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Biomedical subjects

M R Miller

Publications and source records attributed to M R Miller.

At least 19 recordsLinked to original sources
PubMed2006

Computer based medication error reporting: insights and implications.

BACKGROUND: Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports. OBJECTIVE: To assess the accuracy and define the epidemiology of medication error reports. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of 581 error reports containing 1010 medication errors reported between July 2001 and January 2003 at a large academic children's institution. MAIN OUTCOME MEASURES: Correct classification and types of medication errors. RESULTS: Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non-descript "other" category on the reporting tool (such as "Prescribing other") which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%). CONCLUSIONS: Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer.

Academic Medical Centers↗
PubMed2005

The evolution of host resistance: tolerance and control as distinct strategies.

In response to parasitic infection, hosts may evolve defences that reduce the deleterious effects on survivorship. This may be interpreted as a form of resistance, as long as infected hosts are able to either recover or reproduce. Here we distinguish two important routes to this form of resistance. An infected host may either: (1) tolerate pathogen damage, or (2) control the pathogen by inhibiting its growth. A model is constructed to examine the evolutionary dynamics of tolerance and control to a free-living microparasite, where both forms of resistance are costly in terms of other life-history traits. We do not observe polymorphism of tolerant genotypes. In contrast, the evolution of control may lead to disruptive selection, and ultimately dimorphism of extreme strains. The optimal host genotype also varies with the type of resistance-individuals invest more in tolerance and pay a greater cost. The free-living framework used makes the distinction between tolerance and control explicit but the distinction applies equally to directly transmitted parasites. Due to the evolutionary differences exhibited, it is important to design experiments that distinguish between the two forms of resistance.

Animals↗
PubMed2004

Extracellular nitric oxide release mediates soluble guanylate cyclase-independent vasodilator action of spermine NONOate: comparison with other nitric oxide donors in isolated rat femoral arteries.

Nitric oxide (NO) and NO donors exhibit actions that are not entirely mediated by soluble guanylate cyclase (sGC). The site of NO release may influence the involvement of sGC-independent effects. Here we use spermine NONOate (SPER/NO) to release NO extracellularly, compared with other NO donors. Isolated rat femoral arteries were perfused luminally and perfusion pressure monitored. Vessels were contracted with phenylephrine (2-14 microM) in the presence of an NO synthase inhibitor (N(omega)-nitro-L-arginine methyl ester; 20 microM). Vasodilator responses to NO donors were assessed before and after perfusion of an sGC inhibitor (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one; ODQ; 20 microM), NO scavengers (hemoglobin; Hb & hydroquinone; HQ), and a superoxide generator (duroquinone; DQ). ODQ (20 microM) abolished the vasodilator responses to glyceryl trinitrate (10(-8) - 10(-3) M), and sodium nitroprusside (10(-8) - 10(-4) M), which release NO intracellularly. ODQ (20 microM) attenuated, but failed to abolish, the vasodilator responses to SPER/NO (10(-6) - 10(-3) M). ODQ abolished responses to S-nitrosoglutathione and S-nitroso-N-valeryl-D-penicillamine (10(-8) - 10(-4) M), but a small residual vasodilatation remained in response to 10(-3) M. In the presence of ODQ, the remaining vasodilatation to SPER/NO was all but abolished by scavengers of extracellular NO (Hb; 10 microM, HQ; 100 microM). Superoxide generation (DQ; 100 microM) also attenuated ODQ-resistant vasodilatation. The data suggest that, in rat femoral arteries, NO donors that are capable of releasing extracellular NO cause vasodilatation that is only partially mediated by sGC. Lack of augmentation of sGC-independent effects by superoxide suggests that they are not mediated by peroxynitrite.

Animals↗
PubMed2003

Ozone exposure decreases the effect of a deep inhalation on forced expiratory flow in normal subjects.

