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Biomedical subjects

J M Herman

Publications and source records attributed to J M Herman.

14 recordsLinked to original sources
PubMed1992

Reoperation of the cervical spine for degenerative disease and tumor.

Despite improvements in treatment for cervical spine disease over the last decade, failure that requires a reoperative procedure may represent up to 14% of the cases. With the exception of posterior foraminotomy, the most common failure that requires intervention is instability, which results in an anterior compression of the neural elements. With the advent of new operative approaches and innovative stabilization techniques, the options available to treat these patients have improved.

Adolescent↗
PubMed1992

Are Papanicolaou smears enough? Acetic acid washes of the cervix as adjunctive therapy: a HARNET study. Harrisburg Area Research Network.

BACKGROUND: The Papanicolaou smear has a false-negative rate ranging from 10% to 50%. Adjunctive screening methods for detecting cervical disease are thus of interest. We studied an adjunctive acetic acid wash of the cervix to detect additional cases of cervical disease not found by the Papanicolaou smear. METHODS: All women attending six family practice offices for health maintenance during the period August 1989 through April 1990 were examined (N = 2827). Papanicolaou smears were obtained using a Cytobrush and wooden spatula. Each subject's cervix was also visually examined 1 minute after application of 5% acetic acid. Women with abnormal Papanicolaou smear results or abnormal acetowhite areas on visual inspection of the cervix underwent colposcopy. RESULTS: Ninety-three cases of biopsy-proven condyloma or cervical intraepithelial neoplasia (CIN) were found on the basis of abnormal Papanicolaou smear results alone, 33 on the basis of abnormal acetic acid wash results alone, and 14 on the basis of abnormal results from both a Papanicolaou smear and an acetic acid wash. The prevalence of CIN was 3%. The overall positive predictive value for abnormal results obtained by acetic acid wash was .55 (95% CI = .43 to .63). CONCLUSIONS: Using a 1-minute 5% acetic acid wash improves the detection of cervical disease by 30%. Consideration should be given to augmenting the Papanicolaou smear with this safe, simple, and effective technique on premenopausal women during regular health maintenance examinations.

Acetates↗
PubMed1991

Diving accidents. Mechanism of injury and treatment of the patient.

Diving accidents that result in cervical spinal injuries most often occur in young adult males who have access to alcohol and water. A C-5 injury with permanent neurologic deficit is the most common pattern of injury in these patients. Recommended treatments include emergent alignment, an intravenous bolus of methylprednisolone, and spinal stabilization. Recovery is a function of the severity of the initial neurologic injury.

Clinical Protocols↗
PubMed1990

Diving injuries of the cervical spine.

From 1975 to 1986, 2435 patients were admitted to the Northwestern University-Midwest Regional Spinal Cord Injury Unit. Of these, 220 patients (9.0%) had documented neck fractures from diving accidents, representing the largest series of acute diving injuries yet analyzed. The average age of these patients was 21 years, and males predominated. Two hundred twelve patients (96.4%) were admitted within 48 hours of injury. Associated injuries were rare: none had intracranial mass lesions or systemic injuries, and only nine were near-drowning victims who required endotracheal intubation. The most common levels of injury were C-5 (140 fractures) and C-6 (85 fractures), with 70 patients having fractures at more than one level. Neurological injury was sustained in 154 (70.0%) patients, while 66 (30.0%) patients were neurologically intact. One hundred forty-seven (66.8%) patients underwent posterior cervical fusion, and anterior fusion was performed in 36 (16.4%), allowing for early ambulation and an average hospital stay of 17 days. Hospitalization was relatively uncomplicated, with urinary tract infection in 121 (55.0%), pneumonia in nine (4.1%), and deep vein thrombosis in 24 (10.9%). Long-term follow up averaged 5 years and was obtained in 160 (72.7%) patients. Sixteen (10.0%) improved neurologically, five (3.1%) deteriorated, and 139 (86.9%) were unchanged. Notably, this large study shows that diving accidents occur in a young, healthy population who sustain essentially no other associated intracranial or systemic injuries and have few serious hospital complications. Such patients may be mobilized early in their care after either internal or external stabilization. Subsequent long-term neurological improvement can be expected to occur in about 10% of patients. The importance of water safety and injury prevention is stressed.

