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Miller ME, Bowers KS. Hypnotic analgesia: dissociated experience or dissociated control? JOURNAL OF ABNORMAL PSYCHOLOGY 1993; 102:29-38. [PMID: 8436696 DOI: 10.1037/0021-843x.102.1.29] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
High-hypnotizable subjects (n = 18) were superior to low-hypnotizable subjects (n = 18) in the extent of pain reduction produced by hypnotic analgesia and by a stress-inoculation procedure. However, stress inoculation but not hypnotic analgesia impaired performance on a cognitively demanding task that competed with pain reduction for cognitive resources. This outcome implies that hypnotic analgesia occurs with little or no cognitive effort to reduce pain and challenges the social psychological model of hypnosis. The findings are also inconsistent with the notion of dissociated experience, which proposes that pain and the cognitive efforts to reduce it are cut off from consciousness by an amnesialike barrier. However, the results do support the notion of dissociated control, which proposes that suggestions for hypnotic analgesia directly activate pain reduction and thereby avert the need for cognitive strategies to reduce pain.
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Miller ME, Plumeau P, Blakely E. Elevated phenylalanine concentrations in benign hyperphenylalaninemia from evaporated milk feedings. Clin Pediatr (Phila) 1993; 32:124-5. [PMID: 8432076 DOI: 10.1177/000992289303200214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA 1993; 269:379-83. [PMID: 8418345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess the effects on health care resource utilization of a network of microcomputer workstations for writing all inpatient orders. DESIGN Randomized controlled clinical trial. SETTING Inpatient internal medicine service of an urban public hospital. SUBJECTS A total of 5219 internal medicine patients and the 68 teams of house officers, medical students, and faculty internists who cared for them. INTERVENTION Microcomputer workstations, linked to a comprehensive electronic medical record system, for writing all inpatient orders. MAIN OUTCOME MEASURES Total inpatient charges for each admission and charges for specific categories of orders. A time-motion study of selected interns assessed the ordering system's time consumption. RESULTS Intervention teams generated charges that were $887 (12.7%) lower per admission than did control teams (P = .02). Significant reductions (P < .05) were demonstrated separately for bed charges, diagnostic test charges, and drug charges. Reductions of similar proportion and statistical significance were found for hospital costs. The mean length of stay was 0.89 day shorter for intervention resident teams (P = .11). Interns in the intervention group spent an average of 33 minutes longer (5.5 minutes per patient) during a 10-hour observation period writing orders than did interns in the control group (P < .0001). CONCLUSIONS A network of microcomputer workstations for writing all inpatient orders significantly lowered patient charges and hospital costs. This would amount to savings of more than $3 million in charges annually for this hospital's medicine service and potentially tens of billions of dollars nationwide. However, the system required more physician time than did the paper charts. Research at other sites and system advances to reduce time requirements are warranted.
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Abstract
The use of oral contraceptives (OCs) has been associated with vascular complications. The mechanism(s) by which OCs predispose to thrombotic events remains unclear. Recent studies have demonstrated that postmenopausal (PM) women who take estrogen replacement therapy (ERT) have a decreased incidence of myocardial infarction compared to those who do not take ERT. This study was undertaken to determine if healthy individuals have differences in platelet adhesion depending on hormonal status. Men, PM women taking ERT, PM women not taking ERT, OC users, and premenopausal women not taking any medications were studied. Platelet studies were performed in a Hele-Shaw flow chamber at a low shear rate using platelet-rich plasma. The platelet adhesion process to subendothelial components: fibronectin, collagen I and collagen III was recorded using a 35 mm camera mounted on an inverted microscope. Photographs were taken at 30 second intervals for a total of 12 minutes and analyzed using a modified computer program which provided a numerical account of platelet adhesion. OC users had significantly higher platelet adherence to fibronectin, collagen I and collagen III compared to all other groups. All other study groups had similar platelet adhesion independent of hormonal status. These findings suggest that OCs cause increased platelet adhesion in some individuals and this may be one of the mechanisms by which OCs contribute to thrombotic events.
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Miller ME, Gengler DJ. Medicaid case management: Kentucky's Patient Access and Care Program. HEALTH CARE FINANCING REVIEW 1993; 15:55-69. [PMID: 10133709 PMCID: PMC4193407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since 1981, States have been experimenting with Medicaid managed care programs to improve access and continuity of care and to contain costs by reducing inappropriate and unnecessary utilization. To determine the impact of primary care case management (PCCM) on utilization, the authors examine data from the Kentucky Patient Access and Care program (KenPAC). Using monthly utilization data from 1984 to 1989 and an interrupted time-series research design, the authors find that PCCM reduces the use of independent laboratory, physician, emergency department, and outpatient hospital services. PCCM does not appear to affect utilization of inpatient hospital services or prescription drugs.