Sixteen healthy nonsmoking subjects (7 women), 21-49 yr old, were exposed in a climate chamber to either clean air or 300 parts/billion ozone on 4 days for 5 h each day. Before each exposure, the subjects had been pretreated with either oxidants (fish oil) or antioxidants (multivitamins). The study design was double-blind crossover with randomized allocation to the exposure regime. Full and partial flow-volume curves were recorded in the morning and before and during a histamine provocation at the end of the day. Nasal cavity volume and inflammatory markers in nasal lavage fluid were also measured. Compared with air, ozone exposure decreased peak expiratory flow, forced expiratory volume in 1 s, and forced vital capacity (FVC), with no significant effect from the pretreatment regimens. Ozone decreased the ratio of maximal to partial flow at 40% FVC by 0.08 +/- 0.03 (mean +/- SE, analysis of variance: P = 0.018) and at 30% FVC by 0.10 +/- 0.05 (P = 0.070). Ozone exposure did not significantly increase bronchial responsiveness, but, after treatment with fish oil, partial flows decreased more than after vitamins during the histamine test, without changing the maximal-to-partial flow ratio. The decreased effect of a deep inhalation after ozone exposure can be explained by changes in airway hysteresis relative to parenchymal hysteresis, due either to ozone-induced airway inflammation or to less deep inspiration after ozone, not significantly influenced by multivitamins or fish oil.

Adult↗
PubMed2003

Administrative data based patient safety research: a critical review.

Administrative data are readily available, inexpensive, computer readable, and cover large populations. Despite coding irregularities and limited clinical details, administrative data supplemented by tools such as the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) could serve as a screen for potential patient safety problems that merit further investigation, offer valuable insights into adverse impacts and risks of medical errors and, to some extent, provide benchmarks for tracking progress in patient safety efforts at local, state, or national levels.

Data Collection↗
PubMed2003

Inadequate peak expiratory flow meter characteristics detected by a computerised explosive decompression device.

BACKGROUND: Recent evidence suggests that the frequency response requirements for peak expiratory flow (PEF) meters are higher than was first thought and that the American Thoracic Society (ATS) waveforms to test PEF meters may not be adequate for the purpose. METHODS: The dynamic response of mini-Wright (MW), Vitalograph (V), TruZone (TZ), MultiSpiro (MS) and pneumotachograph (PT) flow meters was tested by delivering two differently shaped flow-time profiles from a computer controlled explosive decompression device fitted with a fast response solenoid valve. These profiles matched population 5th and 95th centiles for rise time from 10% to 90% of PEF and dwell time of flow above 90% PEF. Profiles were delivered five times with identical chamber pressure and solenoid aperture at PEF. Any difference in recorded PEF for the two profiles indicates a poor dynamic response. RESULTS: The absolute (% of mean) flow differences in l/min for the V, MW, and PT PEF meters were 25 (4.7), 20 (3.9), and 2 (0.3), respectively, at PEF approximately 500 l/min, and 25 (10.5), 20 (8.7) and 6 (3.0) at approximately 200 l/min. For TZ and MS meters at approximately 500 l/min the differences were 228 (36.1) and 257 (39.2), respectively, and at approximately 200 l/min they were 51 (23.9) and 1 (0.5). All the meters met ATS accuracy requirements when tested with their waveforms. CONCLUSIONS: An improved method for testing the dynamic response of flow meters detects marked overshoot (underdamping) of TZ and MS responses not identified by the 26 ATS waveforms. This error could cause patient misclassification when using such meters with asthma guidelines.

Analysis of Variance↗
PubMed2002

Increased resting bronchial tone in normal subjects acclimatised to altitude.

BACKGROUND: Normal subjects frequently experience troublesome respiratory symptoms when acclimatised to altitude. Bronchial hyperresponsiveness (BHR) and full and partial flow-volume loops were measured before and after ascent to 5000 m altitude to determine if there are changes in resting bronchial tone and BHR that might explain the symptoms. METHODS: BHR to histamine was measured using a turbine spirometer to record partial and full flow-volume curves and expressed as log dose slopes. Twenty one subjects were tested at sea level and after acclimatisation at 5000 m altitude. RESULTS: No significant change in log dose slope measurements of forced expiratory volume in 1 second occurred after acclimatisation, and the maximal expiratory flow with 30% of forced vital capacity remaining (MEF(30%)) rose on the full loop and fell on the partial loop. Their ratio (full divided by partial) rose on average by 0.28 (95% confidence limits 0.14 to 0.42) from the mean (SD) sea level value of 0.87 (0.20). CONCLUSIONS: There is no increase in BHR in normal subjects acclimatised to altitude but an increase in resting bronchial tone occurs that could be released by deep inspiration. This may be the result of increased cholinergic tone.

Adaptation, Physiological↗
PubMed2002

Time domain and flow indices of bronchial hyperresponsiveness: association with asthma symptoms, atopy and smoking.

