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Biomedical subjects

J Merrill

Publications and source records attributed to J Merrill.

At least 19 recordsLinked to original sources
PubMed1999

Prior treatment history and its impact on criminal recidivism.

This study examines the hypothesis that treatment is a cumulative process; that is, treatment success is best viewed in terms of the patient's entire treatment history, rather than the index treatment episode. Three-hundred and eight patients with a primary heroin addiction were studied for 2 years posttreatment. Using posttreatment arrests as the dependent variable, the effects of prior treatment were assessed. Those with six or more prior treatment episodes and who had been in treatment for 12 or more months during the most recent episode averaged only 0.2 arrests in the 2 years posttreatment, while those with no prior treatment, but 12 or more months in the recent treatment averaged 0.88 arrests. Logistic analysis found that each prior treatment reduced the probability of a posttreatment arrest by 25%. Based on a linear regression, patients with six or more treatments prior treatments averaged half the number of posttreatment arrests as someone with no treatments before the index episode.

Adult↗
PubMed1999

Changes in oxygenation with inhaled nitric oxide in severe bronchopulmonary dysplasia.

BACKGROUND: Severe bronchopulmonary dysplasia (BPD), which is associated with high mortality and morbidity, is thought to be the result of mechanical, inflammatory, and oxidant injury to the immature lung, and includes the development of pulmonary hypertension with vascular remodeling. METHODS: A phase II pilot study was conducted to determine the effect of inhaled nitric oxide (iNO) on oxygenation in severe BPD. This was an open-labeled, noncontrolled trial to evaluate safety and determine appropriate dosing for a future randomized controlled trial. Infants were eligible for enrollment if they were >/=4 weeks of age and ventilator dependent with a mean airway pressure of >/=10 cm H2O and an FIO2 of >/=0.45. Study infants received iNO (20 ppm) for 72 hours, and FIO2 was adjusted to maintain oxygen saturations of >92%. Infants who had a >/=15% reduction in FIO2 after 72 hours received prolonged treatment with low-dose iNO, weaning by 20% every 3 days as tolerated. FINDINGS: Sixteen preterm infants (23-29 weeks of gestation), age 1 to 7 months, were enrolled. Eleven of 16 infants had a significant increase in PaO2 after 1 hour of iNO (median change, 24 mm Hg; range, -15 to 59 mm Hg; P <.01), but there was no significant change in PaCO2. After 72 hours of iNO, 11 infants had >/=15% reduction in FIO2, and 7 of the 11 had >/=35% reduction (P <. 01). Among the 11 infants who responded to iNO after 72 hours, 10 had a sustained improvement in oxygenation throughout their course of treatment (duration, 8-90 days), and ventilator support could also be decreased. No adverse effects from iNO (increased methemoglobin, bleeding, or increased plasma 3-nitrotyrosine) were observed. Four of the 11 infants (36%) who responded to iNO ultimately weaned off mechanical ventilation and 4 died, whereas all the infants who failed to respond to iNO either died or continue to require mechanical ventilation. INTERPRETATION: We conclude that the use of low-dose iNO may improve oxygenation in some infants with severe BPD, allowing decreased FIO2 and ventilator support without evidence of adverse effects. Randomized clinical trials of low-dose iNO for BPD are warranted.

Administration, Inhalation↗
PubMed1998

Caring for terminally ill persons: comparative analysis of attitudes (thanatophobia) of practicing physicians, student nurses, and medical students.

To investigate why some caregivers desire to avoid patients with terminal illnesses, a thanatophobia scale assessing caregivers' uncomfortable feelings and sense of helplessness was developed and evaluated among practicing physicians and student nurses and medical students. As a group, student nurses scored lower on the thanatophobia scale than practicing physicians and medical students. Higher scores on intolerance to clinical uncertainty were associated with higher thanatophobia scores in all groups. Scores for depressed mood, decreased sensitivity, and Machiavellianism were statistically significant predictors in some groups. Higher thanatophobia scores also predicted lower scores for ratings of self-esteem in caring for elderly patients. Among senior medical students, those with lower thanatophobia scores tended to enter primary care residencies. Health professional educators may find this scale helpful both in pinpointing sources of caregivers' angst and useful in counseling students in management of terminally ill persons.

