Biomedical subjects
N M Hadler
Publications and source records attributed to N M Hadler.
Knee pain is the malady--not osteoarthritis.
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Arm pain in the workplace. A small area analysis.
In the mid-1980s, use-related arm pain was recognized as a major issue for worker health and workplace safety. National policy targeted these "cumulative trauma disorders," "overuse syndromes," and "motion illnesses" for a "special emphasis program" by the Occupational Safety and Health Administration, a federal regulatory agency. The program begins with case recognition to identify the responsible ergonomic hazards with the goal of mandating ergonomic remedies. This report is a small area analysis of the impact of this process on the US West Communications, Inc work force. US West employs some 55,000 workers in 14 states. Commencing in the mid-1980s, workers in four of these states complained of upper extremity pain and were diagnosed as suffering from conditions encompassed by the "cumulative trauma disorders" rubric. The incidence was tenfold higher in one task category, directory assistance operators. No ergonomic descriptor can account for the four endemics of arm pain in directory assistance operators. The response of the medical communities to the plight of these injured claimants varied considerably from community to community. Denver represents one extreme where the clinical judgments led to multiple surgical interventions, generated a total direct cost of some $1.5 million, and left many permanently disabled workers in their wake. This analysis raises many reservations about the validity of the "cumulative trauma disorder" hypothesis and provides an object lesson in the potential for untoward outcomes from the premature introduction of clinical hypotheses into the arena of health policy.
Managing toxicopathic rheumatic diseases in the current legal climate.
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Current principles of rehabilitation for patients with rheumatoid arthritis.
Rehabilitation is rooted in the comfort and palliation that sufferers of rheumatic symptoms have sought from physical modalities throughout history. In recent decades, several of these empiricisms have been tested scientifically. Furthermore, function has joined comfort as a desirable and measurable outcome. This article highlights some of the more substantive information as it relates to rheumatoid arthritis. It is clear that such information facilitates more effective and efficient programs of intervention. It is equally clear that the therapeutic perspective of rehabilitation for rheumatoid arthritis is more appropriately applied throughout the course of the disease in an ongoing program of habilitation than held in reserve as a form of salvage.
Double-crush nerve compression in thoracic-outlet syndrome.
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Another colloquy at Delphi: an unabashed parody.
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There's the forest. The object lesson of NSAID "gastropathy".
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Cumulative trauma disorders. An iatrogenic concept.
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The roles of work and of working in disorders of the upper extremity.
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Disabling backache in France, Switzerland, and The Netherlands: contrasting sociopolitical constraints on clinical judgment.
A century has passed since clinicians assumed a linchpin role in the administration of programs to provide recourse and redress for persons suffering the illness of work incapacity. Medicine was asked to certify whether the illness was an injury in the absence of trauma, to ascertain whether further healing was possible, and to quantify the residual functional capacity. The response has been to force the vagaries of clinical judgment into the programmatic algorithm. No country has abandoned or redirected all three of these charges. Physicians have generally remained passive or intransigent as the society in which they function attempts to compensate for the indeterminate nature of these clinical questions. The current study compares the fashion in which the programs in Holland, Switzerland, and France have evolved in response to the clinical uncertainties. The Dutch have discarded the accident question. The Swiss emphasize the accident issue but consider the work-relatedness of the event to be irrelevant. The French have honed the traditional paradigm and have added a tier of clinical judgment within the program to monitor that without. These and other distinctions should cause all physicians to question their own convictions with regard to the three issues and, further, to question whether the basic paradigm is clinically flawed and therapeutically counterproductive.
Prognosis in SLE: comparison of Markov model to life table analysis.
A Markov model of prognosis was evaluated by comparing the duration of disease activity states and life expectancy with Kaplan-Meier survival curves for 98 patients with systemic lupus erythematosus with 1080 patient-years of observation. A four state (remission, active, flare and death) homogeneous Markov chain was constructed to determine the transition probabilities between disease states, the probability of disease states over the subsequent 25 years, time in each disease state, and life expectancy. Approximately 85% of the clinical course of patients was in the active disease state; no patient made a transition directly between remission and flare; virtually all deaths occurred from the flare disease state. The proportion of the patient population in each disease state over time provided a convenient graphic summary of the natural history of SLE that supplemented the Kaplan-Meier survival curves. A Markov model analysis yields a clinically useful description of outcome for multistate diseases that supplements survival curves.
Medical disability assessment of the back pain patient for the Social Security Administration: the weighting of presenting clinical features.
