Biomedical subjects

D R Miller

Publications and source records attributed to D R Miller.

At least 37 records · Page 2Linked to original sources

PubMed2001

Systemic fat and thrombus embolization in patients undergoing total knee arthroplasty with regional heparinization.

A double-blind, randomized, controlled study was undertaken to determine if a technique of intraoperative anticoagulation would decrease the incidence or severity of venous embolization after tourniquet release during total knee arthroplasty. Sixty-six patients were randomized to receive either the heparin or placebo treatment. Transesophageal echocardiography was performed before and after tourniquet release to detect embolic material in the right atrium. Transient opacification of the right atrium was observed in all patients within the first 30 seconds after tourniquet release. Regional limb heparinization is not effective in reducing the intensity of right atrium opacification because much of the echogenic material was composed of fat rather than thrombus.

Aged↗

PubMed2001

Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research.

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. It is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.

Aftercare↗

PubMed2001

Self-reported and clinical oral health in users of VA health care.

BACKGROUND: This article describes the oral health of users of Veterans Administration (VA) health care using both clinical and self-report measures, and models relationships between these measures and self-perceived oral health. METHODS: We conducted a cross-sectional study of 538 male users of VA outpatient care in the Boston area. Questionnaires assessed self-reported oral health, oral-specific health-related quality of life, health behaviors, and sociodemographic information. Clinical data were collected on oral mucosa status, number of teeth and root tips, dental caries, and periodontal treatment need. We report clinical and self-reported oral health status by age group (era of military service). We regressed models of self-perceived oral health on clinical indices and self-reported measures of the impact of oral health on daily life, adjusting for sociodemographic characteristics and health behavior. RESULTS: Among those participants aged 65 to 91 years old, 2.8%, 18.7%, and 41.5% rated their oral health as excellent, very good, or good, respectively. Among 50- to 64-year-old men, the corresponding values were 1.4%, 18.5%, and 40.4%, while among those aged 22 to 49 years old, the values were 2.3%, 17%, and 34.1%. Tooth loss was common among users of VA care; 34% of those aged 65-90 years, 28% of those aged 50-64 years, and 8% of those aged 25-49 years had no teeth. Periodontal treatment needs were uniformly high among persons with teeth; mild mucosal change was common, and 10% had root tips. Regression models showed self-perceived oral health was better in persons with more teeth and recent dental treatment, and worse with tooth mobility, coronal decay, and more medical problems. Measures of the impact of oral conditions on daily life added significantly to the amount of explained variance in self-perceived oral health. CONCLUSIONS: Clinical conditions and the impact of oral health on daily life are important determinants of self-perceived oral health.

Adult↗

PubMed2000

Some potential errors in the measurement of mercury gas exchange at the soil surface using a dynamic flux chamber.

A series of controlled environment experiments were conducted to examine the use of a dynamic flux chamber to measure soil emission and absorption of total gaseous mercury (TGM). Uncertainty about the appropriate airflow rates through the chamber and chamber exposure to ambient wind are shown to be major sources of potential error. Soil surface mercury flux measurements over a range of chamber airflow rates showed a positive linear relationship between flux rates and airflow rate through the chamber. Mercury flux measurements using the chamber in an environmental wind tunnel showed that exposure of the system to ambient winds decreased the measured flux rates by 40% at a wind speed of 1.0 m s(-1) and 90% at a wind speed of 2 m s(-1). Wind tunnel measurements also showed that the chamber footprint was limited to the area of soil inside the chamber and there is little uncertainty of the footprint size in dry soil.

Air Pollutants↗

PubMed2000

Some local environmental effects on mercury emission and absorption at a soil surface.

