Fluid management and arginine vasopressin in bacterial meningitis.
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Arginine Vasopressin↗
Biomedical subjects
M E Miller
Publications and source records attributed to M E Miller.
An infant with trisomy 9 mosaicism presenting as a complete trisomy 9 by amniocentesis.
We present a case in which amniocentesis performed at 33 weeks' gestation because of symmetrical intrauterine growth retardation and decreased amniotic fluid volume led to the prenatal diagnosis of a fetus with a karyotype of 47,XX,+9,t(1;20)(q42;p11.2) pat, i.e., with an extra chromosome 9 and a balanced translocation between chromosomes 1 and 20. At delivery, the baby showed clinical features of trisomy 9, yet chromosome analysis of the cord blood revealed no trisomy 9 cells, a finding confirmed by neonatal blood karyotyping. The balanced translocation was present in all cells. A skin biopsy confirmed trisomy 9 mosaicism with 10 per cent trisomy 9 cells. The baby died at 6 weeks and an autopsy was obtained. Chromosome analysis of different organs demonstrated different frequencies of the mosaicism of trisomy 9. The possible underlying mechanism for the discrepancy between the karyotype results by amniocentesis and those of other tissues is discussed.
Adult↗
Gigantic osteoma of the mandible: report of a case.
A case of a very large solitary osteoma of the right posterior mandible in a 22-year-old man is presented. The tumor was asymptomatic despite its location and large size. It was removed via an extraoral Risdon approach without complication. The importance of differentiating a large solitary osteoma from a parosteal osteogenic sarcoma is emphasized. Any patient presenting with a solitary osteoma also should be evaluated for Gardner's syndrome.
Adult↗
Differences across sexual orientation on HIV risk behaviours in injecting drug users.
Injecting drug users (IDUs) play a disproportionate role in the spread of HIV given their injecting and sexual contacts, and thereby act as conduits between these risk groups. We investigated differences in risk behaviour and HIV seroprevalence in a Sydney sample of 1,245 IDUs. Significant differences were observed across sexual orientation in HIV serostatus for males, with homosexual men having the highest HIV seroprevalence rate (35%), bisexual men intermediate (12%) and heterosexual men lowest (3%). Sexual HIV risk behaviours were lowest for homosexual men, intermediate for bisexual men, and highest for heterosexual men in the case of condom use: however, for numbers of partners, seroprevalence, and anal sex the trends were reversed. There were no differences across sexual orientation for either sex for injecting drug risk behaviours. Both male and female respondents reported having more than 50% of sexual contacts while under the influence of drugs. This study suggests that risk reduction in the sexual domain has not generalized to the injecting risk domain regardless of sexual orientation, and demonstrates that sexual risk behaviours in IDUs are lowest in homosexual, intermediate in bisexual, and highest in heterosexual IDU men.
Adult↗
State border crossing for Medicare hospital admissions.
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Catchment Area, Health↗
Frequency of medium-chain acyl-CoA dehydrogenase deficiency G-985 mutation in sudden infant death syndrome.
A small percentage of apparent sudden infant death syndrome (SIDS) victims may have an unsuspected metabolic disorder. Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency is a disorder of fatty acid oxidation that has been the most common such metabolic disorder found in series of SIDS victims. A single mutation in MCAD deficiency has been recently described (G-985) that accounts for approximately 90% of MCAD deficiency mutations. We studied the hypothesis that heterozygosity or homozygosity for this specific MCAD deficiency mutation might be associated with SIDS. DNA was extracted from the paraffin-embedded autopsy tissues of 67 victims of SIDS in Monroe County, NY who died between 1984 and 1989. Using the polymerase chain reaction/NcoI digestion method, we found no G-985 homozygotes and three (4.5%) G-985 heterozygotes. In 70 newborn controls, there were no G-985 homozygotes and one (1.4%) heterozygote. Although the frequency of G-985 heterozygotes was slightly greater than in our control group, it was not statistically different. We conclude that the specific MCAD deficiency mutation G-985 is not strongly associated with SIDS and that MCAD deficiency probably does not make a significant contribution to the etiology of SIDS.
Acyl-CoA Dehydrogenase↗
Decisions without consequences: cost control and access in state Medicaid programs.
States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.
Cost Control↗
Physician charges in the hospital. Exploring episodes of care for controlling volume growth.
