Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.     

Transoral surgery: some lessons learned

The experience gained over the last decade has provided some further understanding of the rare, but potentially fatal problems associated with pathology at the craniovertebral junction. Some original concepts of the disease in the area have been challenged; new evidence has been provided to explain our alternative theories. The transoral procedure as a surgical tool is now well established. It is, however, technically demanding, and requires careful anatomical study and 'hands-on' workshop training before the novice will be competent.     

School consultation: Some considerations from a cognitive psychology perspective.

The cognitive psychology literature examining expert vs novice problem-solving approaches contributes to the conceptualization of school consultation as a problem-solving activity. As an initial step in pursuing those ideas systematically, think-aloud protocols were collected from 11 school psychology students and 21 school psychologists responding to an actual taped consultation case. Preliminary data analyses identified 3 levels of problem finding during the entry state of consultation. Results suggest that the identified levels were not necessarily related to experience or training. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Immunizations from ground zero: lessons learned in urban middle schools

The Centers for Disease Control and Prevention funded a three-year demonstration project in San Francisco to assess the feasibility of a large-scale school-based vaccination effort. The project overcame a number of barriers, including lack of pre-existing health services, diversity of home languages, and an every-50-minute-bell schedule. The project targeted seventh graders and all special education students for hepatitis B vaccine (HBVac). Of 4,928 students targeted, 3,509 (71%) consented to vaccination and received the first dose. Of these 3,509 students, 3,256 (93%) completed the three-dose series at school. Key lessons learned include emphasizing a collaborative process in the planning stage, offering an educational component for students, providing an incentive to get timely parental consent, planning distribution and collection of parent materials, and planning vaccination clinics to minimize interrupting the school day. The project clearly demonstrated that, with sufficient attention to political and logistical dimensions, school-based vaccination programs are possible in large urban schools.     

中美在城市水源地供水过程中生态补偿的差异性

饮用水源保护是确保饮用水安全的重要保障.为了深入探讨不同国家生态补偿的经验教训,以城市供水系统为案例,分析美国纽约州与中国北京密云水库在城市供水过程中生态服务付费的差异性.结果表明:虽然美国和中国之间的生态补偿制度具有一定的独特性,但美国在市郊水库为纽约市政供水过程中的补偿效应值得中国借鉴.中国的生态补偿中的关键步骤必须包括生态效益评价的数量化和货币化.此外,现有研究结果认为,美国在公众参与生态补偿全过程的做法值得中国效法,而中国的退耕还林工程的生态效率和效益值得美国借鉴.     

Some salient lessons from research and practice.

Discusses the therapist's indispensable abilities to listen and to resonate to his or her own inner world and the patient's inner world, and to manage his or her own emotional reactions. In short, transference and countertransference are the key to a successful working alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reactions to school consultation: Some considerations from a problem-solving perspective.

W. Pryzwansky's (see record 1989-38304-001) research on cognitive aspects of problem solving as applied to experts and novices in school psychology is critiqued, and contributions to the literature are highlighted. Major issues discussed include potential differences between expert problem solving in the sciences and collaborative problem solving in school consultation. Also discussed are problem-solving research applied to school consultation, the demand (or lack of) for consultative services, and implications (e.g., timing) for training. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Management practices for on-site consultants: Lessons learned from the expatriate experience.

Over the past decade, research on two specific types of nontraditional work arrangements, expatriate employees and consultants, has increased. However, despite the plethora of research exploring the key factors associated with effective expatriation, few links have been made between the similarities in job attributes and experiences of consultants and expatriates. This article reviews the similarities between consultants and expatriates, including issues related to selection, socialization, learning orientation, role definition, family adjustment, career development, and repatriation. An examination of the management practices related to each of the key dimensions of expatriate assignments is made and lessons for consultants are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk Adjustment for the Medicare program: lessons learned from research and demonstrations

The Balanced Budget Act (BBA) of 1997 requires numerous changes in Medicare. Medicare's managed care program has been reinvented as "Medicare + Choice," offering an expanded range of delivery system options for beneficiaries and a schedule of payment changes that will dramatically affect managed care plans. Preceding some of these BBA-legislated changes to Medicare were years of research and demonstrations. Risk-adjusted payment in the Medicare + Choice program, which is mandated for implementation in 2000, is one example of a longstanding developmental initiative. This paper provides a brief overview of risk adjustment-related research and demonstration activities carried out by the Health Care Financing Administration (HCFA) since the 1980s, and describes a possible technical approach for the implementation of risk-adjusted Medicare managed care payments in 2000.     

Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

Training for audit: lessons still to be learned

BACKGROUND: Audit is a criterion for training in general practice, and registrars are reliant on their trainers' teaching of basic audit methods. Their ability to teach this had been assumed, but registrars' projects submitted as part of summative assessment offered an opportunity to test this. AIM: To test trainers' knowledge of basic audit methods. Their knowledge was based on an ability to recognize key audit criteria using a marking schedule that they had helped to create. METHOD: All 158 trainers in the west of Scotland were asked to mark five general practice registrar audit projects using a marking schedule consisting of five independent criteria. Each project had one criterion that was below a level of minimum competence, as agreed by a group of 'expert' assessors. RESULTS: A total of 114 trainers (72%) completed the marking exercise of five audit projects. Three (3%) correctly identified the five criteria that were below minimum competence. They did this by highlighting many other criteria not below minimum competence. For all trainers, there was a direct relationship between the number of criteria they correctly identified as being below minimum competence and the total number of other criteria that they incorrectly identified. CONCLUSION: Trainers are failing to recognize basic audit methodology using a marking schedule they themselves helped to design. This has implications for their ability to teach audit to their registrars and may explain some of the difficulty in implementing audit.     

Consultant's tool kit: Personal lessons of experience.

Over time, consultants draw on their experiences to build a "tool kit" that helps them to more effectively facilitate organization change. The tool kit is much less a bag of tricks and exercises than it is a set of lessons used to think about change management and the ways consultants can contribute to each particular organizational initiative. Some of the personal lessons of the author's own experience are described in this article as a way of illustrating the consultant's tool kit. A summary of the lessons drawn form the tool kit appears in the Appendix. The lessons are grouped into the following categories: (1) understand the desired change and its context, (2) establish relationships necessary to carry out the work, (3) use role reflection to clarify what the change initiative means to you and others, and (4) communicate in ways that make a difference. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Architectural lessons from environmental psychology: The case of biophilic architecture.

A review of findings from the field of environmental psychology shows that humans are aesthetically attracted to natural contents and to particular landscape configurations. These features are also found to have positive effects on human functioning and can reduce stress. However, opportunities for contact with these elements are reduced in modern urban life. It is argued how this evolution can have subtle but nontrivial adverse effects on psychological and physiological well-being. These can be countered by integrating key features of natural contents and structural landscape features in the built environment. Several practical proposals are discussed, ranging from literal imitations of natural objects (such as plants) to the use of nature's fractal geometry in an architectural context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Leadership, followership, and evolution: Some lessons from the past.

This article analyzes the topic of leadership from an evolutionary perspective and proposes three conclusions that are not part of mainstream theory. First, leading and following are strategies that evolved for solving social coordination problems in ancestral environments, including in particular the problems of group movement, intragroup peacekeeping, and intergroup competition. Second, the relationship between leaders and followers is inherently ambivalent because of the potential for exploitation of followers by leaders. Third, modern organizational structures are sometimes inconsistent with aspects of our evolved leadership psychology, which might explain the alienation and frustration of many citizens and employees. The authors draw several implications of this evolutionary analysis for leadership theory, research, and practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)