Biomedical subjects

M D Walters

Publications and source records attributed to M D Walters.

At least 37 records · Page 2Linked to original sources

PubMed1999

Laparoscopic surgery for enterocele, vaginal apex prolapse and rectocele.

Laparoscopy has been applied to all aspects of gynecologic surgery, but few investigators have reported the repair of vaginal apex prolapse, enterocele and rectocele via the laparoscopic route. This article reviews the indications, anatomy, operative technique, clinical results and complications of laparoscopic culdeplasty, enterocele repair, posterior repair, sacral colpopexy and vaginal vault-uterosacral ligament suspension.

Female↗

PubMed1999

Laparoscopic surgery for genuine stress incontinence.

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.

Clinical Competence↗

PubMed1999

Functional outcomes and satisfaction after abdominal hysterectomy.

OBJECTIVES: Our aim was to compare urinary, lower gastrointestinal, and sexual function and to describe patients' expectations and satisfaction before and after hysterectomy. STUDY DESIGN: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower gastrointestinal, and sexual function and satisfaction with treatment were assessed. To account for multiple comparisons, only P </=.002 was considered statistically significant. RESULTS: There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy, with preoperative symptoms resolving in some women after surgery and developing in others. Sexual function including orgasmic ability did not change in the 34 sexually active women. The level of satisfaction with treatment was very high. CONCLUSIONS: Women experience high degrees of satisfaction and no consistent changes in urinary, lower gastrointestinal, or sexual function after abdominal hysterectomy for benign gynecologic conditions.

Adult↗

PubMed1999

Laparoscopic management of pelvic organ prolapse.

Until recently, most major gynecologic surgery was performed either vaginally or by laparotomy. In the last decade, surgeons have explored laparoscopic access for many gynecologic surgical disorders. Pelvic reconstructive surgery can be performed laparoscopically but demands a high skill level especially in suturing. Initial reports for laparoscopic bladder neck suspension for genuine stress urinary incontinence are encouraging but lack long term follow-up. The literature contains only a few case studies addressing pelvic support procedures. In this review we present our methods for laparoscopic management of different types of pelvic floor support defects. We view laparoscopy as a method of access rather than a procedure. We present laparoscopic techniques that do not modify the surgical procedures that have been validated by conventional surgery.

Female↗

PubMed1999

Small bowel obstruction in a peritoneal defect after laparoscopic Burch procedure.

With expansion of laparoscopic surgery, the gynecologic surgeon faces a new set of complications not encountered in open surgery and completely related to the laparoscopic approach. A rare complication occurred after laparoscopic Burch colposuspension performed in a patient with genuine stress urinary incontinence. Although the fascial incision at the right lower quadrant cannula insertion site was closed, a loop of small bowel herniated through the nonclosed peritoneal defect and caused intestinal obstruction 9 days after surgery. For cannula insertion sites 10-mm and greater, we recommend suturing peritoneal defects at the time of fascial closure. (J Am Assoc Gynecol Laparosc 6(3):343-345, 1999)

Aged↗

PubMed1999

What is the cost of getting the price wrong?

BACKGROUND: The objective of this study was to compare differences in cost estimates for paediatric HIV hospital service provision based on hospital prices with cost estimates obtained through a research-based service-specific costing exercise. METHODS: Activity data on the use of hospital services of children by stage of HIV infection were collected from case-notes for 118 HIV antibody positive children, managed at St Mary's Hospital NHS Trust, London, 1 January 1986-31 December 1994. Hospital unit prices were obtained from the Hospital Trust Finance Department; unit cost estimates were obtained from relevant hospital departments through a research-based service-specific costing exercise. Financial data related to the 1993-1994 financial year, and were indexed to 1995-1996 prices. The main outcome measures were cost estimates per patient-year by stage of HIV infection. Three cost scenarios were calculated: first by linking activity data with hospital prices (Trust Prices); second by linking activity data with routinely available hospital prices plus units costs from the costing exercise where no relevant hospital prices existed (Supplemented Trust Prices); third, by linking activity data exclusively with unit costs from the hospital-specific costing exercise (Unit Costs). RESULTS: There were substantial differences between unit cost estimates per patient-year based on Trust Prices and Supplemented Trust Prices compared with those based on Unit Costs. Differences increased with more intense use of services. The deficit based on Trust Prices compared with Unit Costs ranged from Pound Sterling 432 per patient-year for HIV negative children, Pound Sterling 574 for asymptomatic HIV-infected children, Pound Sterling 1288 for indeterminate children, Pound Sterling 1814 for children with symptomatic non-AIDS to Pound Sterling 7418 per patient-year for children with AIDS. CONCLUSIONS: In this hospital, reliance on generic hospital prices to derive cost estimates for paediatric HIV services produced considerable underestimates of the cost of service provision compared with data derived through the costing exercise. If this occurs across all or most areas of service provision, this can lead to substantial financial deficits, which in turn may mean that the needs of specific client populations may not be met.

