacilli are inhaled into the lungs. Moreover, there is persuasive evidence that in the presence of HIV infection, new-onset tuberculous infection will progress rapidly to clinically significant disease and the probability that latent tuberculous infection will reactivate is enormously increased. The accelerating and amplifying influence of HIV infection is also contributing to the increasing incidence of disease caused by multidrug-resistant strains of M. tuberculosis. Neither clinical nor radiographic features reliably distinguish the majority of patients with HIV-associated tuberculosis from those who are non-HIV-infected. Some HIV-infected patients, however, have atypical manifestations and are difficult to diagnose. Chemotherapy for 6 months with conventional antituberculosis drugs cures most patients, but many died during or after treatment of other AIDS-related complications. HIV is contributing heavily to the worldwide increase in tuberculosis. There is also mounting evidence that tuberculosis accelerates the course of co-existing HIV disease.

Methods for diagnosing tuberculosis among in-patients in eastern Africa whose sputum smears are negative

SETTING

Two University hospitals in Eastern African capital cities where large prospective studies had been carried out on hospitalized patients to determine the cause of their respiratory diseases.

OBJECTIVE

To identify features that differentiated between tuberculosis (TB) and non-tuberculous respiratory disease (non-TB) in hospitalized patients from Bujumbura, Burundi (n = 111) and Dar es Salaam, Tanzania (n = 71) whose sputum smears were negative on microscopic examination for acid-fast bacilli (AFB).

DESIGN

Review of clinical findings, radiologic abnormalities, and laboratory test results from 182 patients, first by univariate and then by multivariate (stepwise logistic regression) analysis to assess the contribution of each factor to the final diagnosis.

RESULTS

Of the 182 patients with two or more negative AFB smears, 41 had TB and 141 had non-TB. Stepwise regression analysis revealed four easily ascertained symptoms were associated with TB: 1) cough > 21 days; 2) chest pain > 15 days; 3) absence of expectoration; and 4) absence of shortness of breath. Any two of the four diagnosed TB with 85% sensitivity and 67% specificity; any three of the four with 49% sensitivity and 86% specificity. Multivariate analysis showed that adding lymphadenopathy and hematocrit < 30% improved discrimination.

CONCLUSION

This methodological approach provides a means for diagnosing TB among all AFB smear-negative hospitalized patients. In this setting, simple clinical symptoms alone are helpful. Similar studies are needed to develop a system for out-patient TB suspects.

USQA Health Profile Database as a tool for health plan quality improvement

Managed care organizations are in a unique position to evaluate and improve the quality of care delivered to their defined memberships. Traditionally, health services delivery has been claims-focused. We describe a potentially richer, patient-centered approach, whereby patients with certain chronic diseases are first identified and then used as the unit of analysis. U.S. Quality Algorithms (USQA), a subsidiary of U.S. Healthcare (USHC) based in Blue Bell, Pennsylvania, has developed selection criteria for 36 different chronic diseases and a new database, the USQA Health Profile Database (HPD), to identify and archive patients with those diseases. Examples of how this approach and database can be used as a quality tool are demonstrated.

Bridging the gap between managed care and academic medicine: an innovative fellowship

Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1-year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education.

Pulmonary complications of HIV infection in Dar es Salaam, Tanzania. Role of bronchoscopy and bronchoalveolar lavage

To determine the pulmonary complications in HIV-1-infected patients in Dar es Salaam, Tanzania, and to evaluate the diagnostic utility of bronchoscopy and bronchoalveolar lavage, we carried out a prospective study of 237 patients with acute respiratory disease who were hospitalized at Muhimbili Medical Center (MMC). Diagnoses were made using well-defined criteria. Of the total, 127 (54%) were HIV-1-seropositive and 110 (46%) were seronegative. Tuberculosis was the most common diagnosis occurring in 95 (75%) HIV-1-seropositive and 87 (79%) seronegative patients. Bacterial pneumonia was the next most common diagnosis occurring in 18 (14%) HIV-1-seropositive and 17 (15%) seronegative patients. Pneumocystis carinii pneumonia was diagnosed in one and Kaposi's sarcoma was seen in only two HIV-1-seropositive patients. Bronchoscopy with bronchoalveolar lavage was the sole source of a diagnosis in nine (8%) seropositive and six (5%) seronegative patients. We conclude that the HIV seroprevalence rate among patients hospitalized for acute respiratory disease at MMC is extremely high. Tuberculosis was the most common cause of pulmonary disease, regardless of HIV serostatus, and other HIV-associated opportunistic pulmonary infections were unusual. Bronchoscopy with bronchoalveolar lavage added little to the diagnosis and thus should not be high-priority procedures for the routine workup in resource-poor areas where tuberculosis is endemic.

