Biomedical subjects
F M Howard
Publications and source records attributed to F M Howard.
Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse.
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Surgical management of benign cystic teratoma. Laparoscopy vs. laparotomy.
OBJECTIVE: To compare laparoscopy to laparotomy for the surgical treatment of benign cystic teratomas. STUDY DESIGN: This was a retrospective, case series comparison of 20 patients who had surgery at Rochester General Hospital from June 1991 to January 1993 for benign cystic teratomas. Statistical comparisons were made by Student's t test or chi 2 analysis. RESULTS: Eight patients had surgery via laparoscopy and 12 via laparotomy. Laparoscopic oophorectomy and cystectomy resulted in significantly shorter hospital stays and decreased hospital costs, but the surgery time was significantly increased. The patients' fertility status influenced the choice of conservative cystectomy or nonconservative oophorectomy as the surgical procedure. There were no serious complications in any patients, including those with laparoscopic cystectomies and intraperitoneal spill. CONCLUSION: Oophorectomy and ovarian cystectomy via operative laparoscopy appear to be reasonable options for the surgical treatment of benign cystic teratoma.
Laparoscopic evaluation and treatment of women with chronic pelvic pain.
STUDY OBJECTIVE: To evaluate the effectiveness of operative laparoscopic treatment at the time of diagnostic laparoscopy in patients with chronic pelvic pain (CPP). DESIGN: A retrospective study of women with CPP and at least 6 months of follow-up after laparoscopic evaluation and treatment. SETTING: A faculty practice and community teaching hospital. PATIENTS: A series of 65 consecutive women with greater than 1 month of pelvic pain who underwent laparoscopy. Thirty-two were referred by other physicians for evaluation of CPP. INTERVENTIONS: Patients had operative laparoscopic treatment of all abnormal findings at the time of diagnostic laparoscopy. Nonspecific treatment such as presacral neurectomy or uterine nerve ablation was not performed. MEASUREMENTS AND MAIN RESULTS: After laparoscopic evaluation and treatment, 78% of patients had decreased pain and 45% were pain free. Prior unsuccessful medical or surgical treatment did not affect the response rate. Endometriosis and adhesive disease were the most common diagnoses, 38% and 34%, respectively. CONCLUSIONS: Laparoscopic surgical treatment of pathology noted at the time of diagnostic laparoscopy in women with CPP is appropriate, but less than one-half of patients may be expected to have complete pain relief.
Laparoscopic adnexal surgery during pregnancy.
Adnexal masses diagnosed in a gravid woman sometimes must be surgically evaluated and treated during the pregnancy. A laparoscopic approach may have several advantages over laparotomy, but only one case of laparoscopic adnexal surgery during pregnancy has been previously reported. Two pregnant patients with acute pelvic pain and adnexal masses were treated by operative laparoscopy. One patient had a large benign cystic teratoma and the other had torsion of the fallopian tube secondary to a paratubal cyst. Cystectomies were performed in both women, and in the second patient the tube was reduced and conserved. It appears that with proper care of surgical technique and caution to exclude malignancy, laparoscopy may be performed successfully to remove adnexal masses during the second trimester of pregnancy.
Infant formula distribution and advertising in pregnancy: a hospital survey.
A survey was conducted at a 526-bed community hospital in Rochester, New York, to determine the prevalence of formula advertising and distribution during pregnancy to 136 consecutive intrapartum patients. Women answered a questionnaire about their choice of infant feeding methods and prenatal exposure to formula advertising. Of those who received printed information on infant feeding, 78 percent reported that it was published by a formula company, and 65 percent recalled receiving offers for free formula during their pregnancy. The likelihood of having received such offers was the same in women who planned to breastfeed as in those who planned to formula feed. Thirty-eight percent of women obtained formula through a free offer before their infant's birth. Women who were privately cared for were more likely to have received offers for free formula (p < 0.001) than were women cared for in hospital-affiliated clinics. Ninety percent of women who received free formula prenatally reported their prenatal caregiver as a source of samples. Of samples that women obtained prenatally, 93 percent were from companies that advertise only indirectly through hospitals and physicians, whereas 7 percent were from companies that advertise directly to patients. The prevalence of formula company advertising during the prenatal care of women who deliver in this hospital is high. The continued participation of prenatal caregivers in promotion efforts of formula companies provides a negative or mixed message about the importance of breastfeeding and may be a barrier to its success.
Antenatal formula advertising: another potential threat to breast-feeding.
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A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women.
BACKGROUND: The objective of this study was to determine the ability to predict benign adnexal masses in postmenopausal women and to evaluate the effectiveness of laparoscopic management in selected patients. STUDY DESIGN: Postmenopausal women found to have an adnexal mass were prospectively evaluated with clinical examination, sonography, and serum CA-125 levels. Women with cystic masses greater than 3 cm but less than 10 cm, with distinct borders, without solid parts or septations greater than 2 mm, without ascites or matted bowel, and with serum CA-125 levels less than 35 IU per mL were operated upon by laparoscopy. RESULTS: Sixty-one women gave consent for the study. Cyst size ranged from 3 to 10 cm. All masses were accurately predicted to be benign. Fifty-eight (95 percent) women were successfully managed by operative laparoscopy and three required laparotomy. For the patients managed by laparoscopy, the mean operative time was 63 minutes, the mean postoperative hospitalization period was 12 hours, and the mean return to normal activity was 5.6 days. CONCLUSIONS: The combination of clinical examination, sonographic appearance and serum CA-125 levels can accurately predict benign masses in postmenopausal women. Operative laparoscopy is acceptable for these patients and provides for a short period of hospitalization and a rapid recovery.
Omental herniation after operative laparoscopy. A case report.