Bias↗

PubMed1999

Effective dose equivalent due to gamma-ray emissions from hot particles.

The quantification of dose from hot particles in the nuclear power industry has received a good deal of attention in the past few years. Specifically, calculational models have been developed to determine shallow dose equivalent from both beta and gamma-rays (using VARSKIN) and to estimate deep dose equivalent based upon the gamma dose at a tissue depth of 1 cm. These two values are reported for regulatory purposes. The purpose of this study is to estimate another measure of dose from hot particles (or from skin contamination over a small area), specifically the effective dose equivalent which takes into account all organs of the body receiving appreciable dose from the gamma-ray emissions from the contamination. While it is generally recognized that this dose will be small, this study gives representative doses for a range of hot particle locations and gamma-ray energies. MCNP and the ADAM phantom have been used for the calculational model. The effective dose equivalent is found to range from 0.1 to 12 microSv h(-1) MBq(-1) (0.4 to 43 microrems h(-1) microCi(-1)) of gamma activity, depending upon the location of the hot particle on the body.

Dose-Response Relationship, Radiation↗

PubMed1998

Posterior vaginal prolapse and bowel function.

OBJECTIVE: This study's objectives were to describe symptoms related to bowel dysfunction in women with uterovaginal prolapse and to compare these symptoms according to extent of posterior vaginal prolapse. STUDY DESIGN: One hundred forty-three women completed a questionnaire assessment of bowel function and underwent standardized physical examination according to the International Continence Society's system for grading uterovaginal prolapse. RESULTS: The mean age was 59.2 years (SD 11.8 years); 78% of the women were postmenopausal. According to the furthest extent of posterior vaginal prolapse at point Bp, 22 (15.5%) were in stage 0, 46 (32.4%) were in stage I, 50 (35.2%) were in stage II, 23 (16.2%) were in stage III, and 1 (0.7%) was in stage IV. Ninety-two percent of women reported having bowel movements at least every other day. When asked whether straining was required for them to have a bowel movement, 38 (26.6%) reported never or rarely, 71 (49.6%) reported sometimes, 20 (14.0%) reported usually, and 14 (9.8%) reported always. When asked whether they ever needed to help stool come out by pushing with a finger in the vagina or rectum, 98 (69.0%) reported never or rarely, 30 (21.1%) reported sometimes, 8 (5.6%) reported usually, and 6 (4.2%) reported always. Twenty-three women (16.1%) had fecal incontinence, with 11 having loss of control of stool less often than once a month and 12 having it more often than once a month. When asked whether to rate how much they were bothered by their bowel function on a scale of 1 to 10, with 1 being not at all and 10 being extremely, 51.7% of women chose 1 to 4, 20.3% chose 5 to 7, and 28% chose >/=8. There were no clinically significant associations between any of the questions related to bowel function and severity of posterior vaginal prolapse. CONCLUSION: Women with uterovaginal prolapse frequently have symptoms related to bowel dysfunction, but this is not associated with the severity of posterior vaginal prolapse.

Attitude to Health↗

PubMed1998

Staple pull-out strength in an animal model of Cooper's ligament.

STUDY OBJECTIVE: To understand the effect of staple number, orientation, and configuration on pull-out strength in an animal model of Cooper's ligament, and compare it with force to knot failure or suture breakage. DESIGN: Comparative study (Canadian Task Force classification I). SETTING: Ethicon Endo-Surgery Institute, Cincinnati, Ohio. SUBJECTS: Fibrous connective tissues from bovine ischia were the tissue model. INTERVENTION: Specimens were fixed in a cement-plaster compound and mounted in a tensiometer. Endoscopic staples were used to hold a loop of 0-braided polyester suture to the tissue. MEASUREMENTS AND MAIN RESULTS: The suture loop was pulled perpendicularly away from tissue at a constant rate of 2.1 mm/second and peak force to staple pull-out was recorded. Two staple orientations and four staple configurations were studied. Tests were applied in a factorial arrangement. Ten-millimeter stitches of 0-braided polyester suture in the model were also tested. Maximum force to staple pull-out depended on staple number, orientation, and configuration. Peak force required to remove two staples was significantly higher than that to remove one. Spacing between two staples was less important. Pull-out strength was significantly higher when staples were placed parallel to tissue fibers. Stitches placed perpendicular to fibers failed at the knot or by suture breakage with a mean force approximately two times the peak force to remove two staples. CONCLUSION: Two staples placed 2 to 5 mm apart parallel to tissue fibers resulted in the greatest pull-out strength of studied configurations.