Conventional measures of bronchial hyperresponsiveness (BHR) are only weakly associated with respiratory symptoms in epidemiological studies. Partial and maximal forced expiratory manoeuvres were recorded during histamine challenge testing in 1,959 young male farmers. Analysis was performed to test whether novel measures of BHR, using alternative flow and time domain indices, are more closely associated with asthma symptoms, smoking status and atopy than forced expiratory volume in one second (FEV1) and conventional measures of BHR. The first moments to 75% and 90% of the forced vital capacity (FVC) were calculated from full (F) and partial (P) forced expiratory manoeuvres (i.e. alpha1 75%F, alpha1 75%P), together with the instantaneous flows when 40% and 30% of the FVC remained to be expired (MEF40 and MEF30). BHR was measured by the provocative dose causing a 20% change (PD20) in the FEV1 and alpha1 75%, and also by the method of log dose slopes (LDS). Asthma was diagnosed from symptoms associated with asthma in 158 (8.1%) of the subjects. PD20 FEV1 could only be recorded in 190 subjects (9.7%), of whom only 48 had asthma, whereas LDSFEV1 was recorded in 1,725 (88%) subjects. From the prechallenge data, alpha1 75%, expressed as standardised residuals, showed the largest difference between smokers with and without asthma symptoms, and no indices showed significant differences between nonsmokers with and without asthma symptoms. From BHR data in both smokers and nonsmokers, LDSFEV1 showed one of the largest differences between those with and without asthma symptoms. With smoking status and atopy accounted for, the greatest partial correlation with asthma diagnosis was found for LDSMEF40P, and then for LDSFEV1, but LDSMEF40P was measurable in only just over one-half of the subjects. The authors conclude that time-domain indices are promising measures for longitudinal epidemiological studies concerning the relationship between bronchial hyperresonsiveness and environmental exposures. However, indices from the partial flow-volume loop suffer from censored data.

Adult↗
PubMed2002

Recording flow in the first second of a maximal forced expiratory manoeuvre: influence of frequency content.

The frequency content of the first second of the maximum forced expiratory manoeuvre (MFEM) was measured to determine if the currently accepted frequency limit of 20 Hz for MFEM is adequate for recording peak expiratory flow (PEF). The frequency response of a Fleisch pneumotachograph (PT) was measured and used to record MFEM from 24 patients attending a lung-function laboratory and 26 normal volunteers. The first 1.024 s of the signal recorded at 1,000 Hz for that blow with maximum PEF, underwent fast Fourier transformation using a triangular window function, applied after 0.75 s to reduce flow linearly to zero. All the frequencies above a set limit were removed, followed by inverse transformation to reconstitute the blow. The limits for this frequency cut-off were progressively varied from 100 Hz down to 15 Hz, with the resulting PEF being compared with the PEF from the reconstituted blow with no frequency reduction. The average+/-SD age for the group was 47+/-18 yrs and the average PEF was 450+/-187 L x min(-1), which, when expressed as a standardized residual, was 0.1+/-2.1, with a range from -4.5-3.9 indicating a good spread around normal values. Average rise time to PEF was 83+/-38 ms and dwell time >90% PEF was 45+/-25 ms. Cut-off >20 Hz reduced the mean PEF of the group by 8.5 L x min(-1) (95% confidence limit 5.5-11.4 L x min(-1)), whereas cut-off >30 Hz reduced mean PEF by 4.4 L x min(-1) (2.6-6.2). In the present study subjects, 30 Hz was on the 95th percentile of frequencies for defining the upper limit for 98% of the power spectrum for the first second of the blow. It has been shown that there are frequencies >20 Hz that contribute to peak expiratory flow enough to influence readings made using conventional hand-held peak expiratory flow meters, such as the mini-Wright. Devices used for recording flow from a maximum forced expiratory manoeuvre should therefore have an adequate frequency response of up to 30 Hz.

Adult↗
PubMed2001

Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey.