Omental herniation through an 11-mm umbilical incision occurred 36 hours after operative laparoscopy. It was attributed to large amounts of residual irrigation fluid in the abdominopelvic cavity and failure to close the fascia of the umbilical incision. This case stresses the importance of closing the fascia of larger laparoscopic incisions, especially if irrigation fluid is left in the abdominal cavity postoperatively.
Acetaminophen analgesia in neonatal circumcision: the effect on pain.
OBJECTIVE: Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure. DESIGN: A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation. RESULTS: Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration. CONCLUSIONS: This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intraoperative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.
A comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy.
The goal of this study was to compare laparoscopically assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH). We performed a prospective comparison of the hospital courses of 30 women, 15 undergoing LAVH and 15 undergoing TAH, in a teaching hospital setting. Analysis of variance (ANOVA) was used, with statistical evaluation of differences by Student's t-test for normally distributed data and Kruskal-Wallis for data with dissimilar variances. Fourteen of fifteen patients scheduled for LAVH had their surgery completed without need of a laparotomy. In the LAVH group, (1) mean surgical time was 50 minutes longer, (2) blood loss, complications, and hospital costs were not statistically different, (3) hospital days averaged 1 1/2 less, and (4) postoperative pain ratings and medication requirements were significantly decreased, compared with the TAH group. In many cases, LAVH may be reasonably performed instead of an indicated TAH.
The role of laparoscopy in chronic pelvic pain: promise and pitfalls.
Published studies relating to the usefulness of diagnostic and operative laparoscopy in women with chronic pelvic pain (CPP) were reviewed. This revealed that approximately 40 per cent of all laparoscopies were done for CPP. However, the definition of CPP was found to be nebulous and inconsistent, and that muddled definitive conclusions about patient diagnoses and treatments. The following definition of CPP was proposed: nonmenstrual pain of 3 or more months duration that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. A survey of published reports showed laparoscopically diagnosable abnormalities in 61 per cent of patients, compared with abnormalities in 28 per cent of women without CPP. Studies in adolescents were also reviewed and showed that adolescents with CPP also had significant laparoscopically diagnosed abnormalities, with 78 per cent showing some pathology, especially endometriosis (40 per cent). Endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, and ovarian cysts were the diagnoses most commonly made via laparoscopy in CPP patients. The potential roles of each of these abnormalities in CPP were discussed, as well as the results of laparoscopic treatment of each disease. Laparoscopy was also found to have a limited role in women with CPP after hysterectomy or bilateral salpingo-oophorectomy, with usefulness in diagnosing and treating adhesions and residual ovary syndrome, although its role in ovarian remnant syndrome was uncertain. Overall, the data showed that less than 50 per cent of women with CPP were helped by diagnostic and operative laparoscopy, stressing the need for both physicians and patients to recognize that laparoscopy is neither the ultimate evaluation nor the panacea for CPP.
What the candidates did not tell us about health care.
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The physician as advertiser: the unintentional discouragement of breast-feeding.
To be consistent with national health goals and ACOG policies and recommendations, physicians providing prenatal care should encourage breast-feeding whenever possible. The parents' choice to breast- or formula-feed their infant is the consequence of a complex decision. The physician's role is to provide information objectively so that the parents' decision can be made on an informed and factual basis. Clearly, the physician must support parents' decisions. However, the distribution of formula or vouchers in the physician's office during the antepartum period places the physician in the position of advertising or promoting a specific product and of potentially contributing to the failure of some patients to nurse their infants. We urge physicians not to distribute formula or formula vouchers to their pregnant patients, and encourage local and national obstetrics organizations to consider devising and discussing a policy statement discouraging such practices.
Breaking new ground or just digging a hole? An evaluation of gynecologic operative laparoscopy.
The gynecological surgical procedures that may be accomplished via operative laparoscopy have dramatically increased in the past decade. Ideally, strong evidence of advantages over traditional surgical approaches should be presented for each surgical procedure before widespread use occurs. Such evidence is generally lacking. This review of recent publications concludes that laparoscopic operations for tubal ectopic pregnancy have been demonstrated generally to be preferable to laparotomy. Although evidence is very suggestive, clear superiority of laparoscopy has not been proven for endometriosis, ovarian cystectomy, oophorectomy, distal salpingostomy, or adhesiolysis for infertility. There is not adequate evidence to reach a conclusion on the use of laparoscopic myomectomy for fertility. When appropriately indicated, vaginal hysterectomy seems preferable to abdominal or laparoscopic hysterectomy, and preliminary evidence suggests that laparoscopic hysterectomy may have some advantages over abdominal hysterectomy. There is no evidence that laparoscopic tubal sterilization is better than minilaparotomy tubal sterilization. Much more scientific study of operative laparoscopic procedures is needed before universal change to these procedures can be fully endorsed.
Lax ligament syndrome in children associated with blue sclera and bat ears.
The child that is slow to walk causes concern. When cerebral palsy, mental retardation and muscular dystrophy have been excluded, what remains? Thirty five children (19 boys and 16 girls) with hypermobile joints, blue sclera and bat ears (the 'lax ligament syndrome') were referred by general practitioners to a general paediatric outpatient clinic over two years. Three were referred in the first three months of life because of clicking hips; 14 children aged one to two years, had delayed milestones of motor development and exhibited bottom shuffling; 10 children aged four to five years presented with 'growing pains' or 'funny gait' and eight older children had multiple minor complaints. The lax ligament syndrome is a comparatively common mild collagenopathy. It may well come to light on routine surveillance in general practice. It is dominantly inherited and improves with time; management is therefore expectant and symptomatic. A firm and reassuring diagnosis can be given which saves both anxiety and investigations.