[Current clinical manifestations of tuberculosis]

Tuberculosis is an enormously serious and growing global disease that is becoming increasingly concentrated in the so-called "developing" nations of the world, where the epidemic is fuelled by the rapid expansion of the population, the presence of extreme poverty, and the coexistence of HIV infection. Most persons who become infected with M. tuberculosis do not develop the disease tuberculosis. In those who do, two types are recognised: 1) early progression of the primary pulmonary lesion or its lymph node component, or a complication from hematogenous dissemination, and 2) late reactivation of one or more previously latent sites, of which upper lobe pulmonary disease is the most common; extrapulmonary disease may also occur. Progressive immunosuppression from HIV infection exaggerates and accelerates the evolution of virtually all aspects of tuberculosis.

Pulmonary complications of HIV infection

Pulmonary disease is a major source of morbidity and mortality in HIV-infected persons. Pneumocystis carinii pneumonia has decreased substantially during the last eight years, but in the United States it remains the most common disorder that announces the onset of AIDS. In contrast, tuberculosis is by far the most important AIDS-associated indicator disease in developing countries. Community-acquired acute bacterial pneumonia is a common HIV-linked complication throughout the world; pneumonia occurs at all levels of immune suppression but increases in frequency as CD4 counts decrease. Fungal infections mainly afflict persons who live or have lived in the various endemic areas. AIDS-related Kaposi's sarcoma and lymphoma generally do not involve the lungs until the malignancies are advanced. The increasing use of successful chemoprophylaxis against many important HIV-associated infections is increasing the incidence of other end-stage complications such as cytomegalovirus and disseminated MAC disease.

Tuberculosis and HIV infection worldwide

The incidence of HIV-associated tuberculosis is increasing worldwide and will continue to increase during the foreseeable future, especially in developing countries. HIV infection appears to increase the opportunity for M. tuberculosis to succeed in causing infection after inhalation into the lungs. Moreover, there is persuasive evidence that in the presence of HIV infection, new-onset tuberculous infection will progress rapidly to clinically significant disease and the likelihood that latent tuberculous infection will reactivate is enormously increased. The accelerating and amplifying influence of HIV infection is contributing to the increasing incidence of disease caused by multidrug-resistant strains of M. tuberculosis. Neither clinical or radiographic features reliably distinguish the majority of patients with HIV-associated tuberculosis from those who are non-HIV-infected. The remainder, however, may have atypical manifestations and be difficult to diagnose. Six months of chemotherapy with conventional antituberculosis drugs cures most patients, but many die during or after treatment of other AIDS-related complications.

Using comparative clinical and economic outcome information to profile physician performance

This paper presents strategies and empirical examples of comparative physician profiling under conditions of limited patient sample sizes and varying patient severity. A method by which clinical and cost outcomes may be evaluated simultaneously is also presented. Physician economic and clinical performance are compared using data abstracted from nine hospitals into the MedisGroups clinical information management system for inpatients treated from July, 1990 through June, 1992. The main outcome measures are comparative total and ancillary adjusted charges, and morbidity status. Results suggest that objective comparative outcome data provide useful information to assist in evaluating physician performance. A simultaneous comparison of clinical outcomes and adjusted charges identifies physicians who experience favorable outcomes at lower charges, as well as those who have higher charges and/or poorer outcomes. Strategies outlined in this paper may be of value to clinicians, governing boards, and third party payors. These strategies may be used to assist with privileging and other peer review activities when pursued proactively within a Continuous Quality Improvement framework to improve care.

Radiographic abnormalities in tuberculosis and risk of coexisting human immunodeficiency virus infection. Methods and preliminary results from Bujumbura, Burundi

We evaluated the age profile and chest radiographic abnormalities in 158 patients from Bujumbura, Burundi, with new-onset intrathoracic tuberculosis (pulmonary, pleural, or hilar/mediastinal adenopathy), to identify features that were associated with and would allow prediction of HIV seropositivity or seronegativity. Using agreed-upon criteria and prepared reporting forms, initial chest radiographs were reviewed by three readers, first independently and then at a consensus conference. Of the 158 patients, 105 (66%) were HIV seropositive and 53 patients were seronegative. Seropositive subjects (mean age, 35.8 yr) were older (p = 0.001) than seronegative subjects (mean age, 29.4 yr). Significant or borderline differences between HIV-seropositive and -seronegative patients included the frequency of small nodular lesions (p = 0.03), upper lobe cavitation (p = 0.05), and lymphadenopathy (p = 0.12), and the location of parenchymal abnormalities (p = 0.0006). Stepwise logistic regression revealed four important variables: age, small lesions, location, and lymphadenopathy; these were then used to derive an equation to calculate the probability that a given tuberculosis patient was HIV seropositive. Our mathematical model fit the observed data and the equation predicted serologic findings reasonably well. We conclude that it is possible to determine with useful probability a Burundian tuberculosis patient's HIV serologic status.