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131
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Miller ME, Zuckerman S, Gates M. How do Medicare physician fees compare with private payers? HEALTH CARE FINANCING REVIEW 1993; 14:25-39. [PMID: 10130578 PMCID: PMC4193371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Under the new fee schedule, Medicare physician fees are 76 percent of private fees. Consistent with the intent of payment reform, Medicare physician fees more closely approximate private fees for visits (93 percent) than for surgery (51 percent) and in rural areas as compared with large metropolitan areas. Variation in private fees across the country is considerably greater than it is for Medicare fees. Consequently, Medicare fees are most generous in areas that compare least favorably with the private market because private fees in these areas are well above average. These results shed light on the impact of the fee schedule and on the implications of using Medicare payment methods as part of a broad-based health reform.
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132
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Miller ME, Langefeld CD, Tierney WM, Hui SL, McDonald CJ. Validation of probabilistic predictions. Med Decis Making 1993; 13:49-58. [PMID: 8433637 DOI: 10.1177/0272989x9301300107] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Current advances in high-speed computing and increased availability of statistical software have led to widespread use of statistical methods for the development of computerized protocols predictive of binary health outcomes. If these predictive algorithms are to be used in settings other than those for which they were developed, e.g., applied in a different geographic setting or extrapolated for use in a slightly different population, then they should be carefully validated to ensure appropriate application. Miller et al. (Stat Med. 1991) provided a comprehensive methodology for external validation of logistic prediction models, and applied these methods in a temporal validation setting. In this article, the authors emphasize how these methods can be applied to general forms of probabilistic predictions and provide several SAS macros for computation of the desired statistics.
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133
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Miller ME, Welch WP. Medicare inpatient physician charges: an econometric analysis. HEALTH CARE FINANCING REVIEW 1993; 15:155-71. [PMID: 10135341 PMCID: PMC4193423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To control Medicare physician payments, Congress in 1989 established volume performance standards (VPS) that tie future physician fee increases to the growth in expenditures per beneficiary. The VPS risk pool is nationwide, and many observers believe it is too large to affect behavior. VPS could be modified by defining a separate risk pool for inpatient physician services and placing each hospital medical staff at risk for those services. Using a national random sample of 500,000 Medicare admissions, we explore the determinants of medical staff charges and comment on the policy implications. Multivariate analysis shows that charges increase with case mix and bed size but, surprisingly, decrease with the level of teaching activity. The teaching result is explained by the substitution of residents for physicians in these hospitals.
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135
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Miller ME, Welch WP. Physician charges in the hospital. Exploring episodes of care for controlling volume growth. Med Care 1992; 30:630-45. [PMID: 1614232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Abstract
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.
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Miller ME, Brooks JG, Forbes N, Insel R. Frequency of medium-chain acyl-CoA dehydrogenase deficiency G-985 mutation in sudden infant death syndrome. Pediatr Res 1992; 31:305-7. [PMID: 1570195 DOI: 10.1203/00006450-199204000-00001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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138
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Ross MW, Wodak A, Gold J, Miller ME. Differences across sexual orientation on HIV risk behaviours in injecting drug users. AIDS Care 1992; 4:139-48. [PMID: 1606209 DOI: 10.1080/09540129208253085] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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139
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Miller ME, Chourey PS. The Maize Invertase-Deficient miniature-1 Seed Mutation Is Associated with Aberrant Pedicel and Endosperm Development. THE PLANT CELL 1992. [PMID: 12297647 DOI: 10.2307/3869541] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Genetic evidence is presented to show that the developmental stability of maternal cells in the pedicel at the base of maize seeds is determined by the genotype of the developing endosperm. An early degeneration and withdrawal of maternal cells from the endosperm of homozygous miniature (mn mn) seed mutants were arrested if mn plants were pollinated by the wild-type Mn pollen. Similarly, the stability of the wild-type, Mn mn, maternal cells was also dependent on whether or not these cells were associated with the normal (Mn) or the mutant (mn) endosperm on the same ear. Biochemical and cellular analyses indicated that developing mn kernels have extremely low (<0.5% of the wild type) to undetectable levels of both soluble and wall-bound invertase activities. Extracts from endosperm with a single copy of the Mn gene showed a significant increase in both forms of invertases, and we suggest it is the causal basis of the wild-type seed phenotype. Collectively, these data provide evidence that invertase-mediated maintenance of a physiological gradient of photosynthate between pedicel and endosperm constitutes the rate-limiting step in structural stability of maternal cells as well as normal development of endosperm and seed.