We investigated how physicians use history and physical findings when assessing disability for low back pain. Thirty-six North Carolina physicians, either practitioners experienced in disability determinations (26) or employees of the Social Security disability agency (10), responded to 48 clinical vignettes. They rated each case on a scale of 0 to 1.0, according to their degree of certainty that the patient was disabled. All combinations of five patient variables were presented in the vignettes: pain (mild or severe), physical examination (normal, reflex loss or muscular weakness), mobility (normal or restricted), X-rays (normal or osteoarthritis), and occupational history (normal or light work). The mean certainties for the individual vignettes ranged from 0.08 to 0.43. Mean certainty estimates across physicians ranged from 0 to 0.61, indicating substantial variability in how physicians assess disability. Practicing physicians had higher certainty of patients' disability than did physicians employed by Social Security, 0.37 vs 0.07 (p less than 0.01). Degree of pain was not associated with certainty of disability. All other clinical factors were highly significant predictors of physician assessment of certainty of disability. The emphasis on physical and radiographic findings over history places disability evaluation distinctly apart from other medical assessments.
Back pain.
Among the multitude of potential etiologies for low back pain in the elderly, cauda equina syndrome is the only genuine surgical emergency. The consequence of delayed recognition, referral, and decompression may be permanent neurologic deficit. Fortunately, this event is rare. Certain other warning signs and symptoms (as outlined in Fig. 1) should alert the clinician to possible systemic disease and warrant earlier, more aggressive evaluation. Careful history-taking and focused physical examination remain the cornerstones of clinical decision making in managing the geriatric patient with back pain. Laboratory and/or radiologic studies are indicated in carefully defined circumstances. Advanced age, independent of other risk factors, is probably not an indication for obtaining roentgenograms and laboratory studies as part of the initial screening of patients with back complaints. Available epidemiologic studies suggest that the predicament as well as the illness of back pain is common in the elderly, and that most people who suffer from back pain in old age had back complaints before the age of 65. Furthermore, although back complaints are among the most commonly mentioned symptoms by elderly patients to their physicians, they are less often the chief or presenting complaint. Studies that examine the reasons for health-care-seeking behavior in older patients with back pain, or that compare older and younger patients in this regard, are lacking. Several factors potentially contribute to age-related differences in patient behavior related to back pain. The removal of employment compensation issues in the postretirement population may alter the relative frequency of physician visits. A higher incidence of serious chronic and/or life-threatening disease in the elderly, as well as perceived threats to independent function, may heighten anxiety about back pain. Conversely, because of the greater prevalence of musculoskeletal and other activity-limiting conditions in the elderly, older patients may believe that back pain is just another burden of aging. These questions await further research.
The patient with low back pain.
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Treatment of calcinosis universalis with low-dose warfarin.
Patients with calcinosis universalis secondary to dermatomyositis or systemic sclerosis have increased levels of the calcium-binding amino acid, gamma-carboxyglutamic acid. The enzyme that effects gamma carboxylation of glutamic acid is warfarin-sensitive. Four patients with calcinosis universalis were treated with 1 mg per day of warfarin for 18 months in a non-blind initial study. Two patients had both decreased gamma-carboxyglutamic acid urinary concentration and decreased extra-skeletal uptake on technetium 99m-diphosphonate whole-body nuclear scanning. In a subsequent double-blind placebo study, two thirds of the patients receiving 1 mg per day of warfarin had decreases in extra-skeletal nuclear tracer uptake after 18 months, compared with none of the four patients receiving placebo. No patient had a change in clinical assessment, bleeding complication, or baseline normal prothrombin time. This low-dose warfarin regimen appears to have no demonstrable adverse effects, and these results suggest a beneficial effect on the progression of calcinosis in these rheumatic diseases.
Regional musculoskeletal diseases of the low back. Cumulative trauma versus single incident.
Discomfort in the low back is a common problem that has been investigated for centuries. The need to cope has not changed, but for the past 50 years, the way in which one copes has been dramatically changed by the interaction of a pathophysiologic insight within a legal construct. The development of the concept of "ruptured disc" as a cause of backache allowed, for the first time, the perception that a drastic dissolution of anatomy accompanied the discomfort. Regardless of the precipitant, the inference of "trauma" was compelling. This heuristic pathophysiologic inference found a ready ear in the Workers' Compensation Insurance system. If backache is a personal injury, it would be compensable if it arise out of and in the course of employment. Today one no longer suffers a backache; one "injures" one's back. The experience is further confounded if the sufferer perceives himself as an injured worker. He must prove his persisting illness in an adversarial climate that questions the validity of his symptoms and their pathogenesis on the job. In this contest, the worker, the clinician, and the ethical fabric of Workers' Compensation all fare poorly.