Medicare physician payments are growing rapidly. At least 40% of the annual growth is due to volume increases. Reforms passed in 1989 include volume performance standards that attempt to control volume by linking future physician fee increases to volume growth. There is concern that defining the entire nation as the risk pool will result in an unworkable volume performance standard. One way to improve incentives is to create a separate volume performance standard for in-hospital physician services, define bundles of services related to the hospital stay, and place the medical staff of the hospital at risk for volume growth. To forestall the unbundling of services outside the stay, windows could be defined around the stay. This study reports physician services during the stay and in windows around the stay. In so doing, the study creates the knowledge base necessary to design better volume control policies and judge among alternative window definitions. Using 1987 data, this study presents average physician charges by type of service during: 1) the hospital stay; and 2) 1-month windows before and after the stay. For all admissions, 85% of charges occur during the stay and 15% occur during the windows (windows for surgical admissions and medical admissions are 9% and 23%, respectively). Pre- and postwindows are roughly symmetrical and average charges per day gradually increase before the admission and decline after discharge. A small physician panel commented on the clinical appropriateness of the one month windows. The panel indicates that defining in-hospital episodes of physician care is feasible.
Ambulatory Surgical Procedures↗
Validation techniques for logistic regression models.
This paper presents a comprehensive approach to the validation of logistic prediction models. It reviews measures of overall goodness-of-fit, and indices of calibration and refinement. Using a model-based approach developed by Cox, we adapt logistic regression diagnostic techniques for use in model validation. This allows identification of problematic predictor variables in the prediction model as well as influential observations in the validation data that adversely affect the fit of the model. In appropriate situations, recommendations are made for correction of models that provide poor fit.
Benzothiadiazines↗
Phase II trial of high-dose cisplatin plus etoposide plus vinblastine in non-small-cell lung cancer. A Hoosier Oncology Group study.
Fifty-one patients with advanced non-small-cell lung cancer were treated on a Hoosier Oncology Group protocol with an aggressive, high-dose cisplatin combination chemotherapy regimen. All patients had a Karnofsky performance status of 80% or higher and had no prior chemotherapy. The drug regimen consisted of cisplatin 30 mg/m2 days one through five, etoposide 40 mg/m2 days one through five, and vinblastine 5 mg/m2 day one. Therapy was given every three weeks for a total of three courses. Forty-five patients were evaluable for response and an objective response was seen in 15 patients (33%) with only one complete responder. The median duration of response was 16.5 weeks. The median survival for the entire group was 29.0 weeks. Toxicity was moderately severe with two treatment-related deaths (4%). Despite an aggressive chemotherapy regimen in a favorable patient population, there was no obvious evidence of a major therapeutic value.
Antineoplastic Combined Chemotherapy Protocols↗
Emotional support. Learning to cope with disability.
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Adaptation, Psychological↗
Sexually transmissible diseases in injecting drug users.
Self-reported histories of sexually transmissible diseases (STDs) and HIV serostatus were investigated as part of a study of HIV risk behaviour in a sample of 1245 Syndey injecting drug users (IDUs) (mean age 27.5 years) both in and out of treatment. A high lifetime prevalence of STDs was reported in both men and women. For male IDUs, the lowest reported lifetime prevalence of STDs was in heterosexuals, with bisexuals intermediate and homosexuals reporting the highest prevalence. HIV seroprevalence followed the same pattern. For women, bisexuals had the highest reported STD history, heterosexual women were intermediate and homosexual women reported the lowest prevalence. Over one third of the bisexual women reported having been involved in prostitution. These data indicate that over one third of IDU men and over half of IDU women reported at least one STD in their lifetime. The high lifetime prevalence of STDs in IDUs indicates that this group is at increased risk of sexual transmission of HIV, given the importance of STDs as a cofactor. Reducing the prevalence of STDs in IDUs is a possible additional strategy to diminish the spread of HIV among IDUs and from them to non-IDU sexual contacts.
Adult↗
Megaloblastic hematopoiesis in vitro. Interaction of anti-folate receptor antibodies with hematopoietic progenitor cells leads to a proliferative response independent of megaloblastic changes.
We tested the hypothesis that anti-placental folate receptor (PFR) antiserum-mediated effects on hematopoietic progenitor cells in vitro of increased cell proliferation and megaloblastic morphology were independent responses. We determined that (a) purified IgG from anti-PFR antiserum reacted with purified apo- and holo-PFR and specifically immunoprecipitated a single (44-kD) iodinated moiety on cell surfaces of low density mononuclear cells (LDMNC); (b) when retained in culture during in vitro hematopoiesis, anti-PFR IgG (in contrast to PFR-neutralized anti-PFR IgG and nonimmune IgG) consistently led to increased cloning efficiency of colony forming unit-erythroid (CFU-E), burst forming unit-E (BFU-E), CFU-granulocyte macrophage (CFU-GM), and CFU-GEM megakaryocyte (CFU-GEMM), and objectively defined megaloblastic changes in orthochromatic normoblasts from CFU-E- and BFU-E-derived colonies; (c) when anti-PFR antiserum was removed after initial (less than 1 h) incubation with LDMNC, a cell proliferation response was induced, but megaloblastic changes were not evident. (d) Conversely, delay at 4 degrees C for 24 h before long-term plating with antiserum resulted in megaloblastosis without increased cell proliferation; (e) however, 500-fold molar excess extracellular folate concentrations completely abrogated the expected anti-PFR antiserum-induced megaloblastic changes, without altering cell proliferative responses. Thus, although cell proliferative and megaloblastic changes are induced after short-term and prolonged interaction of antibody with folate receptors on hematopoietic progenitors, respectively, they are independent effects.
