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Biomedical subjects

J G Miller

Publications and source records attributed to J G Miller.

At least 55 records · Page 3Linked to original sources
PubMed1997

Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report.

We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.

Attitude to Computers↗
PubMed1997

Teaching skills for accessing and interpreting information from systematic reviews/meta-analyses, practice guidelines, and the Internet.

Skills and practice related to accessing and interpreting clinical information from systematic reviews/meta-analyses, practice guidelines, and the Internet have been integrated into a new senior year elective designed to teach medical students how to critically appraise information from a variety of sources and evaluate it's applicability to patient care. Small groups of senior medical students under the direction of a multidisciplinary team (behavioral scientist, information specialist, physician) facilitate discussions of clinical articles using checklists designed to evaluate their quality. The central feature of the course is a demonstration of the Cochrane Database of Systematic Reviews (CDSR), an electronic journal distributed by BMJ Publishing, and the requirement that students conduct a literature review on a topic of their choice and present an oral and written summary in the form of a "draft" meta-analysis. Students are provided with strategies to "surf" the Internet/WWW for information, e.g., practice guidelines/treatment protocols, descriptions of on-going clinical trials. A total of 52 students have participated to date. Students have selected project topics across a wide range of medical disciplines, including internal medicine, family practice, OB/GYN, pediatrics, surgery, neurology, emergency medicine, and psychiatry. The course is one of the most favorably evaluated of all senior electives and rated more favorably than the overall mean ratings for all electives combined on 8 of 9 scales, including "Quality of course overall" (4.39 vs. 3.92 on 5-point scale).

Computer Communication Networks↗
PubMed1996

A novel site-targeted ultrasonic contrast agent with broad biomedical application.

BACKGROUND: In this work, we report a novel targetable ultrasonic contrast agent with the potential to noninvasively define and localize myriad pathological tissues for diagnosis or therapy. The agent is a biotinylated, lipid-coated, perfluorocarbon emulsion that has low inherent echogenicity unless bound to a surface or itself. METHODS AND RESULTS: In study 1, emulsions with and without biotin were suspended in buffered saline and imaged with a 7.5-MHz linear-array transducer. Neither emulsion manifested significant ultrasonic backscatter until avidin was added. Avidin-induced aggregation produced a marked enhancement in backscatter from the biotinylated but not from the control emulsion. In study 2, porcine fibrin clots in vitro were pretargeted with biotinylated antifibrin monoclonal antibodies and then exposed to avidin and then to biotinylated or control perfluorocarbon emulsions. The basal acoustic reflectivity of clots imaged with a 7.5-MHz linear-array transducer was uniformly low and was increased substantially by exposure to the targeted biotinylated emulsion. In study 3, partially occlusive arterial thrombi were created in dogs and then exposed to antifibrin antibodies and avidin in situ. Biotinylated or control emulsion was administered either in situ or systemically. At baseline, all thrombi were undetectable with a 7.5-MHz linear-array transducer. Thrombi exposed to antifibrin-targeted contrast exhibited increased echogenicity (P < .05); control thrombi remained acoustically undetectable. CONCLUSIONS: These data provide the first in vivo demonstration of a site-specific ultrasonic contrast agent and have potential for improved sensitivity and specificity for noninvasive diagnosis of thrombi and other pathological diseases.

Animals↗
PubMed1996

Dissociation between wall thickening of normal myocardium and cyclic variation of backscatter during inotropic stimulation.

The purpose of this study was to determine the relation between increased myocardial wall thickening during inotropic stimulation and quantitative acoustic properties of normal myocardium in humans. We first validated a new 2-dimensional ultrasonic backscatter imaging approach for measurement of cyclic variation in the parasternal long-axis view against conventional M-mode integrated backscatter technique in 41 patients and controls (group A). We then performed 2-dimensional ultrasonic integrated backscatter imaging in 18 patients (group B) with normal segmental function at baseline to determine the magnitude of the cyclic variation of the septum and the posterior wall before and during infusion of dobutamine (10 and 20 microgram/kg/min). Group A patients showed a close correlation of the cyclic variation obtained by the new 2-dimensional ultrasonic integrated backscatter imaging approach and the conventional M-mode technique. Group B patients had mean values of cyclic variation that remained unchanged in the septum (4.4 +/- 1.4, 4.3 +/- 1.7, and 4.8 +/- 1.6 dB at baseline and at each dobutamine stage, respectively, p = NS) and in the posterior wall (6.4 +/- 1.7, 6.4 +/- 1.8 and 6.1 +/- 1.9 dB, respectively, p = NS) despite progressive dobutamine-induced increases in percent wall thickening (septum: 38 +/- 10% to 57 +/- 17% and 68 +/- 19%, respectively, and posterior wall 42 +/- 13% to 72 +/- 20% and 77 +/- 18%, respectively; both p <0.001 vs baseline for both walls). Thus, physical properties of normal myocardium remain unchanged during inotropic stimulation.