The purpose of this study was to quantify effects of some local environmental variables on the soil surface exchanges of total gaseous mercury (TGM), under controlled conditions. A dynamic flux chamber with a Tekran mercury analyzer was used to quantify TGM emissions from, and absorption by, a clean, fine sandy loam soil with very low mercury content inside of a building and in a low TGM environment, outside. Simultaneous measurements of mercury flux, air and soil temperatures, ozone concentration, humidity, soil moisture and solar radiation were made. Controlled applications of water were made to change soil H2O content and measure the response of mercury flux. Air-soil exchanges were highly dependent on soil temperature (r2 = 0.78) and the mercury concentration gradient between the TGM in the soil pores and the ambient TGM above the soil surface (r2 = 0.98 for absorption and r2 = 0.408 for emissions). Correlations with air temperature and ozone levels are explained by the relationships of these variables with soil temperature. No detectable correlation was found with solar radiation or humidity. Wet soil maintained higher rates of soil TGM emission and decreased soil absorption. Emissions increased with increasing soil H2O, peaked at approximately field capacity, and then decreased slightly until saturation.

Air Pollutants↗

PubMed2000

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion.

PURPOSE: The dissimilar pharmacokinetic properties of cisatracurium (CIS) and rocuronium (ROC) predict different potential for drug cumulation when these drugs are administered by continuous infusion. A study was therefore undertaken to compare cumulation potential of CIS and ROC during surgical procedures of relatively long duration (2-4 hr). METHODS: Sufentanil/propofol-N2O anesthesia was administered to 40 ASA I and II adults. In a double-blind protocol, patients were randomly allocated to receive a continuous i.v. infusion of either CIS or ROC, titrated in progressive increments or decrements as required to achieve and maintain 95 +/- 5% depression of the T1 response of the adductor pollicis muscle, using a Datex NMT-100 Relaxograph EMG monitor applied at the wrist. At the end of surgery, 60 microg x kg(-1) neostigmine plus 15 microg x kg(-1) atropine were administered for reversal. RESULTS: The duration of infusion was 104 +/- 33 min in group CIS and 110 +/- 23 min in group ROC (P=NS). In both groups, a progressive decrease in potency-adjusted infusion rates was observed after 30 min, then stabilized beyond 60 min. When allowing for an initial period of stabilization, mean potency-adjusted infusion requirements were: CIS 0.81 +/- 0.02 microg x kg(-1) x min(-1) and ROC 5.58 +/- 1.94 microg x kg(-1) x min(-1). There were no differences between groups at any time with regard to potency-adjusted infusion requirements necessary to maintain 90-99% block (P=NS). However, drug costs/hr for maintenance of neuromuscular block were less with CIS ($3.57 +/- 0.09) than with ROC ($6.03 +/- 0.27), P < 0.001. CONCLUSION: When adjusted to equipotency, infusion requirements of CIS and ROC vary at similar rates during general anesthesia. Despite pharmacokinetic differences, neither drug demonstrates cumulation for infusion lasting up to 3.5 hr.

Adult↗

PubMed1999

Screening for malignant melanoma: A cost-effectiveness analysis.

BACKGROUND: Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined. OBJECTIVE: We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons. METHODS: We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings. RESULTS: Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer-related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0. 0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57. CONCLUSION: Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies.

Cost-Benefit Analysis↗

PubMed1999

Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts.

BACKGROUND: More than 1 million Americans have attended the American Academy of Dermatology's Melanoma/Skin Cancer Screening Programs since 1985. However, there have been no reports of the participants' perceived value, satisfaction, and benefits of skin cancer screening. OBJECTIVE: We attempted to measure the benefits and subsequent screening practices of persons with presumptive positive screening diagnoses. METHODS: A self-administered questionnaire was sent to participants with positive screening diagnoses in Massachusetts. RESULTS: Of the 643 respondents, 81% rated their satisfaction as high and 84% had similar ratings for the value of the screening. Screenings apparently led to an increase in self-screening (60% before screening compared with 84% after screening). CONCLUSION: Although screening appears to have relatively strong benefits, further studies should be conducted nationally.

Adult↗

PubMed1999

Update on the incidence and mortality from melanoma in the United States.

