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Biomedical subjects

R J Muller

Publications and source records attributed to R J Muller.

18 recordsLinked to original sources
PubMed2002

Safe and cost effective use of alteplase for the clearance of occluded central venous access devices.

PURPOSE: To determine whether cryopreserved solutions of the thrombolytic agent alteplase could be used as a safe, effective, and economically reasonable alternative to urokinase in patients presenting with occluded central venous access devices (CVADs). MATERIALS AND METHODS: Alteplase has been reported as an efficacious alternative to urokinase for treatment of occluded CVADs. However, the practicality of using alteplase as the thrombolytic of choice for this indication remained conjectural. To make this approach economically feasible, alteplase was diluted to 1 mg/mL and 2.5-mL aliquots were stored at -20 degrees C until use. A need to confirm that the cryopreserving and thawing of the reconstituted solution did not compromise the safety and efficacy reported from prior trials was recognized. A quality assessment initiative was undertaken to concurrently monitor the safety and efficacy of this approach. Patients presenting with occluded CVADs received a sufficient volume of the thawed alteplase solution to fill the occluded catheter(s). Data, including efficacy, adverse reactions, dwell time, and catheter type, were collected over a 5-month period. RESULTS: One hundred twenty-one patients accounting for 168 attempted clearances were assessable for safety and efficacy. One hundred thirty-six (81%) of the 168 catheter clearance attempts resulted in successful catheter clearance (95% confidence interval, 74% to 86%). No adverse events were reported. CONCLUSION: Cryopreserved 1-mg/mL aliquots of alteplase are safe and effective in the clearance of occluded CVADs when stored at -20 degrees C for 30 days. The ability to cryopreserve alteplase aliquots makes it an economically reasonable alternative to urokinase in the setting of CVAD occlusion.

Adolescent↗
PubMed2001

A brief review of antifungal therapy for deep fungal infection.

With the continuing increase in clinically important fungal disease, especially seen in the neutropenic patient, the need for new and improved systemic antifungal agents marches on. A pharmacy and therapeutics committee may select an antifungal agent based on these criteria: spectrum of action, pharmacokinetic profile, toxicity, potential for resistance, and cost. A number of agents are now available for treating deep fungal infections, including amphotericin B in conventional and liposomalformulations, and the triazoles itraconazole (Sporanox) and fluconazole (Diflucan). It is important to note that there is lack of agreement in practice over what constitutes ideal therapy. The lipidformulations of amphotericin B and the improved oral solution and new intravenous formulation of itraconazole are recent additions to therapeutic options that are already having a significant influence on drug selection and treatment practices.

Amphotericin B↗
PubMed1996

Preventing medication errors in cancer chemotherapy.

Recommendations for preventing medication errors in cancer chemotherapy are made. Before a health care provider is granted privileges to prescribe, dispense, or administer antineoplastic agents, he or she should undergo a tailored educational program and possibly testing or certification. Appropriate reference materials should be developed. Each institution should develop a dose-verification process with as many independent checks as possible. A detailed checklist covering prescribing, transcribing, dispensing, and administration should be used. Oral orders are not acceptable. All doses should be calculated independently by the physician, the pharmacist, and the nurse. Dosage limits should be established and a review process set up for doses that exceed the limits. These limits should be entered into pharmacy computer systems, listed on preprinted order forms, stated on the product packaging, placed in strategic locations in the institution, and communicated to employees. The prescribing vocabulary must be standardized. Acronyms, abbreviations, and brand names must be avoided and steps taken to avoid other sources of confusion in the written orders, such as trailing zeros. Preprinted antineoplastic drug order forms containing checklists can help avoid errors. Manufacturers should be encouraged to avoid or eliminate ambiguities in drug names and dosing information. Patients must be educated about all aspects of their cancer chemotherapy, as patients represent a last line of defense against errors. An interdisciplinary team at each practice site should review every medication error reported. Pharmacists should be involved at all sites where antineoplastic agents are dispensed. Although it may not be possible to eliminate all medication errors in cancer chemotherapy, the risk can be minimized through specific steps. Because of their training and experience, pharmacists should take the lead in this effort.

Antineoplastic Agents↗
PubMed1995

A pharmacy intervention program: recognizing pharmacy's contribution to improving patient care.

An on-line pharmacy intervention program developed to document and evaluate pharmacist's contribution to patient care is described. Over a 1-year period, the number and types of interventions and their impact on patient care were collated and reviewed by a clinical coordinator. Two thousand four hundred ninety-nine interventions were recorded. The most common types of interventions were order clarification/change (18%), pharmacokinetic consult (16%), chart review (13%), restricted drug follow-up (8%), discharge medication screen (7%), initiate drug therapy (6%), drug information (5%), discontinued drug (4%), and therapeutic alternative (4%). There were 3459 impact codes assigned to these interventions. Forty-one percent decreased toxicity, 35% increased efficacy, 17% decreased cost, 16% avoided allergy or drug interaction, 8% improved compliance, and 22% were classified as other. Our analysis found that pharmacy interventions elevated the standard of care and prevented major organ damage and potentially life-threatening events. This program shows that pharmacists play a significant role in improving patient outcomes.