Animals↗

PubMed1997

The spectrum of eye disease in children with AIDS due to vertically transmitted HIV disease: clinical findings, virology and recommendations for surveillance.

BACKGROUND: Eye disease in children infected with HIV is uncommon, but there is little information on which children require screening or surveillance and the management of those with retinitis. METHODS: We examined 12 children with symptomatic HIV disease (of a cohort of 98 HIV-positive children) using indirect ophthalmoscopy. When retinitis was found it was documented photographically at the time of diagnosis and on follow-up. RESULTS: Four cases of infective retinitis were diagnosed: three with probable cytomegalovirus retinitis and one with progressive outer retinal necrosis. CONCLUSION: Detection of reactivation is difficult and we recommend fundus photography under general anaesthesia wherever possible. Children with other end-organ disease, symptomatic eye disease and advanced HIV disease with severe immunosuppression require ophthalmological surveillance.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Uterine myomas and factors associated with hysterectomy in premenopausal women.

OBJECTIVE: Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy. STUDY DESIGN: Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression. RESULTS: Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of > 2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy. CONCLUSIONS: In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall.

Adult↗

PubMed1997

Anterior vaginal prolapse: review of anatomy and techniques of surgical repair.

OBJECTIVE: To summarize the literature on anterior vaginal prolapse, focusing on vaginal anatomy, etiologic theories, and comparison of anterior colporrhaphy and paravaginal repair. DATA SOURCES: We identified articles related to anterior vaginal prolapse through a MEDLINE search of English-language literature published from January 1966 through December 1995 and in bibliographies in gynecologic textbooks. METHODS OF STUDY SELECTION: We reviewed 80 articles published in peer-reviewed journals or textbooks and related to anterior vaginal prolapse. In addition, ten articles on operative procedures for urinary incontinence were studied. TABULATION, INTEGRATION, AND RESULTS: We abstracted and synthesized information from 31 papers that contained descriptions of and opinions on vaginal anatomy and etiology of vaginal prolapse. The vagina has three layers-mucosa, muscularis, and adventitia; there is no vaginal "fascia." Vaginal support is provided by the underlying levator ani muscles and by lateral connective-tissue attachments at the arcus tendineus fasciae pelvis or "white line." Anterior vaginal prolapse results from direct or indirect damage to the pelvic muscles or connective tissue or both. Forty-nine articles described surgical techniques for the correction of anterior vaginal prolapse, and 24 of them reported postoperative outcomes. Reported failure rates ranged from 0-20% for anterior colporrhaphy and 3-14% for paravaginal repair. No controlled studies compared different procedures performed primarily for correction of anterior vaginal prolapse. CONCLUSIONS: Dissection during anterior colporrhaphy splits vaginal muscularis, and repair involves plication of the muscularis and adventitia (not vaginal "fascia") in the midline, which may pull the lateral attachments further from the pelvic sidewall. Paravaginal repair restores the lateral attachments to the pelvic sidewall at the white line. Controlled studies that compare directly these two procedures for anterior vaginal prolapse repair are necessary to determine their relative effectiveness.

Female↗

PubMed1997

Fecal incontinence in women with urinary incontinence and pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of and factors associated with fecal incontinence in women with urinary incontinence or pelvic organ prolapse. METHODS: Study subjects were recruited prospectively, and all participants received questionnaires regarding bowel function and underwent a standardized history and physical examination. Fecal incontinence was defined as the involuntary loss of feces sufficient to be considered a problem by the patient. RESULTS: Forty-two subjects had fecal incontinence, an overall prevalence of 17%. One hundred seventy women had urinary incontinence, pelvic organ prolapse, or both, and 36 of these (21%) had fecal incontinence. One hundred (40%) women had urinary incontinence, of whom 31 also had fecal incontinence. Seventy women had isolated pelvic organ prolapse and five (7%) were incontinent of feces. Univariate analysis revealed that any degree of pelvic organ prolapse, increasing degrees of prolapse within each vaginal segment, urinary incontinence, advanced age, postmenopausal status, increased vaginal parity, prior hysterectomy, history of irritable bowel syndrome, and abnormal sphincter tone were associated significantly with fecal incontinence. Multiple logistic regression analysis indicated that only urinary incontinence (odds ratio [OR] 4.6, P < .001, 95% confidence interval [CI] 1.9, 11.2), abnormal anal sphincter tone (OR 2.3, P = .04, 95% CI 1.1, 5.1), and irritable bowel syndrome (OR 8.3, P = .002, 95% CI 2.1, 32.8) were associated with fecal incontinence. CONCLUSIONS: There is a high rate of fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Clinicians providing health care to a similar group of women should inquire routinely and specifically about fecal incontinence.