Adolescent↗
PubMed1990

Vaginal intraepithelial neoplasia: methodologic problems in a case-control study.

Vaginal Intraepithelial Neoplasia (VAIN) has recently received increased attention as a precursor to vaginal cancer, yet its natural history remains largely obscure. Several case series have implicated hysterectomy as a risk factor for the subsequent development of vaginal neoplasia. A recent case-control study failed to support an association with vaginal cancer when controlling for age, sex, and prior cervical dysplasia or neoplasia. In order to further investigate the possible association of hysterectomy with vaginal neoplasia, we performed the following retrospective case-control study. We compared 39 cases of VAIN with 39 controls matched for age, race, and prior cervical dysplasia or neoplasia. Matched-pair analysis yielded an odds ratio of 7.0 with a 95% confidence interval of 1.7 to 28. This would suggest that previous hysterectomy is indeed associated with the development of VAIN. However, several potential sources of systematic error were identified in the study design. Thus this association can not be supported. Further, this study exemplifies the difficulty of generalizing study results from a tertiary care population to primary care settings.

Bias↗
PubMed1988

Long-term follow-up of the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous fistula for haemodialysis.

During a 10-year period vascular access in 86 patients receiving long-term haemodialysis was provided by the insertion of 100 polytetrafluoroethylene grafts. In 24 patients (28%) the PTFE prosthesis was used as a primary access operation; 62 patients (72%) had had previous access procedures. Early thrombosis and infection led to graft failure in eight patients. Late fistula occlusion developed in 67 instances in 39 fistulae. Thrombectomies were performed in 53 fistulae with good result in 46 (86.8%). Infection after puncture was seen in nine grafts and was treated by incision and drainage (33%) or graft removal (67%). False aneurysms developed in six patients; prolonged haemorrhage from the puncture site occurred in one patient and haemodynamic complications (ischaemic steal syndrome; venous hypertension) developed in four. The cumulative patency of PTFE AV fistulae was 74% after 1 year; 59% after 2 and 3 years and 47% after a follow-up of 5 years. Despite the high rate of complications the PTFE AV fistula has proved an acceptable technique in secondary access surgery for haemodialysis.

Adult↗
PubMed1986

Is hysterectomy a risk factor for vaginal cancer?

Several recent case series have called attention to a possible association between previous hysterectomy and the subsequent development of vaginal cancer. To study this relationship, we compared 49 patients with vaginal cancer with 49 controls matched for age, race, and prior cervical dysplasia or neoplasia. Patients and controls were alike in terms of exposure to estrogens. Twenty-four patients (49%) had had prior hysterectomies, of which 13 (27%) were for benign disease. Similarly, 24 controls had a history of a hysterectomy. The matched-pairs odds ratio relating prior hysterectomy to vaginal cancer was 1.00 based on these data, with a 95% confidence interval of 0.47 to 2.12. In the subsample of women without a history of cervical disease, a similar odds ratio appeared. Although the study sample size did not permit exclusion of a twofold increase in risk, the statistical power to detect an actual odds ratio of 2.5 is 76%. At this level of statistical power, our data suggest that hysterectomy has a low probability of being a risk factor for vaginal cancer when age and cervical disease are controlled for. In the absence of such a relationship, screening for vaginal cancer does not appear to be necessary for women who have had a hysterectomy for benign disease.

Adult↗
PubMed1986

Present and future patterns of stroke care.

Stroke care represents a major use of community hospital resources. Age-related patterns in the care of elderly patients who have had strokes may be supported by recent changes in Medicare reimbursement strategies. The effects of these patterns on the overall quality of stroke care needs to be monitored.