Cancer Care Facilities↗
PubMed1993

Jet-ski injury: a case history.

A case history is presented which involves a patient who sustained severe vaginal lacerations as a result of falling backwards off of a jet-ski. The surgical repair of the lacerations and postoperative course is discussed. An extensive search of the literature has failed to reveal any published reports of a similar injury.

Adult↗
PubMed1991

Patient education: a multidisciplinary approach to influence patient compliance.

The Department of Pharmacy and Nursing should collaborate on a consistent basis to proactively implement and evaluate the patient education program. Although many hospitals educate their patients, the systems can often be fragmented. Unanswered questions may include how and where the education takes place, the method of documentation, and who specifically educates the patient. Selection of the best media for educational materials requires that the broad array of printed (i.e., manuals, programmed texts, booklets) and nonprint material (i.e., videotape, motion pictures, etc.) be considered. A multidisciplinary patient education committee facilitates the program at MSKCC. Approximately 50 chemotherapy fact cards have been used at MSKCC for six years. This program has yielded positive perceptions from patients as well as from the pharmacy and nursing staff. Future trends will probably include widespread use of interactive patient education programs to provide indexing, order entry, and documentation of patient education materials.

Cancer Care Facilities↗
PubMed1981

Parenteral nutrition program in a major cancer center.

In this article, formulation ordering, manufacturing procedures, and the quality control techniques utilized by the parenteral nutrition program at Memorial Sloan-Kettering Cancer Center are described. The cancer patient's metabolic status frequently changes; therefore, individualized prescriptions are used for all parenteral nutrition solutions. Due to the cancer patient's high risk of infection, related to disease-induced or iatrogenic immunosuppression, strict attention to aseptic procedures is required, including personnel wearing disposable gowns, head and shoe coverings, face masks, and surgical gloves. Specific emphasis has been placed on maximal cost effectiveness in manufacturing protocols. Preparation of solutions is, however, only one component of the role played by the pharmacists on the nutrition team. We describe the clinical responsibilities which are of paramount importance, since medications and other treatment modalities can markedly alter nutritional status and electrolyte balance. Monitoring the medications a patient receives and carefully watching a patient's laboratory results are important functions of the pharmacist. For the cancer patient, particular emphasis must be placed on nutritional and metabolic aberrations caused by antibiotics, corticosteroids, diuretics, antineoplastic agents, and narcotic analgesics. Radiation therapy can result in serious physiologic and nutritional effects. An innovative patient profile for monitoring a cancer patient receiving parenteral nutrition is introduced. The pharmacists are also involved in several teaching programs and a new outpatient program for administration of I.V. antibiotics to selected home total parenteral nutrition patients.

Cancer Care Facilities↗
PubMedDate not supplied

Is there a neural basis for borderline splitting?

It is proposed here that borderline splitting and borderline pathology may have a neural basis. For the infant who splits its emotional and cognitive constitution of its mother during separation-individuation, the "good mother"--"bad mother" engram may be lateralized in the brain in a different way than for an infant who does not use this defense. The infant may be developmentally vulnerable to the effects of splitting during separation-individuation (18 to 36 months) because interhemispheric communication necessary for mental unity is not possible at this time, since neurons connecting left and right hemispheres are not totally myelinated and because the infant has not yet fully acquired language, a prerequisite for an integrated psychological reality. Two separate, unintegrated--and alternating--mental systems may come into being. Later, as myelination is completed, the infant's split emotional and cognitive constitutions of mother and of self may create a neural "template" for splitting all further experience and behavior through the two separate, alternating mental systems. The possibility that emotional trauma occurring later than separation-individuation, and involving other issues, may be the occasion for splitting is considered, as well as the possibility that a congenital abnormality in brain structure or function may be a primary factor in borderline pathology. Ways to test the hypothesis that borderline splitting has a neural basis are suggested.

Borderline Personality Disorder↗
PubMedDate not supplied

Karen Horney's "resigned person" heralds DSM-III-R's borderline personality disorder.

It is shown here that what Karen Horney called the resignation solution to the problem of basic anxiety leads to psychopathology very similar to DSM-III-R's borderline personality disorder (BPD). Both the "resigned person" and the borderline personality show instability of self-image, social relationships, and mood, and live out the associated deficits with similar styles. While not specifically using the term "splitting", Horney showed how alternating expansive and self-effacing trends can coexist in the resigned person, and how these oscillations in self-other-world constitution influence the resigned person's behavior in a way similar to borderline splitting. Horney's descriptive and psychodynamic analysis of the resignation phenomenon elaborates and gives additional credibility to DSM-III-R's BPD as a diagnostic category.

Borderline Personality Disorder↗