Animals↗
Randomized study of cisplatin dose intensity in poor-risk germ cell tumors: a Southeastern Cancer Study Group and Southwest Oncology Group protocol.
Between 1984 and 1989, 159 patients presenting with advanced germ cell cancer were entered on a randomized clinical trial comparing the efficacy and toxicity of etoposide and bleomycin and either standard-dose cisplatin (20 mg/m2 daily for 5 days) or high-dose cisplatin (40 mg/m2 daily for 5 days). Of the 159 patients, 153 were assessable for toxicity and response. As expected, patients receiving the high-dose cisplatin regimen experienced significantly more neurotoxicity, ototoxicity, nausea and vomiting, and myelo-suppression. Four patients (3%) died related to therapy. Despite the toxicity encountered, dose intensity was maintained. Overall, 84% of patients in the high-dose arm received 80% or more of the projected dose of cisplatin, etoposide, and bleomycin; and 90% of patients on the standard-dose arm received 80% or more of the projected dose. Of the 76 eligible patients randomized to receive the high-dose cisplatin regimen, 52 (68%) became disease-free with chemotherapy alone or with subsequent resection of residual teratoma or cancer. Of the 77 patients randomized to the standard-dose arm, 56 (73%) became disease-free with chemotherapy alone or with surgery. Median follow-up is now 24 months. Eleven patients (three high-dose and eight standard-dose) relapsed from disease-free status. Overall, 74% of patients receiving the high-dose cisplatin regimen are alive, and 63% are continuously free of disease. Of the patients receiving the standard-dose cisplatin regimen, 74% are alive, and 61% are continuously free of disease. This randomized prospective trial in advanced germ cell cancer achieved dose intensity of the most active single agent in this disease. This dose intensity did not translate into an improved survival or cure. We conclude that dose escalation of cisplatin beyond standard doses results in excess toxicity with no accompanying therapeutic benefit.
Adolescent↗
Comparing urban and rural physicians.
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Fees, Medical↗
Practice randomization and clinical research. The Indiana experience.
Thoughtful preparation of a research laboratory is an early step in designing a program for scientific investigation. The Division of General Internal Medicine at Indiana University has maintained a "laboratory" for outpatient clinical investigation for more than 15 years. In this report, we describe the structure and function of the General Medicine Practice in the Regenstrief Health Center on the campus of the Indiana University School of Medicine in Indianapolis. Specifically, we discuss the ongoing random allocation of subjects, the local resources for data management and tracking of patients' use of clinical services, and how combining this information system into a randomized primary care system has fostered successful ventures in clinical investigation.
Health Services Research↗
Scapular fractures. Analysis of 113 cases.
Scapular fractures have been the subject of study since Desault's treatise of 1805, but few large-scale studies have been completed with long-term follow-up evaluation of displaced scapular neck and spine fractures. This series of 148 fractures in 116 scapulae (113 patients) appears to be the largest ever reported and the only one with a follow-up study of a significant group (24 patients). Significant disability was found in patients with displaced scapular spine and neck fractures: (1) pain at rest in 50%-100%, (2) weakness with exertion in 40%-60%, and (3) pain with exertion in 20%-66%. Based on these findings, the indications for operative management should be expanded to include displaced scapular neck and spine fractures. Using extensile exposure through a posterior Judet incision, rigid internal fixation, and early motion, results in eight cases were excellent. All patients recovered at least 85 degrees of glenohumeral abduction, normal scapulothoracic motion, and none had resting pain, night pain, or pain with abduction. The minimum follow-up study period was 15 months.
Adolescent↗
A herald bleed: a case of aortoesophageal fistula and a review of the literature.
Survival in AEF is rare because the diagnosis of this uncommon entity is not always suspected, and few patients survive despite aggressive but often late intervention. We present this case to increase awareness of AEF, which although rare, does occur and should be suspected in any patient who presents with midthoracic pain or dysphagia and herald bleeding.
Aged↗