Adult↗
PubMed1996

Rapid determination of amphetamine stereoisomer ratios in urine by gas chromatography-mass spectroscopy.

We describe a method for the determination of amphetamine optical isomer ratios. A simple basic extraction of amphetamine from urine is followed by on-column derivatization with (S)-(-)-N-(trifluoroacetyl)-L-prolyl chloride and analysis by gas chromatography-mass spectroscopy. This approach has been shown to be satisfactory for the separation of d- and l-amphetamine isomers and precision data shows the method to be reproducible. Patient data is presented to demonstrate the ability to differentiate between patients taking d-amphetamine and those using illicit (racemic) amphetamine by their l/d amphetamine ratio.

Amphetamine↗
PubMed1995

Helping community health centers adapt to changing environments: one foundation's response.

The history of community health centers (CHCs) reflects attitudes toward health care delivery in general. Developed as part of the war on poverty, they later survived the more conservative attitudes of the early 1970s to flourish in the late 1970s. In the 1980s, we again witnessed a reduction in the funding available to CHCs. In response to this, The Robert Wood Johnson Foundation (RWJF) established The Program to Strengthen Primary Care Health Centers. The program was designed to help centers to adapt to this environment by becoming more businesslike in their operations and decreasing their dependence on public dollars.

Community Health Centers↗
PubMed1995

Coagulation monitoring during extracorporeal membrane oxygenation: the role of thrombelastography.

Patients undergoing extracorporeal membrane oxygenation (ECMO) are at an increased risk for developing coagulopathies due to the adverse effects of extracorporeal circulation on the hemostatic mechanism. Methods of determining causative factors of bleeding diathesis are often inconsistent and non-specific. ECMO patients require aggressive transfusion therapy with autogenic blood products to stabilize and maintain hemostasis. The present study evaluated the coagulation status of newborn patients undergoing ECMO therapy, using a viscoelastic monitor (Thrombelastograph -TEG) that measures functional aspects of clot development and stabilization. Seventeen neonatal patients undergoing ECMO for severe respiratory dysfunction were entered into this study. Serial blood samples were obtained and routine coagulation assessment including fibrinogen concentration, platelet count and ionized calcium was performed. In addition, fibrin(ogen) degradation products (FDP), d-Dimers, antithrombin III and plasma free hemoglobin were measured. Transfusion indicators were established and total transfusion requirements recorded. TEG profiles were determined with the use of heparinase, an enzyme that degrades heparin but has little effect on other coagulation factors. The most commonly encountered complication was hemorrhaging which was diagnosed by laboratory and clinical assessment in 11 of 17 patients. Transfusion requirements (measured in ml/kg/ECMO hour) were the following: packed red blood cells--1.34 +/- 0.5; platelets--0.71 +/- 0.57; fresh frozen plasma--0.09 +/- 0.12; cryoprecipitate 0.05 +/- 0.05. Thrombelastograph profiles reflected hemostatic conditions that ranged from severe coagulopathies (DIC) to hypercoagulability. Interpretation of TEG profiles identified hemostatic abnormalities in 57 of 101 profiles (46.5%), with the most common etiology related to platelet dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Coagulation Disorders↗
PubMed1994

Henoch-Schönlein purpura remitting in pregnancy and during sex steroid therapy.

This paper reports on a 22-yr old female patient with recurrent bouts of Henoch-Schönlein purpura since puberty occurring monthly at the time of menstruation. Remissions occurred during pregnancy, and on several occasions and in a dose responsive manner when the patient was prescribed birth control pills containing progesterone and oestradiol. Flares recurred when this therapy was discontinued. We hypothesize that this patient has an inflammatory disease involving neutrophil activation by excessive IgA, which is modulated by exogenous and endogenous sex steroids. It is unlikely that these hormonal influences are a common occurrence, but rather represent, in this case, a singular example of potential endocrine modulation of inflammatory disease.

Adult↗
PubMed1993

Neonatal complications after the administration of indomethacin for preterm labor.