Adult↗
PubMed1996

Anisotropy of the transverse mode ultrasonic properties of fixed tendon and fixed myocardium.

This study investigates the influence of the fiber-reinforced nature of myocardium and tendon on the propagation of transverse mode ultrasonic waves. Formalin fixed specimens of normal human left ventricular cardiac muscle and bovine Achilles tendon were prepared for this study in such a way that transverse mode ultrasonic waves could be propagated perpendicular to the fiber axis of the tissue with the polarization oriented either parallel or perpendicular to the fiber axis. Measurements of velocity and attenuation were made at 3 MHz to assess the degree of anisotropy in these parameters for both tissues. Formalin fixed tendon exhibited a significant anisotropy whereas formalin fixed myocardium displayed a similar trend of more modest magnitude. Results of these measurements were used to compute two elastic stiffness coefficients for each tissue, yielding c44 = 37.2 MPa and c66 = 18.0 MPa for formalin fixed tendon, and c44 = 8.97 MPa and c66 = 8.45 MPa for formalin fixed myocardium. To validate this approach, additional studies were conducted to measure the transverse mode ultrasonic properties of silicone rubber and motor oil.

Achilles Tendon↗
PubMed1996

Anisotropy of the slope of ultrasonic attenuation in formalin fixed human myocardium.

Clinical implementation of quantitative ultrasonic tissue characterization is likely to require imaging the heart with sound propagating at varying angles relative to the fibers of the heart. Under these circumstances, the variation of the ultrasonic properties of myocardium with the angle of propagation relative to the myofibers may represent a significant source of potential misinterpretation. In the present study, the systematic approach of assessing the impact of anisotropy on quantitative myocardial tissue characterization is extended by reporting results of a recent in vitro study to measure the anisotropy of the slope of ultrasonic attenuation in specimens of formalin fixed human myocardium. Data obtained from regions of remote infarct are presented and compared to data acquired from regions identified to be free of infarct. The slope of attenuation for both regions exhibit a sinusoid-like dependence on angle that is approximately doubled for propagation parallel to the fibers as compared to perpendicular. These results are, in turn, compared to an earlier study from the laboratory that examined the effects of myocardial infarction on ultrasonic attenuation and interstitial collagen content in freshly excised canine hearts. Discussion regarding the analysis and interpretation of measurements of slope of attenuation is presented as well as a discussion of the possible influence of formalin fixation on our results.

Animals↗
PubMed1996

Frequency dependence of acoustic backscatter from 5 to 65 MHz (0.06 < ka < 4.0) of polystyrene beads in agarose.

Attenuation and compensated backscatter from suspensions of random distributions of polystyrene beads in agarose are reported across a broad, continuous range of frequencies including frequencies which are currently of interest in the emerging fields of acoustic backscatter microscopy and intravascular imaging. Data are reported over the range of ka from 0.06 to 4, where k is the magnitude of the ultrasonic wave vector and a is the radius of the beads. The attenuation coefficient exhibits a linear dependence on frequency for ka < < 1 and more complex behaviour at larger values of ka. The measured frequency dependence of the compensated backscatter was consistent with the frequency dependence of the differential backscatter cross section for a single polystyrene sphere throughout the range of ka investigated.

Acoustics↗
PubMed1996

Ultrasonic determination of the anisotropy of Young's modulus of fixed tendon and fixed myocardium.

The linear elastic properties of a soft tissue exhibiting a unidirectional arrangement of reinforcing fibers may be described in terms of the five independent elastic stiffness coefficients C11, C13, C33, C44, and C66. In previous studies, ultrasonic measurements of these coefficients for formalin fixed specimens of bovine Achilles tendon and normal human myocardium were reported. In the present study these results are used to analyze the anisotropy of Young's modulus of these tissues. For formalin fixed tendon a value of 1.37 GPa is obtained for Young's modulus along the fiber axis of the tissue, and a value of 0.0706 GPa is obtained perpendicular to the fibers. For formalin fixed myocardium, values of 0.101 and 0.0311 GPa parallel and perpendicular to the fibers, respectively, are obtained. Based on the results for the angular dependence of Young's modulus from unidirectional specimens of myocardium, a model is introduced to estimate these features for the more complicated fiber architecture of the left ventricular wall.

Anisotropy↗
PubMed1996

The influence of a decision support system on the differential diagnosis of medical practitioners at three levels of training.