CONTEXT: Inappropriate medication use is a major patient safety concern, especially for the elderly population. Using explicit criteria, prior studies have found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992, respectively. OBJECTIVES: To determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996, to assess trends over 10 years, categorize inappropriate medication use according to explicit criteria, and to examine risk factors for inappropriate medication use. DESIGN, SETTING, AND PARTICIPANTS: Respondents aged 65 years or older (n = 2455) to the 1996 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population were included. A 7-member expert panel was convened to categorize inappropriate medications. MAIN OUTCOME MEASURE: Prevalence of use of 33 potentially inappropriate medications. RESULTS: In 1996, 21.3% (95% confidence interval [CI], 19.5%-23.1%) of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients (95% CI, 2.0%-3.2%) used at least 1 of the 11 medications that should always be avoided by elderly patients; 9.1% (95% CI, 7.9%-10.3%) used at least 1 of the 8 that would rarely be appropriate; and 13.3% (95% CI, 11.7%-14.9%) used at least 1 of the 14 medications that have some indications but are often misused. Use of some inappropriate medications declined between 1987 and 1996. Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use. CONCLUSIONS: Overall inappropriate medication use in elderly patients remains a serious problem. Despite challenges in using explicit criteria for assessing inappropriate medications for elderly patients, such criteria can be applied to population-based surveys to identify opportunities to improve quality of care and patient safety. Enhancements of existing data sources to include dosage, duration, and indication may augment national improvement and monitoring efforts.

Aged↗
PubMed2001

Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter.

BACKGROUND: Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use. OBJECTIVES: To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF. SEARCH STRATEGY: Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until December 1999. SELECTION CRITERIA: Included Randomized controlled trials of drugs to prevent thromboembolism in adults with non-postoperative AF. Excluded RCTS of patients with rheumatic valvular disease. DATA COLLECTION AND ANALYSIS: Data were abstracted by two reviewers. Odds ratios from all qualitatively similar studies were combined, with weighting by study size, to yield aggregate odds ratios for stroke, major hemorrhage, and death for each drug. MAIN RESULTS: Fourteen articles were included in this review. Warfarin was more efficacious than placebo for primary stroke prevention [aggregate odds ratio (OR) of stroke=0.30 [95% Confidence Interval (C.I.) 0.19,0.48]], with moderate evidence of more major bleeding [ OR= 1.90 [95% C.I. 0.89,4.04].]. Aspirin was inconclusively more efficacious than placebo for stroke prevention [OR=0.68 [95% C.I. 0.29,1.57]], with inconclusive evidence regarding more major bleeds [OR=0.81[95% C.I. 0.37,1.78]]. For primary prevention, assuming a baseline risk of 45 strokes per 1000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin [aggregate OR=0.64[95% C.I. 0.43,0.96]], with only suggestive evidence for more major hemorrhage [OR =1.58 [95% C.I. 0.76,3.27]]. However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared to aspirin was low (5.5 per 1000 person-years) compared to an older group (15 per 1000 person-years). Low-dose warfarin or low-dose warfarin with aspirin was less efficacious for stroke prevention than adjusted-dose warfarin. REVIEWER'S CONCLUSIONS: The evidence strongly supports warfarin in AF for patients at average or greater risk of stroke, although clearly there is a risk of hemorrhage. Although not definitively supported by the evidence, aspirin may prove to be useful for stroke prevention in sub-groups with a low risk of stroke, with less risk of hemorrhage than with warfarin. Further studies are needed of low- molecular weight heparin and aspirin in lower risk patients.

Anticoagulants↗
PubMed2001

Influence of peat on Fenton oxidation.

A diagnostic probe was used to estimate the activity of Fenton-derived hydroxyl radicals (.OH), reaction kinetics, and oxidation efficiency in batch suspensions comprised of silica sand, crushed goethite (alpha-FeOOH) ore, peat, and H2O2 (0.13 mM). A simple method of kinetic analysis is presented and used to estimate the rate of .OH production (POH) and scavenging term (ks), which were used to establish the influence of organic matter (Pahokee peat) in Fenton systems. POH was greater in the peat-amended systems than in the unamended control, and ks was approximately the same. Any increase in scavenging of .OH that resulted from the addition of peat was insignificant in comparison to radical scavenging by reaction with H2O2. Also, treatment efficiency, defined as the ratio of probe conversion to H2O2 consumption over the same period was greater in the peat-amended system. Results suggest that .OH production is enhanced in the presence of peat by one or more peat-dependent mechanisms. Fe concentration and availability in the peat, reduction of Fe(III) to Fe(II) by the organic matter, and reduction of organic-complexed Fe(III) to Fe(II) are discussed in the context of the Fenton mechanism.

Hydroxyl Radical↗