Radiographic abnormalities in tuberculosis and risk of coexisting human immunodeficiency virus infection. Results from Dar-es-Salaam, Tanzania, and scoring system

First, we evaluated the age profile and chest radiographic abnormalities in 146 patients from Dar-es-Salaam, Tanzania, with new-onset intrathoracic tuberculosis (pulmonary, pleural, or hilar/mediastinal adenopathy), to identify features that were associated with human immunodeficiency virus (HIV) seropositivity or seronegativity; then, we combined these data with those from a companion investigation in Burundi to develop a simple scoring system to predict HIV serologic status. Using agreed-upon criteria and simplified reporting forms, initial chest radiographs were reviewed by three readers, first independently and then at a consensus conference. Of the 146 patients, 80 (55%) were HIV seropositive and 66 were seronegative. More seropositive than seronegative subjects were 31 to 40 yr old (p = 0.03). Because the radiographic characteristics of the two serologic groups were similar in Tanzania and Burundi, we combined the data for stepwise logistic regression that revealed four highly significant variables: age, small lesions, location, and lymphadenopathy. From these, we obtained an equation to calculate the probability that a given tuberculosis patients was HIV seropositive and then we derived a scoring system that in its simplest form (threshold) predicted serologic status correctly in 68.1% of patients; a graded scale was even more accurate in the high (89.1%) and low (82.6%) ranges. This scoring system should be useful when serologic testing is unavailable or refused.

A glossary of medical decision-making terms

Many of the terms used in medical decision making are foreign to clinicians. This problem creates a barrier that can prevent physicians from acquiring these new clinical tools. This glossary contains definitions of the most common terms as well as examples of their usage by using Down syndrome as the illustrative condition.

Using data from epidemiologic studies to revise probabilities

Information about the relationship between risk factors and the probability of disease is often reported by an odds ratio, although its use for revising the probability of disease in a clinical setting is not intuitive and requires complex computations. A somewhat better approach is Bayesian probability revision. The authors present a method where likelihood ratios can be obtained from odds ratios, and they present simple computational methods for implementing all of the techniques described.

The International Union Against Tuberculosis and Lung Disease: its contribution to world lung health

Most readers of the American Journal of Respiratory and Critical Care Medicine probably know that beginning in 1986 the number of reported cases of tuberculosis in the United States, which had been declining at a steady rate of 5%-6% per year, increased for the first time in 33 yr; moreover, since then the number of reported cases has continued to increase nearly every year until 1993. Similar increases in tuberculosis have been observed in other countries, such as Denmark, Italy, the Netherlands, Spain, Switzerland, France, and the United Kingdom. Unfortunately, there has been a global resurgence of tuberculosis and, as is predictable from the prevailing geographic distribution of persons with the disease, the great majority of the "extra" cases, almost 90%, do not live in the rich industrialized nations of North America and Europe or in Japan or Australia; they live in the impoverished countries of Asia, Africa, and South America (1). Among the journal's sophisticated audience, probably only a few know that the health organization with the longest and by far the best track record in actually doing something about the immense problem of tuberculosis in developing nations is the International Union Against Tuberculosis and Lung Disease or, as it is customarily known, the IUATLD. This article recounts the origins of the IUATLD and describes what it has done to combat tuberculosis and other perils to lung health in some of the poorest countries of the world.

Changes in progesterone secretion following treatment with transforming growth factor alpha (TGF-alpha) during the follicular phase of the sheep oestrous cycle

The effects of transforming growth factor alpha (TGF-alpha) on ovarian steroid secretion were investigated. Three crossbred ewes synchronized for oestrus with ovarian autotransplants were infused with TGF-alpha (30 micrograms in 12 h) via the ovarian artery for 12 h before withdrawal of progestagen pessary. Three ewes were used as controls. Jugular and ovarian venous blood samples were taken at intervals of 10 min at two stages during the follicular phase (21-27 h and 38-42 h after pessary withdrawal) and every 2 h from 44 to 86 h. Plasma LH and FSH concentrations, and ovarian secretion rates of inhibin, androstenedione, oestradiol and progesterone were determined using radioimmunoassays. LH pulse amplitude increased in ewes treated with TGF-alpha in the early follicular phase (0.92 +/- 0.25 micrograms l-1 in controls versus 3.10 +/- 0.35 micrograms l-1 in TGF-alpha treated ewes; P < 0.05) and remained high in the late follicular phase. Plasma FSH concentrations were high during the follicular phase in ewes treated with TGF-alpha (P < 0.05). The infusion of TGF-alpha had no significant effect on the ovarian rate of secretion of androstenedione and, although the secretion rates of oestradiol and inhibin were consistently lower in TGF-alpha-infused ewes, the differences were not significant. The ratio of secretion of androstenedione to oestradiol was greater during the follicular phase in TGF-alpha-treated ewes (P < 0.05), suggesting that the efficiency of aromatization had been impaired.(ABSTRACT TRUNCATED AT 250 WORDS)

The Rorschach and diagnosis of neurotic conditions in children and adolescents: a case study

The diagnosis of neurotic disturbance in children and adolescents can be an exceedingly complex decision given the impact of developmental and situational factors on aspects of personality organization and personality style. The potential for rapid regression, rapid development, and incomplete structuralization of personality organization and style complicates our understanding of the meaning of particular symptoms or behavior. The Rorschach offers help in sorting through these issues because it can uniquely assess aspects of personality organization, personality style, and the impact of developmental or situational factors.