The need for risk management to evolve to assure a culture of safety.

There is a need for the traditional risk management model, which focuses on department based risk assessment, loss management and risk financing, to evolve to enable it to become more responsive to the increasing demands for safety and accountability imposed on the current US healthcare system. The risk management focus must become more strategic and systems based, and less crisis orientated and individual provider based, in order to provide its greatest value to the organization and the patients those organizations serve.

The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome.

BACKGROUND: Postmastectomy pain syndrome (PMPS) has been reported following procedures involving complete lymph node dissection (CLND). Since the triggering event is probably related to nerve injury, sentinel lymph node dissection (SLND) should decrease the incidence of PMPS. The purpose of this report is to determine the impact of SLND on the number of patients referred to the pain clinic for PMPS treatment. METHODS: The records of all breast surgical patients with a diagnosis of PMPS referred to the Moffitt Cancer Center pain clinic were reviewed. The criterion for diagnosis of PMPS was a history of postoperative pain in the upper anterior chest wall, upper extremity, axilla, and/or shoulder in the absence of recurrent disease. RESULTS: A total of 55 patients with a diagnosis of PMPS were seen in the pain clinic since 1991. Treatments included local anesthetics/corticosteroid injection, stellate ganglion block, and tricyclic antidepressants. A decrease from 15 patients in 1991 to 3 in 1998 was observed. All but one of the 55 patients with PMPS had CLND, and none referred to the pain clinic had undergone SLND. CONCLUSIONS: PMPS is a complication of CLND. The increased use of SLND in our center has reduced the number of referrals to the pain clinic for treatment of PMPS. This benefit of SLND reduces suffering in the postoperative breast patient.

Synthesis of methyl alpha-D-glucopyranosyl-(1-->4)-alpha-D-galactopyranoside and methyl alpha-D-xylo-hex-4-ulopyranosyl-(1-->4)-alpha-D-galactopyranoside.

The syntheses of methyl alpha-D-glucopyranosyl-(1-->4)-alpha-D-galactopyranoside (1) and methyl alpha-D-xylo-hex-4-ulopyranosyl-(1-->4)-alpha-D-galactopyranoside (4) are reported. The keto-disaccharide 4 is of interest in our design, synthesis, and study of pectate lyase inhibitors. The key step in the syntheses was the high-yielding, stereospecific formation of methyl 4,6-O-benzylidene-2',3'-di-O-benzyl-alpha-D-glucopyranosyl-(1-->4)-2,3,6-tri-O-benzyl-alpha-D-galactopyranoside (15), which was accomplished by reacting 2,3-di-O-benzyl-4,6-O-benzylidene-D-glucopyranosyl trichloroacetimidate (10) with methyl 2,3,6-tri-O-benzyl-alpha-D-galactopyranoside (14) in the presence of a catalytic amount of tert-butyldimethylsilyl trifluoromethane sulfonate (TMSOTF). Compound 15 was either hydrogenolyzed to yield disaccharide 1 or treated with NaBH3CN-HCl in 1:1 tetrahydrofuran-ether to yield methyl 2,3,6-tri-O-benzyl-alpha-D-glucopyranosyl-(1-->4)-2,3,6-tri-O-benzyl-alpha-D-galactopyranoside (2). The free 4'-OH of compound 2 was oxidized to a carbonyl group by a Swern oxidation, and the protecting groups were removed by hydrogenolysis to yield keto-disaccharide 4. These synthetic pathways were simple, yet high yielding.

Empirical power for distribution-free tests of incomplete longitudinal data with applications to AIDS clinical trials.

The design of AIDS clinical trials is of growing importance. These studies tend to be longitudinal and typically involve missing data. HIV-1 RNA is a common endpoint for these studies and is inherently non-normal, although viral load can be measured only within certain bounds, resulting in censored data. We compared several analysis methods, both univariate and multivariate, on the basis of empirical power and provide an illustrative example of data from a controlled clinical trial. Simulated viral load data demonstrate that methods adjusting for baseline data have power increasing with increasing positive intrasubject correlation expected with this type of data. Several summary measures considered have power compatible with multivariate tests.

Aspectos psicanalíticos da vertigem / Psychoanalytical aspects of vertigo

As implicaçöes psicológicas no sistema vestibular, apontam a possibilidade de ocorrência de desordens vestibulares de origem psíquica. O enfoque psicanalítico foi o suporte teórico utilizado para a compreensäo dessas manifestaçöes

Do perfil psicologico nas sindromes labirinticas com exame vestibular normal e alterado. / Psychological profile in labyrinthic syndromes with normal and alterate vestibular test

O perfil psicologico de 40 individuos portadores de sindromes vestibulares perifericas, foi realizado atraves do Teste das Piramides Coloridas de Pfister, teste projetivo que faz uma avaliacao da personalidade, em seus niveis latentes e manifestos tendo sido conhecido para informar sobre a expressao da afetividade e o controle dos impulsos. O teste de Pfister sempre foi realizado apos a avaliacao otoneurologica de casuistica, e pos computacao dos dados objetivos da sua interpretacao nos pacientes labirinticos, observou-se a ocorrencia expressiva de determinados eventos, com signficados explicitos: 1: - constriccao do campo psicologico. 2 - insuficiencia de mecanismos defensivos adequados, prevalecendo o carater primariamente funcional e secundariamente, o carater organico.O grupo de pacientes que apresentou exame vestibular alterado foi considerado em piores condicoes psicologicas do que o grupo de pacientes em que o exame vertibular foi normal