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W Nugent

Publications and source records attributed to W Nugent.

17 recordsLinked to original sources
PubMed2003

Catheter-associated masses in patients receiving intrathecal analgesic therapy.

UNLABELLED: A cohort of seven patients receiving intrathecal analgesic drug therapy for chronic intractable pain underwent radiocontrast myelography and computed tomography (CT) scanning to screen for catheter-associated intrathecal masses. Three of seven patients examined had intraspinal masses associated with the tip of the drug infusion catheter after a total of 118 mo of therapy. The index case presented with exacerbation of neuropathic pain and paralysis of the left lower extremity. The two additional cases detected by CT myelography were asymptomatic at the time the catheter-associated mass was assessed. The mean duration of therapy before diagnosis of the catheter-associated mass was 19.6 mo, with a range of 16-25 mo. An intergroup comparison of demographic and treatment variables between patients, with and without catheter-associated masses, demonstrated that patients with masses were younger and were receiving a larger morphine dose than patients without masses. The differences were statistically significant (P = 0.05). In one patient with an asymptomatic catheter-associated intrathecal mass, regression of the mass was observed after cessation of therapy. In a second asymptomatic patient, the mass remained stable over 1 yr of continued treatment after substitution of hydromorphone for morphine without interruption of therapy. Neither asymptomatic patient has subsequently developed additional neurologic findings or injury after detection of occult catheter-associated intrathecal masses and clinical intervention. We suggest that all patients receiving long-term intrathecal analgesia should undergo periodic radiographic surveillance to further define their risk of developing occult catheter-associated masses and to allow intervention before neurologic injury can develop. IMPLICATIONS: Catheter-associated intrathecal masses were detected in three of seven patients receiving long-term intrathecal analgesia. In the two asymptomatic patients, timely clinical intervention was associated with the avoidance of subsequent neurologic injury and spontaneous resolution of one of the occult masses.

Aged↗
PubMed2002

Comparison of transvaginal ultrasound, hysteroscopy, and dilatation and curettage in the diagnosis of abnormal vaginal bleeding and intrauterine pathology in perimenopausal and postmenopausal women.

STUDY OBJECTIVE: To compare transvaginal ultrasound, hysteroscopy, and dilation and curettage (D&C) in the evaluation of women with perimenopausal and postmenopausal bleeding. DESIGN: Descriptive study (Canadian Task Force classification II-1). SETTING: Seven outpatient clinics. PATIENTS: One thousand two hundred eighty-six women. INTERVENTION: Transvaginal ultrasound, hysteroscopy, and D&C. MEASUREMENTS AND MAIN RESULTS: Of our patient population, 29 (2.26%) had a histologic diagnosis of endometrial carcinoma; in 2 of them (7.14%) endometrial thickness was 5 mm or less. In 10 women (34.5%), endometrial carcinoma was missed by hysteroscopy (sensitivity 65.52%, specificity 99.92%). Complication rate of D&C was 1.4%. CONCLUSION: In women with perimenopausal and postmenopausal bleeding neither transvaginal ultrasound nor hysteroscopy as a single diagnostic tool is suitable to rule out endometrial cancer.

Dilatation and Curettage↗
PubMed1999

Field triage of the pulseless trauma patient.

HYPOTHESIS: Trauma patients who are pulseless at the scene of injury and whose electrical cardiac activity is less than 40 beats/min cannot be revived. DESIGN: Retrospective review. SETTING: University hospital, level I trauma center. PATIENTS: Pulseless trauma patients who had cardiopulmonary resuscitation at the scene, en route, or in the emergency department and presented between January 1, 1991, and July 1, 1996. MAIN OUTCOME MEASURE: Survival after traumatic cardiopulmonary arrest. RESULTS: Sixteen thousand seven hundred twenty-four trauma patients were admitted. The study cohort comprised 604 victims of traumatic cardiopulmonary arrest, 304 as a result of blunt injury and 300 as a result of penetrating injury. Transport time for the study patients was 11+/-6.1 minutes (mean +/- SD). Cardiopulmonary resuscitation was performed on them for 22+/-11 minutes. Three hundred four patients (50%) had resuscitative thoracotomy in the emergency department; 160 patients were taken to the operating room for further resuscitation and treatment of their injuries. Sixteen patients (2.6%) survived to discharge from the hospital; 7 had severe neurologic disabilities. No patient (0/212) with electrical asystole survived. Five of 134 patients with an initial electrical heart rate between 1 and 39 beats/min survived long enough to reach the intensive care unit but died within 48 hours (4 died within 24 hours). No patient survived to leave the hospital if the initial electrical heart rate was less than 40 beats/min. All 16 survivors had an initial heart rate of 40 beats/min or greater. CONCLUSION: Trauma victims who are pulseless and have asystole or agonal electrical cardiac activity (heart rate <40 beats/min) should be pronounced dead at the scene of injury.

Adult↗
PubMed1996

Using qualitative and quantitative patient satisfaction data to improve the quality of cardiac care.