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140
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Miller ME, Chourey PS. The Maize Invertase-Deficient miniature-1 Seed Mutation Is Associated with Aberrant Pedicel and Endosperm Development. THE PLANT CELL 1992; 4:297-305. [PMID: 12297647 PMCID: PMC160130 DOI: 10.1105/tpc.4.3.297] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Genetic evidence is presented to show that the developmental stability of maternal cells in the pedicel at the base of maize seeds is determined by the genotype of the developing endosperm. An early degeneration and withdrawal of maternal cells from the endosperm of homozygous miniature (mn mn) seed mutants were arrested if mn plants were pollinated by the wild-type Mn pollen. Similarly, the stability of the wild-type, Mn mn, maternal cells was also dependent on whether or not these cells were associated with the normal (Mn) or the mutant (mn) endosperm on the same ear. Biochemical and cellular analyses indicated that developing mn kernels have extremely low (<0.5% of the wild type) to undetectable levels of both soluble and wall-bound invertase activities. Extracts from endosperm with a single copy of the Mn gene showed a significant increase in both forms of invertases, and we suggest it is the causal basis of the wild-type seed phenotype. Collectively, these data provide evidence that invertase-mediated maintenance of a physiological gradient of photosynthate between pedicel and endosperm constitutes the rate-limiting step in structural stability of maternal cells as well as normal development of endosperm and seed.
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141
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Sherer DM, Wang N, Thompson HO, Peterson JC, Miller ME, Metlay LA, Abramowicz JS. An infant with trisomy 9 mosaicism presenting as a complete trisomy 9 by amniocentesis. Prenat Diagn 1992; 12:31-7. [PMID: 1557309 DOI: 10.1002/pd.1970120105] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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142
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Miller ME, Sulvetta MB. Medicare hospital outpatient services and costs: implications for prospective payment. HEALTH CARE FINANCING REVIEW 1992; 14:135-49. [PMID: 10171489 PMCID: PMC4193309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Medicare expenditures of hospital outpatient department (HOPD) services are growing rapidly, prompting congressional interest in a prospective payment system. In this article, the authors identify frequently provided services and examine service volume and charges in the HOPD. Relatively few services drive Medicare HOPD spending, and volume is dominated by visits, imaging and laboratory tests, whereas surgery accounts for a large proportion of charges. Hospital-level variations in charges, costs, case mix, and outliers are also explored. There is substantial variation in charges and costs across hospital types. However, after case-mix adjustment, all hospital types have average costs within 6 percent of the national average.
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143
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Eklund E, Miller ME, Ansari R, Fisher WB, Einhorn LH. Phase II trial of high-dose cisplatin plus etoposide plus vinblastine in non-small-cell lung cancer. A Hoosier Oncology Group study. Am J Clin Oncol 1991; 14:412-5. [PMID: 1659175 DOI: 10.1097/00000421-199110000-00010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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144
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Ada JR, Miller ME. Scapular fractures. Analysis of 113 cases. Clin Orthop Relat Res 1991:174-80. [PMID: 1864036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Abstract
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.
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146
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147
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Tierney WM, Miller ME, Hui SL, McDonald CJ. Practice randomization and clinical research. The Indiana experience. Med Care 1991; 29:JS57-64. [PMID: 1857137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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148
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Nichols CR, Williams SD, Loehrer PJ, Greco FA, Crawford ED, Weetlaufer J, Miller ME, Bartolucci A, Schacter L, Einhorn LH. Randomized study of cisplatin dose intensity in poor-risk germ cell tumors: a Southeastern Cancer Study Group and Southwest Oncology Group protocol. J Clin Oncol 1991; 9:1163-72. [PMID: 1710655 DOI: 10.1200/jco.1991.9.7.1163] [Citation(s) in RCA: 240] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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149
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Miller ME, Landis JR. Generalized variance component models for clustered categorical response variables. Biometrics 1991; 47:33-44. [PMID: 2049507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A generalized variance component model is proposed for the analysis of a categorical response variable with extra-multinomial variation. Categorical data obtained from research designs such as randomized multicenter clinical trials or complex sample surveys with clustering frequently exhibit extra-variation resulting from intracluster correlation. General correlation patterns are accounted for by utilizing a mixed-effects modelling approach, estimating the cluster variance components through the method of moments and modelling functions of the observed proportions through the use of estimating equations. A flexible set of assumptions characterizing the underlying covariance structure for the proportions can be accommodated. The importance of accounting for extra-variation when performing hypothesis tests is highlighted with an application to data from a multi-investigator clinical trial.
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150
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Dores GM, Miller ME, Kaufman DG. A herald bleed: a case of aortoesophageal fistula and a review of the literature. RHODE ISLAND MEDICAL JOURNAL 1991; 74:123-6. [PMID: 2038647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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