BACKGROUND: The use of indomethacin as a tocolytic agent in pregnant women appears to be accompanied by a low incidence of neonatal complications. However, the neonatal effects of indomethacin have been studied primarily in infants born after 32 weeks' gestation. This study was designed to examine the incidence of neonatal complications in very premature infants. METHODS: We identified 57 infants delivered at or before 30 weeks' gestation whose mothers had been treated with indomethacin for preterm labor and matched them with 57 infants whose mothers had not received indomethacin. The infants in the two groups were matched for sex, gestational age at delivery (mean [+/- SD], 27.6 +/- 2.0 weeks), exposure to betamethasone for 24 hours or more before delivery, and rupture of membranes 24 hours or more before delivery. RESULTS: There were no significant differences between the two groups in birth weight, Apgar scores, cord-blood gas values, frequency of multiple gestation, or incidence of respiratory distress syndrome. The proportion of infants who required exogenous surfactant was similar, as were ventilator settings at 24 hours, the incidence of chronic lung disease, and the incidence of sepsis. The infants exposed to indomethacin had a lower urine output and higher serum creatinine concentrations during the first three days after delivery. More indomethacin-exposed infants had necrotizing enterocolitis (29 percent vs. 8 percent, P = 0.005), intracranial hemorrhage grade II to IV (28 percent vs. 9 percent, P = 0.02), and patent ductus arteriosus (62 percent, vs. 44 percent, P = 0.05). More indomethacin-exposed infants with a patent ductus arteriosus required surgical ligation because of either a lack of initial response or a reopening of the duct after postnatal indomethacin therapy (50 percent vs. 20 percent of the unexposed infants, P = 0.05). CONCLUSIONS: Antenatal indomethacin therapy for preterm labor appears to increase the risk of serious neonatal complications in infants born at or before 30 weeks' gestation.

Cerebral Hemorrhage↗
PubMed1993

Novel brainstem syndrome associated with prostate carcinoma.

Two patients successfully treated for prostatic cancer developed a progressive neurologic syndrome beginning with loss of voluntary horizontal eye movements followed by severe, persistent muscle spasms of the face, jaw, and pharynx. Both had mild gait unsteadiness, and one exhibited facial and abdominal myoclonus. Extensive diagnostic studies, including MRIs of the brainstem (with and without contrast), were normal. CSF examination showed mild pleocytosis and elevated IgG. Quantitative eye movement recordings documented selective involvement of voluntary horizontal saccades with sparing of horizontal slow eye movements. Neither patient had antineuronal antibodies in the blood. Postmortem examination revealed perivascular chronic inflammatory cells and microglial infiltration of the pons and medulla. One patient also had perivascular infiltrates in both mesial temporal lobes. Neuronal loss was localized to the pontine tegmentum, the medullary sensory nuclei, and the cerebellum. Brainstem motor nuclei were preserved. The clinical and pathologic findings suggest an autoimmune process (probably paraneoplastic) with selective damage to a subpopulation of brainstem neurons critical for horizontal eye movements and recurrent inhibition of bulbar nuclei.

Adenocarcinoma↗
PubMed1993

Hematological assessment of patients undergoing plasmapheresis during cardiac surgery.

Methods of reducing patient exposure to homologous blood transfusions include the technique of intraoperative plasmapheresis for the production of platelet rich plasma (PRP). The present study was designed to determine the patient benefits of PRP by examining hemostatic changes in coagulation screens and viscoelastic whole blood monitoring (Thrombelastography, [TEG]). One hundred fifteen patients undergoing elective cardiac surgery were prospectively randomized into a blinded study. Sixty-three patients had 20 percent of the circulating plasma volume sequestered prior to heparinization and pheresed into PRP, which was reinfused 10 minutes following heparin reversal with protamine. The control (CTR) group of 52 patients were exposed to no sequestration procedure. Patients were followed to discharge and 112 parameters, including anthropometric, operative, and postoperative factors, were measured. There were no significant differences between patient groups in preoperative, cardiopulmonary bypass (CPB), or surgical parameters. Average PRP volume was 600+/-100 ml with a total platelet yield of 1.1 billion platelets per patient. TEG indices were determined at four distinct times during the surgical procedure. The CTR group had significantly higher pre-CPB TEG indices of 2.3+/-1.2 and 2.1+/-1.2 (mean+/-SD), vs. 1.8+/-1.5 and 1.4+/-1.7 in the PRP group (p less than .04). Following heparin reversal, pre-PRP reinfusion TEG values were similar between groups, although both groups had significantly decreased indices when compared to pre-CPB values. Thirty minutes post-PRP infusion the treatment group had significantly improved TEG recovery when compared to the CTR group, 1.0+/-1.2 vs. 0.3+/-1.7 (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Alcohol and attempted suicide.