Adult↗

PubMed1997

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Adult↗

PubMed1997

Combination of pessary and periurethral collagen injections for nonsurgical treatment of uterovaginal prolapse and genuine stress urinary incontinence.

BACKGROUND: The combination of severe uterovaginal prolapse and stress urinary incontinence in medically compromised patients in whom surgery is contraindicated is a difficult treatment dilemma. CASE: A 75-year-old woman with severe cardiac compromise and a history of pulmonary embolus presented with severe uterovaginal prolapse and stress urinary incontinence. The combination of a vaginal pessary and three periurethral collagen injections resulted in successful management of her prolapse and resolution of her stress urinary incontinence. CONCLUSION: Although pessaries are frequently a satisfactory treatment option for women with severe uterovaginal prolapse, the appearance or worsening of urinary incontinence may make the option of pessary use less attractive. The addition of periurethral collagen injections will improve or cure urinary incontinence symptoms.

Aged↗

PubMed1996

Endotoxin exposure-response in a fiberglass manufacturing facility.

Peak expiratory flow (PEF) and workplace exposure to endotoxin, phenolic resin, and formaldehyde were measured to investigate asthma symptoms and medication use among employees in a fiberglass wool manufacturing plant. Self-recorded PEF was obtained from 37 workers, for a total of 181 days off work and 187 days at work with concurrent personal exposure monitoring. Pre- and post-shift spirometry were obtained on at least 2 days. The 8 hr time-weighted average personal exposure ranges were endotoxin; 0.4-759 ng/m3; phenolic resin, 5.7-327 micrograms/m3; and formaldehyde, 1.2-265 micrograms/m3. Amplitude percent mean peak flow was associated with years since starting regular work in the highest endotoxin exposure area, although current assignment in that area was associated with reduced amplitude--evidence for a healthy worker effect. Exposure-response was analyzed by regression of lung function change on exposure using generalized estimating equations with robust variance estimates. Endotoxin exposure above 4 ng/m3 (8 hr time-weighted average) was associated with a decline in lung function across the work shift, and with drops in lung function 16-20 hr after exposure. Phenolic resin exposure was not consistently associated with decrements, and formaldehyde was not associated with decrements in lung function.

Adult↗

PubMed1996

Interobserver variation in the assessment of pelvic organ prolapse.

The aim of this study was to determine the interobserver agreement of two grading systems for pelvic organ prolapse: the vaginal profile and the International Continence Society (ICS) draft proposal. Forty-nine consecutive women referred for evaluation of urinary incontinence and/or pelvic organ prolapse were studied. Patients were first examined by a physician and a nurse clinician using the vaginal profile, followed by an examination according to the technique described in the ICS draft proposal for standardization of terminology (1994). kappa statistic and Pearson's correlation coefficient were used to determine interobserver variability for the ICS system by overall stage, by stage-specific comparison, and by specific anatomic location. The vaginal profile was evaluated by obtaining a kappa for overall degree of prolapse, stage-specific comparison and by anatomic area. The kappa for the ICS stage was 0.79 (P < 0.001), and the kappa for the vaginal profile by area of greatest prolapse was 0.68 (P < 0.001), indicating substantial interobserver agreement for both systems. The ICS system was noted to have substantial interobserver agreement by a stage-specific comparison. All anatomic locations of the ICS staging system were found to correlate significantly, and a high degree of interobserver precision was found. The vaginal profile also showed significant interobserver agreement by overall degree of prolapse, by specific degree of prolapse, and by anatomic area. It was concluded that both the proposed ICS staging system and the traditional vaginal profile show significant interobserver agreement both by overall stage, stage-specific analysis and specific location. The registered nurse examination correlated well with the physician examination, indicating that the most important factor in obtaining reproducible results may be definition and close attention to examination technique.

Female↗

PubMed1996

Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy.

OBJECTIVE: To describe a technique of transvaginal mobilization and removal of ovaries and tubes, and to assess its use in older women undergoing vaginal hysterectomy. METHODS: Charts of 151 women age 50 and older who underwent vaginal hysterectomy by one senior gynecologic surgeon during 1991-1993 were reviewed. RESULTS: Ninety of 138 women (65%) who chose ovarian removal had their ovaries successfully removed vaginally. In 48 women, one or both ovaries were examined and noted to be normal, and they were not removed or could not be removed vaginally. Operating time, estimated blood loss, length of hospital stay, and rates of intraoperative complications and postoperative morbidity did not differ significantly in the bilateral salpingo-oophorectomy and ovarian conservation groups. CONCLUSION: Transvaginal removal of ovaries and tubes can be achieved in about two-thirds of women undergoing vaginal hysterectomy with minimal or no increases in operating time and surgical morbidity.

Aged↗