BACKGROUND: In early 1993 leaders within the Hitchcock Clinic and cardiac services section at Dartmouth-Hitchcock Medical Center (Lebanon, NH) formed the Cardiac Services Improvement Group (CSIG) as a pilot program for patient-centered quality improvement (QI) at the sectional level. CSIG PROGRAM: For open heart surgery (OHS) and percutaneous transluminal coronary angioplasty (PTCA), a flowchart was constructed of sequential patient experiences. Content analysis of focus group discussions resulted in six key patient-defined quality characteristics: comfort, caring, certainty, convenience, communication, and cost. Linking of patient comments to points on the patient experience flowchart made it possible to determine where particular quality characteristics were most relevant. A patient satisfaction survey with questions that were specific to a patient experience and to a quality characteristic was mailed to 100 consecutively discharged OHS and PTCA patients; 35 of the 50 patients in each group responded. EVALUATING SUCCESS: Analysis of the survey results led to the formation of two QI teams. One team began work on development of a critical pathway for discharge preparation and identified marker questions to track and monitor pathway success in subsequent surveys. Another team began the development of protocols for more effective pain management during and after the PTCA procedure. A repeat patient satisfaction survey that took place from November 1994 to March 1995 suggested a global improvement in patient satisfaction for all patient experiences and all key quality characteristics. CONCLUSION: The CSIG pilot program of patients-based quality measurement and management at the sectional level has been successful in fostering QI team formation and has been associated with a positive deflection in patient-based quality measures. Additional sections of the medical center have initiated similar projects, beginning with process definition and focus groups.

Angioplasty, Balloon, Coronary↗
PubMed1996

Transcostal Access with the Veress Needle in Women with Several Previous Surgeries

Establishing pneumoperitoneum using the classic umbilical port in women who have had several previous surgeries is risky, life threatening, and a diabolic challenge for the surgeon. Open laparoscopy is one alternative, with a risk factor for bowel injury of 0.5%. Since 1992 we have preferred the transcostal approach. A stab incision is made between the ninth and tenth ribs in the left medioclavicular line and a disposable Veress needle is pushed into the coelomic cavity. Passing the needle only in this area of strongly attached peritoneum, the typical needle click is heard and its intraabdominal position is confirmed by an insufflation pressure below 5 mm Hg. After insufflation of 0.5 L, percussion in the right hypochondric quadrant ensures correct distribution of the gas. A contraindication for this port is a prior splenectomy. No complications occurred in our series of 64 patients.

Journal Article↗
PubMed1996

A hemodynamic comparison of Omniscience and Medtronic Hall aortic prostheses.

BACKGROUND AND AIMS OF THE STUDY: Preliminary reports have suggested hemodynamic disparities between single leaflet tilting disc prostheses. We tested the hypothesis that similarities in prosthetic design may not necessarily indicate hemodynamic equivalence. MATERIALS AND METHODS: In a retrospective analysis, we compared the functional characteristics of two single tilting disc (Omniscience and Medtronic Hall) prostheses implanted in the aortic position in 30 patients matched for valve size and left ventricular systolic function. RESULTS: Echocardiographic and Doppler analysis blinded to patient and valve type indicated similar quantitative left ventricular ejection fractions (64% +/- 6% for both) and cardiac outputs (4.8 +/- 1.2 vs. 4.6 +/- 1.2 l/min, p = 0.65) in the Onmiscience and Medtronic Hall groups, respectively. Transprosthetic instantaneous peak gradients were greater for Omniscience than for Medtronic Hall valves (44 +/- 8 vs. 35 +/- 11 mmHg, p < or = 0.02), as were the mean values (24 +/- 6 vs. 18 +/- 6 mmHg, p = 0.01). Even when 21 and 23 mm prostheses were analyzed separately to allow for unequal sewing ring diameters in the smallest valve sizes (Omniscience = 19 mm, Medtronic Hall = 20 mm), higher gradients were noted in the Omniscience prostheses. Effective orifice areas were smaller in the Omniscience than Medtronic Hall prostheses whether data from all prostheses (0.92 +/- 0.11 cm2 vs. 1.09 +/- 0.18 cm2, p < or = 0.05), or only data from 21 and 23 mm valves (0.94 +/- 0.11 cm2 vs. 1.10 +/- 0.18 cm2, p < 0.05) were included. Similarly, the dimensionless obstructive index, a parameter independent of left ventricular flow and annular size, was reduced in the Omniscience valves, indicating greater obstruction, whether all valves (0.31 +/- 0.04 vs. 0.36 +/- 0.07, p < or = 0.01) or only 21 and 23 mm valves (0.31 +/- 0.04 vs. 0.36 +/- .04, p < 0.001) were analyzed. CONCLUSION: Despite prosthetic design similarities, resting hemodynamic assessment indicates greater stenosis in Omniscience than Medtronic Hall valves when placed in the aortic position. The long term effects of these differences in terms of ventricular diastolic and systolic function and mass regression requires further evaluation.

Aortic Valve Insufficiency↗
PubMed1996

[Aspects of peritoneal fascia closure after surgical laparoscopy].