Aged↗
PubMedDate not supplied

Tethered cord as a cause of scoliosis in children with a myelomeningocele.

Scoliosis interferes significantly with the functional ability of most children with a myelomeningocele. While it is recognized that tethered cord at the repair site causes neurological deterioration, it has been controversial whether tethered cord causes scoliosis. The spinal cord was untethered in 30 children with progressive loss of function and scoliosis. Of 6 children with curves greater than 50 degrees only 1 improved. Of the other 24 children their curves were stable or improved at 1 year follow-up. At late follow-up, 2-7 years, 63% were stable or improved while 38% began to progress. Tethered cord causes scoliosis and stability or improvement can be anticipated following untethering. Close long-term follow-up is essential to identify those individuals with retethering of their cord.

Adolescent↗
PubMedDate not supplied

Pediatric intracranial aneurysms: simple and complex cases.

Between 1984 and 1990, 20 aneurysms in 16 patients (9 males and 7 females), 18 years or younger (mean age, 8 years; range, 7 months to 18 years), were treated at our institution. Seven patients had a solitary saccular aneurysm located at an arterial bifurcation which manifested as a subarachnoid hemorrhage. Six of these patients were treated with clip obliteration. Postoperative results were excellent or good in 5 and fair in 1. Nine patients had complex or multiple aneurysms of variable origins (3 giant, 2 infectious, 2 traumatic and 2 associated with an arteriovenous malformation) and presentation. Surgical treatment of these children required the use of hypothermic arrest, trapping, bypass and anastomotic procedures. Outcome was excellent or good in 7 and fair in 2. An analysis of these patients with regard to pathogenesis and management is presented.

Adolescent↗
PubMedDate not supplied

Case-control studies.

Case-control studies investigate associations between exposures to risk factors and a condition of interest. Subjects with the condition (cases) are compared to subjects known not to have the condition (controls) with respect to the presence of risk factors in the past. This design is particularly useful when the condition of interest is relatively uncommon. Case-control studies are useful for studying the etiology of conditions in primary care. Invalid results may be obtained, however, if a study's design allows the occurrence of selection bias, information bias, or confounding.

Case-Control Studies↗
PubMedDate not supplied

Teaching clinical epidemiology: a controlled trial of two methods.

The teaching of clinical epidemiology to second-year students at the Bowman Gray School of Medicine is carried out using journal articles to illustrate concepts. Because of the need for discussion, the instructors believed that the concepts of epidemiology might best be learned by, and that greater satisfaction with the learning process might be derived from, small group discussions rather than large lecture sessions. To test these hypotheses, students were randomized into either one of two discussion groups or a larger lecture group. The course handouts and text were identical, and the three instructors presented the same material successively to each group. In the final examination, all three groups answered approximately 26 of 36 questions correctly. Seventy percent of students responded to a questionnaire at the end of the course. There were no significant differences between the discussion and lecture groups in their ability to read and understand medical articles. However, the discussion group students were more favorable in their assessment of the success of the teaching method and in their perception of the importance and overall quality of the course. While there may be little difference in the short-term retention of epidemiological principles between the two teaching methods, the greater satisfaction reported by the students in the small groups will stimulate us to try to provide that type of learning environment in the future.

Curriculum↗
PubMedDate not supplied

Utilization review and the family physician.

Family physicians are often in close contact with utilization review programs. Traditional hospital based review programs have included prehospital certification, outpatient and same-day surgery, second opinions, concurrent hospital review, and early discharge planning. The role of utilization review in ambulatory care is expected to increase in the future and will focus on the cost-effective allocation of resources. Family physicians need to be aware of several issues as they interact with utilization review programs, including the preservation of confidentiality, financial obligation in the face of negative review decisions, and the effect of utilization review on liability for adverse outcomes. Family medicine education should encourage familiarity with the structure and function of review programs and should enable practitioners to participate intelligently in such programs.

Adult↗