BACKGROUND: Increases in the incidence of malignant melanoma have been among the largest of all cancers in the United States. OBJECTIVE: We report updated trends in melanoma rates among the US white population. METHODS: Incidence and mortality rates were calculated for 1973 to 1994. Trends were examined with stratification by state, age, and sex, and by anatomic site, stage, and melanoma thickness at diagnosis. RESULTS: Melanoma incidence and mortality rates increased dramatically from 1973 to 1994, rising 120.5% and 38.9%, respectively. In recent years, however, rates for most age-sex groups appeared to stabilize or even decline. Male patients continued to have higher incidence and mortality rates than female patients, but for both male and female patients the largest increases by site were for the trunk. A large proportion of melanomas were detected in the local stage and with a thickness less than 0.75 mm. CONCLUSION: Prevention of sun exposure is recommended to reverse the high incidence rates of melanoma.

Adult↗

PubMed1999

Quality and accountability: Children's emergency services in a managed care environment.

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.

Adolescent↗

PubMed1999

Emergency medical services outcomes project I (EMSOP I): prioritizing conditions for outcomes research.

Over the past several years, out-of-hospital EMS have come under increased scrutiny regarding the value of the range of EMS as currently provided. We used frequency data and expert opinion to rank-order EMS conditions for children and adults based on their potential value for the study of effectiveness of EMS care. Relief of discomfort was the outcome parameter EMS professionals identified as having the most potential impact for the majority of children and adults in the top quartile conditions. Future work from this project will identify appropriate severity and outcome measures that can be used to study these priority conditions. The results from the first year of this project will assist those interested in EMS outcomes research to focus their efforts. Furthermore, the results suggest that nonmortality out-come measures, such as relief of discomfort, may be important parameters in determining EMS effectiveness.

Adolescent↗

PubMed1999

Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military.

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

Adult↗

PubMed1999

Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study.

OBJECTIVE: The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans. METHOD: Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews. RESULTS: The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders. CONCLUSIONS: Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.

Alcoholism↗

PubMed1999

The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth.

A multidimensional community-based skin cancer prevention program was conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The program was associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n = 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents' self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.

Adolescent↗

PubMed1999

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project.

BACKGROUND: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. METHODS: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. RESULTS: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health. CONCLUSIONS: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.

Confounding Factors, Epidemiologic↗

PubMed1999

Patient satisfaction with Department of Veterans Affairs health care: do women differ from men?

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

Cross-Sectional Studies↗

PubMed1998

Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study.

BACKGROUND: The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations. OBJECTIVES: To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status. METHODS: Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described. RESULTS: The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001). CONCLUSIONS: The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

Adult↗

PubMed1998

Influence of arrhythmias on accuracy of non-invasive blood pressure monitors.

PURPOSE: To compare the accuracy of non-invasive blood pressure (NIBP) monitors in response to common cardiac arrhythmias. METHODS: Simulated signals of normal sinus rhythm (NSR), premature ventricular contractions (PVCs), atrial fibrillation (AF) and missed beats (MB) were generated from a Cufflink (Dynatech Nevada) NIBP simulator. Using these signals, the Critikon 1846SX (C1846), Critikon 845xt (C845). Critikon Vital Signs (CVIT), and Hewlett Packard M1008a (HP1008) were studied at a standard dynamic blood pressure of 120/90/80 mmHg, in order to compare monitor accuracy and signal response times. RESULTS: The C845 monitors most closely estimated a simulated SBP of 120 mmHg, although SBP was greater during PVCs and AF than NSR (P < 0.05). The Critikon 1846, Critikon Vital Signs, and Hewlett Packard systematically underestimated SBP during these arrhythmias, but variability was modest, as reflected by small coefficients of variation (< 2% for SBP) with all monitor types. In general, MAP and DBP were less sensitive to the effects of these arrhythmias. Finally, missed beats prolonged signal response times with all four monitor types (P < 0.05), whereas PVCs and AF did not alter this parameter. CONCLUSIONS: This study demonstrates the extent to which the accuracy of NIBP monitors is altered by common cardiac arrhythmias. Differences in the electromechanical characteristics of these devices may help to explain the observed similarities and discrepancies.

Arrhythmias, Cardiac↗