Вы находитесь на странице: 1из 1

Prohovnik edited recently with four on end-tidal xenon concentrations. A 6.

Edwards AL: Experimental Design in Psy-


articles on CBF in normal subjects metronome makes the task of stabiliz¬ chological Research, ed 4. New York, Holt Rein-
hart & Winston, 1972, pp 97-102.
(including one by himself entitled "Ob¬ ing respiration much easier. We have
servations on the Functional Signifi¬ not noticed any differences between
cance of Regional Cerebral Blood Flow patients and controls in this regard.
in Resting Normal Subjects"), no men¬ We do not think that the differences in The Mini-Mental State Examination
tion was made of the exclusion of psy¬ C02 level between the two groups is To the Editor.\p=m-\Inresponse (Ar-
chiatric illnesses.1 We assume that ex¬ significant. Any standard textbook of
clusion of physical and psychiatric physiology will provide the informa¬
chives 1982;39:1443-1445) to a letter
illnesses were the criteria they used tion that respiratory rate is not the by Ganguli and Saul (Archives
for defining normality, as we did. We sole determinant of resting C02 levels 1982;39:1442-1443), Robins and Helzer
stated in our report (p 1122) that the and that even normal subjects show
noted that the Mini-Mental State Ex-
principal investigator (a board-cer¬ wide variations. End-tidal C02 levels amination,1 incorporated into the Di-
tified psychiatrist) interviewed both can be altered substantially by chang¬
agnostic Interview Schedule (DIS) to
assess cognitive impairment, had been
the patients and control subjects. The ing the depth of respiration at the same
control subjects (volunteers) were free respiratory rate.3 reported by Folstein et al to differenti-
of all physical and psychiatric illness. ate between pseudodementia and true
Unequal variances of the CBF organic brain syndromes. We would
The criticisms made about the CBF values between patients and controls like to make that statement more spe-
index we used can only be explained by merit some discussion. The question of cific.
their unfamiliarity with the US litera¬ the need to correct for this is related to The Mini-Mental State Examination
ture. This index was developed by the the robustness of the t test with re¬ was designed as a clinical method for
Harshaw Chemical Company, Cleve¬ spect to types I and II errors. There is
land, in collaboration with Dr John S. evidence to indicate that the t test is grading cognitive impairment. It pro-
robust with respect to nonnormality duces a score that can be used to follow
Meyer, who has published extensively the course of patients or as a case
on the subject. A review of the CBF and heterogeneity of variance.45 We
research conducted with this index recalculated the t tests (two-tailed) detection technique after cutoff scores
are established.
would be beyond the scope of this com¬ more conservatively, after corrections
In a clinical psychiatric setting, a
munication. The only single-authored were made for the inequalities in vari¬
low Mini-Mental score can be associ-
textbook on the inhalation technique ance.6 The patients continued to
ated with many disorders including
where both normal and abnormal show reduced CBF to several regions
mental retardation, delirium, manic-
values are given and a report on the (P<.05 in the right hemisphere for the
responsivity of this index to PEco2 superofrontal, frontal, superotem- depressive disorder, and schizophre-
changes are referenced.2,3 The latter poral, and prefrontal areas, and in the nia, as illustrated by Folstein et al in
reference obviates the need to specu¬ left hemisphere for the frontal, supero- their pre-DSM-III article in 1975.1,2
late whether this index "behaves as the temporal, and temporoparietal areas; However, on a medical unit like the one
from which Ganguli and Saul were
ISI2 does." P<.08 in the right hemisphere for
selecting patients, it has adequate spe-
The statements made about CBF mean CBF and the parietal and tem¬
and PEco2 are difficult to comprehend. poral areas, and in the left hemisphere cificity and sensitivity for surveys of
dementia and delirium.3
Prohovnik et al reiterated our dis¬ for mean CBF and the parietal area).
We await the results of the validation
cussion and provided two additional Large variances in unselected CBF studies being carried out at Johns
references on the PEco2-induced data are a difficulty with which most
changes in CBF as measured by the researchers are familiar. The reasons Hopkins University (Baltimore) and
xenon XE 133 inhalation technique. for this are unclear. The problem is Washington University (St Louis) as
part of the Epidemiological Catchment
These studies and several others3 were compounded by the heterogeneity of Area Project to learn of its specificity
not mentioned in our report as the schizophrenia and lack of knowledge and sensitivity when used by lay inter-
topic was not CBF and C02. Yamamoto regarding the nature of, and interac¬ viewers in the community. Until we
et al ( =
65; mean age, 52 years; range, tions between, the nonspecific factors
35 to 72 years) found an age-related that determine resting CBF in normal analyze these data, we are reluctant to
make claims for what it can do in that
decline in CBF responsivity to C02, and abnormal populations.
while Maximilian and associates Roy J. Mathew, MD setting.
Marshal F. Folstein, MD
(N 10;
= mean age, 26 ±4 years) re¬ Department of Psychiatry Lee N. Robins, PhD
ported a correction factor of 3.2% CBF Vanderbilt University
John E. Helzer, MD
School of Medicine
per 1 mm Hg of PEco2. We cannot see TN 37232 Division of General Hospital Psychiatry
how these two reports are helpful in Nashville, Osier 320
clearing up the issue. There is a con¬ 1. Prohovnik I: Mapping Brainwork. Lund, The Johns Hopkins Hospital
sensus that C02 is the single most Sweden, Gleelrup, 1980. Baltimore, MD 21205
2. Deshmukh VD, Meyer JS: Non-invasive
powerful determinant of CBF. There¬ Measurement of Regional Cerebral Blood Flow 1. Folstein MF, Folstein SE, McHugh PR:
fore, it is obvious that in a study where in Man. New York, SP Medical and Scientific Mini-Mental State: A practical method for grad-
CBF is used as an index of brain func¬ Books, 1978. ing the cognitive state of patients for the clini-
tion, control of the fluctuations of 3. Yamaguchi F, Meyer JS, Sakai F, et al:
Normal human aging and cerebral vasoconstric-
cian. J Psychiatr Res 1975;12:189-198.
2. Folstein MF, McHugh PR: Dementia syn-
PEco2 levels is of paramount signifi¬ tive responses to hypocapnia. J Neurol Sci 1979; dromes of depression, in Katzman R, Terry RD,
cance, especially in the absence of a 44:87-94. Bick KL (eds): Alzheimer's Disease: Senile De-
valid correction factor. Stable respira¬ 4. Box GEP: Non-normality and tests on vari- mentia and Related Disorders. New York, Raven
tion is a fundamental requirement of ances. Biometrica 1953;40:318-335. Press, 1978, vol 7, pp 87-96.
the inhalation technique since the iso¬ 5. Donaldson TS: Robustness of the F test to 3. Anthony JC, LeResche L, Niaz U, et al:
errors of both kinds and the correlation between Limits of the 'Mini-Mental State' as a screening
tope recirculation correction and cal¬ the numerator and denominator of the F ratios. J test for dementia and delirium among hospital
culation of the start-fit time are based Am Stat Assoc 1968;63:660-676. patients. Psychol Med 1982;12:397-408.

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/13/2015