Following laparoscopic surgery using trocar ports of 10 mm and more Richter's hernia and incarceration of bowel are reported. To prevent this wound closure of all layers is a must. Newly developed techniques are described. Fascia closure is accompanied by serious pain. Pain management is achieved by local anesthesia.

Anesthesia, Local↗
PubMed1996

[Laparoscopy in the day clinic--a prospective multicenter study for evaluating complications].

In a six centre prospective study complications after outpatient laparoscopies were registered. Within a four month period 1474 patients have been interviewed after one and four weeks. Surgical complications and conversions to laparotomy 0%, wound infections 2.9%, febrile course 2.4%. 3.7% of the patients were hospitalized > 24 hours. No readmissions occurred. Factors influencing the quality of results are discussed.

Adult↗
PubMed1994

Gynecologic laparoscopy and hysteroscopy in a day clinic: trends and perspectives.

We have increased the performance of minimally invasive gynecologic surgery from about 15% to 20% of operations a year, especially hysteroscopies and laparoscopies, many of which are performed in a free-standing ambulatory unit. In 1992 our team performed 8057 outpatient operations, significantly more than in 1991. As the techniques are developed, the number of indications for these operations expands. By maintaining high standards, even with major endoscopic procedures, we have a very low complication rate.

Female↗
PubMed1993

Differences between men and women in hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group.

BACKGROUND: A prospective study of patients undergoing coronary artery bypass graft surgery (CABG) was conducted to examine differences in hospital mortality by sex. Outcome data on 3055 CABG patients undergoing operation between 1987 and 1989 were examined for differences in patient, disease, and treatment factors. METHODS AND RESULTS: Odds ratios (OR), risk differences, and 95% confidence intervals (CI95%) were calculated. Mortality rates for women (7.1%) and men (3.3%) differed, the OR (women versus men) being 2.23 (CI95%, 1.58 to 3.15). Women were older, more often diabetic, and had more urgent or emergent surgery; adjustment yielded an OR (women versus men) of 1.75 (CI95%, 1.17 to 2.63). Body surface area (BSA) was associated with risk of death in both sexes (P = .007) and positively associated with coronary artery luminal diameters. After adjustment for BSA, sex was no longer significantly associated with mortality (OR [women versus men] of 1.18; CI95%, 0.72 to 1.95). Internal mammary artery (IMA) grafting was performed less frequently among women than men (64.8% versus 78.4%, P < .001). Smaller BSA and absence of IMA grafting were each associated with increased risk of death (RD) from heart failure. Risk of death from heart failure (RD [women minus men] = 2.05; CI95%, 0.89 to 3.22) and hemorrhage (RD [women minus men] = 0.63; CI95%, 0.13 to 1.13) was greater among women; these accounted for 71.1% of the sex-specific difference in mortality rates. CONCLUSIONS: Excess risk of hospital mortality among women having CABG was largely the consequence of death from heart failure and, to a lesser extent, from hemorrhage. Smaller BSA (probably because of its association with coronary artery luminal diameter) and the absence of IMA grafting were each associated with increased risk of death from heart failure.

Aged↗
PubMed1993

[Diagnostic problems in HELLP syndrome--presented with reference to 20 case reports].

15 so-called "definite" cases and five so-called "questionable" cases of HELLP-Syndrome are reported and discussed. The cases demonstrate the chameleon-like behaviour of symptoms and how difficult it can be to avoid it's full manifestation even if careful attention is paid to liver enzymes or platelets. Elevated liver enzymes and low platelets are also found in normal pregnancies making differential diagnosis more difficult as the retrospective analysis of laboratory findings of more than 2000 normal pregnancies shows. Even though, careful attention should be paid to detect any early laboratory finding or clinical sign of HELLP-Syndrome in order to prevent dramatic outcomes. Any symptoms of gestosis should be reason to determine not only liver enzymes and platelets, but also haptoglobin as the latter seems to detect early hemolysis in a beginning HELLP-Syndrome.

Abortion, Induced↗
PubMed1992

[Detection of fibronectin for confirming the diagnosis of premature rupture of fetal membranes].

Diagnosis of premature rupture of membranes (PROM) usually leads to severe clinical consequences. Diagnostic tests for confirmation of suspected rupture of membranes are either unreliable or can adversely affect the pregnancy. Foetal fibronectin is synthesised by the foetoplacental membranes especially in the anchoring villus. Its concentration in the amniotic fluid is 5-10 times greater, than in the maternal plasma. An immunoassay has recently been developed, which detects fibronectin in vaginal secretions using monoclonal antibodies, thereby establishing the presence of amniotic fluid in the vagina. Vaginal specimens were collected from 133 pregnancies. 34 of 35 patients with clearly visible amniotic fluid in the vagina had a positive test result (97.1%), whereas the majority of the control group without any signs of ruptured membranes had negative test results (96.5%). 39 of 41 women with positive test results delivered within 48 hours (95%). A positive test result thus helps to confirm the diagnosis of PROM especially in equivocal cases or may indicate forthcoming labour.

Amniotic Fluid↗