This study investigates the prevalence of excessive drinking and alcohol-related problems amongst suicide attempts. It also compares the characteristics of attempted suicide by alcohol consumption group. Drinking histories were taken on 250 consecutive attempted suicides admitted to the West Midlands Poisons Unit. Fifty-one per cent of the men and 31% of the women drank more than the weekly limits recommended by the Health Education Council. Of the men, 22.5% drank more than 50 units of alcohol a week and 9.5% of the women drank more than 35 units of alcohol a week. Alcohol-related problems (social problems, alcohol dependence or physical illness) were present in 34% of men and 15.5% of women. These results show a greater incidence of alcohol misuse than previous studies on attempted suicide. This is probably because detailed alcohol histories were taken on all patients. Alcohol misuse is best treated before major alcohol-related problems develop. Those responsible for assessing cases of attempted suicide should be adept at detecting alcohol misuse and instituting appropriate management.

Adult↗
PubMed1992

Evaluation of surgical procedures. Changing patterns of patient selection and costs in heart transplantation.

During the past 4 years we have observed a marked increase in costs of heart transplantation in our center. This trend coincides with a shift in our recipient population toward the more severely ill patients. The percentage of patients bound for the intensive care unit has doubled. In analyzing the components of cost, we find that the length of stay, both in special care and regular nursing units, accounts for most of the cost increase. In our study of outcomes we find no significant difference in survival, at 1 month and 1 year, between recipients operated on from the intensive care unit and those not in intensive care. We find that at 1 year after transplantation, approximately 80% of patients are rehabilitated, which we define as the ability to work or to go to school. Only 20% of patients are off disability rolls, however, primarily because of problems related to insurance and the cost of continuing care, including drugs. We conclude that the comprehensive evaluation of surgical procedures requires an approach that balances costs with results on a continuing and long-term basis.

Costs and Cost Analysis↗
PubMed1992

A test of our society: how and for whom we finance long-term care.

Financing long-term care remains an issue of great national interest, but little action. This lack of action is due to a lack of consensus regarding both what we mean by long-term care and what roles the private and public sectors should play. Different solutions have been offered, some focusing on the public sector and others on the private. The reality is that financing the needed care will require participation of both sectors, as well as a redefinition of their roles that makes them complementary rather than competitive, as is now the case. This partnership can take many forms, but must, at a minimum, reflect an explicit societal commitment to what our population is entitled to with respect to long-term care; develop the infrastructure that meets the total--as opposed to only the medical--needs of the population; and make more efficient use of the resources that can be brought to bear on the problem.

Continuity of Patient Care↗
PubMed1991

Detection of lymphocyte subsets using three-color/single-laser flow cytometry and the fluorescent dye peridinin chlorophyll-alpha protein.

The fluorescent dye, Peridinin chlorophyll A protein (PerCP) derived from dinoflagellate organisms (Glenodinium sp.) can be excited by a 488 nm laser and emits light with a large Stokes shift and no major spectral overlap with commonly used chromophores such as fluorescein isothiocyanate (FITC) and R-phycoerythrin (PE). PerCP was conjugated directly to various mouse monoclonal antibodies (mAb) specific for human leukocyte markers or to avidin for use with biotinylated-mAb, and used to perform three color single-laser flow cytometry. The efficacy of this method was demonstrated by analyzing the heterogeneity of thymus T lineage subsets and B lymphocyte subsets in blood. CD4-CD8-, CD4+CD8+ and CD4+CD8- or CD4-CD8+ subsets differ in their expression of cell-cell interaction markers including CD18, CD28, CD44 and Leu 8, and activation/subset markers CD45RO, CD45RA and CD26. Some CD5+ peripheral blood B cells, unlike CD5-B cells, expressed CD45RO or high levels of CD54 (ICAM-1) suggesting the CD5+ B cell population contains activated lymphocytes. The availability of such an accessible method for three color analysis will make it possible to do routine three color monitoring of immunologic diseases such as AIDS, and autoimmune or periodontal diseases.

Antibodies, Monoclonal↗