As computer-based diagnostic consultation systems become, available, their influence and usefulness need to be evaluated. This report, based on partial data from a larger study, examines the influence of Iliad, a diagnostic consultation system, on the differential diagnosis of fourth year medical students, residents in medicine, and attendings in general internal medicine. Our results show that when faced with difficult diagnostic cases, medical students add significantly more diagnoses from Iliad's differential than do residents or attendings. However, the quality of Iliad's diagnostic advice in terms of the presence of the correct diagnosis, is no better for consultations done by students or residents compared to attendings.

Clinical Competence↗
PubMed1995

Ultrasonic tissue characterization of end-stage dilated cardiomyopathy.

The clinical use of angiotensin-converting enzyme (ACE) inhibitors now represents the standard of care for the treatment of chronic congestive heart failure. We utilized ultrasonic tissue characterization to define potentially salutary effects of treatment with ACE inhibitors on the material properties of the heart and its potential influence on cardiac remodeling at the cellular level. Ten 1-month-old cardiomyopathic (CM) Syrian hamsters were treated with captopril (2 g/L water ad libitum), and 10 CM and 5 normal hamsters were maintained untreated for 9 months. Hearts were excised, and backscattered radio-frequency data were acquired from 1200 independent sites from each specimen with a high-resolution 50-MHz acoustic microscope for calculation of integrated backscatter. Treatment with captopril elicited relative decreases in left ventricular (LV) wet weight, LV calcium concentration and integrated backscatter (IB) in treated as compared with untreated cardiomyopathic hearts without affecting LV collagen concentration. The IB from hearts of treated cardiomyopathic hamsters was significantly less in both grossly normal regions of myocardium (P < 0.02) and scar tissue regions (P = 0.0005) as compared with IB from hearts of untreated hamsters. The reduced integrated backscatter from hearts of treated cardiomyopathic hamsters indicates direct alterations in the material properties of cardiomyopathic hearts after captopril therapy. The lower IB from scar tissue in the treated animals was associated with decreased scar tissue calcification, which represents a novel therapeutic effect of captopril. This is the first report that delineates direct effects of ACE inhibitors on the material properties of both scar tissue and grossly normal myocardium at the cellular level in experimental dilated cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1995

Quantitative assessment of myocardial ultrasound tissue characterization through receiver operating characteristic analysis of Bayesian classifiers.

OBJECTIVES: This work proposes a self-consistent assessment methodology for quantitative evaluation of any combination of diagnostic features, with the immediate goal of quantitatively assessing the discriminating power in diabetic patients of features derived from ultrasound backscatter from myocardium. BACKGROUND: Four features from analysis of left ventricular myocardial ultrasound backscatter have previously been shown to be sensitive to potentially cardiomyopathic changes in patients with insulin-dependent diabetes mellitus who have no overt heart disease. The measured features were significantly different between such patients and normal control subjects, as well as among groups of such patients with and without systemic complications of the disease. The quantitative discriminating potential of the features was not assessed. METHODS: Multivariate classifier functions were constructed and analyzed by using the methodology of the receiver operating characteristic curve, which allows quantitative assessment of the discriminating power of these features, alone or in combination. The area under the receiver operating characteristic curve--the true positive rate averaged over all false positive rates--was used as a summary measure of performance. RESULTS: In distinguishing patients with insulin-dependent diabetes mellitus from normal control subjects, the most discriminating combination of ultrasound features for the detection of such changes in these patients yielded receiver operating characteristic curves with area measures of approximately 0.80; for such patients with retinopathy the measure increased to 0.90. This performance is comparable to that of many commonly used diagnostic tests. CONCLUSIONS: A self-consistent set of evaluation methodologies has quantitatively demonstrated the sensitivity of four ultrasound backscatter features to otherwise latent changes in myocardial structure that accompany the evolution of insulin-dependent diabetes mellitus. The results are remarkable in themselves and suggest the potential of the features for the general field of cardiac ultrasound tissue characterization.

Bayes Theorem↗
PubMed1995

Hand ischaemia following radial artery cannulation.

Digital ischaemia following radial arterial cannulation is uncommon. It is usually the result of thrombotic occlusion of a dominant radial artery. However, factors other than arterial thrombosis per se may operate in the critically ill patient to produce digital ischaemia. The following case presentation includes a review of possible mechanisms of digital ischaemia following radial artery cannulation and discusses the therapeutic options available.

Catheterization, Peripheral↗
PubMed1995

Assessment of myocardial viability by ultrasonic tissue characterization.

In conclusion, myocardial tissue characterization with quantitative ultrasonic indices descriptive of the physical state of the tissue is a promising approach to complement conventional echocardiography in the evaluation of patients with coronary artery disease. In particular, differentiation among hibernating, stunned and scarred myocardium may be possible on the basis of the experience accumulated thus far.

Animals↗