Curative surgery following failure of vancomycin therapy: a case report of methicillin resistant staphylococcal endocarditis on a native mitral valve.
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Catheters, Indwelling↗
Biomedical subjects
S J Walsh
Publications and source records attributed to S J Walsh.
Subject loss in spatial analysis of breast cancer.
Possible selection bias from assignment of latitude-longitude coordinates to the place of residence of all Connecticut women diagnosed with breast cancer from 1992 to 1995 (N = 11,470) was evaluated. Exact address-matching was accomplished for 8,121 records (70.8%) and an additional 1,722 records (15.0%) were matched using relaxed criteria. We did not address-match 1,627 records (14.1%) due to missing address information or limitations of the Geographic Information Systems street file. The age-adjusted likelihood of address-matching records was significantly greater for women of color, those born within Connecticut, residents of urban locales or census tracts with low median family incomes and those cases diagnosed nearer to 1992. Few differences in address-matching were attributable to tumor characteristics or therapeutic modality.
Adult↗
Syme amputation for the treatment of fibular deficiency. An evaluation of long-term physical and psychological functional status.
BACKGROUND: Syme amputation is an accepted treatment for fibular deficiency. With improvement in limb-lengthening procedures, there has been renewed interest in limb salvage for these patients. The purpose of the present study was to evaluate the physical and psychological results in ten young adults who had had a Syme amputation for the treatment of fibular deficiency when they were children. METHODS: The evaluation consisted of physical examination, prosthetic assessment, psychological testing, and physical performance testing of knee extension and flexion with use of a Cybex-II dynamometer. RESULTS: Five patients reported no difficulty with the involved limb since the Syme amputation, four had had minor secondary procedures (three medial distal femoral or proximal tibial hemiepiphyseodeses, one reconstruction with an autologous patellar ligament graft, one revision of the stump, and one tibial osteotomy) on the affected extremity, and one had mild instability of the knee that had been treated nonoperatively. All ten patients had an appropriate, functional Syme prosthesis, and none reported difficulty with walking or running. On psychological testing, this group generally did not differ from the norm with regard to occupational satisfaction, personal growth, relationships with family members and peers, and recreational behavior. The patients' overall assessment of self-reported quality of life and self-esteem was similar to that of normative adult samples. In general, these patients were leading active, productive lives and had always done so. CONCLUSIONS: On the basis of the results of this study, we concluded that young adults who have had a Syme amputation apparently are not limited in their ability to pursue and achieve personal goals. In order to justify recommending limb salvage rather than early Syme amputation for the treatment of fibular deficiency, the results of multistaged lengthening and reconstruction would have to match the functional, psychological, and cost-effective results for the patients whom we studied, who had had a Syme amputation.
Adolescent↗
Effects of non-mining occupational silica exposure on proportional mortality from silicosis and systemic sclerosis.
OBJECTIVE: Studies report an association between mining related silica exposure and systemic sclerosis (SSc). This study evaluated associations between non-mining occupational silica exposure, silicosis, and SSc. METHODS: The US National Institute for Occupational Safety and Health (NIOSH) recently identified 36 non-mining occupations in which workers face the "potential for substantial silica exposure." Data from death certificates in 25 US states during 1985-92 were analyzed to determine whether excess proportional mortality from silicosis or SSc occurred among those who worked in these occupations. RESULTS: Proportional mortality from silicosis in the occupations identified by NIOSH was significantly elevated among men [proportional mortality ratio (PMR) = 1.4; p < 0.0001] and women (PMR = 7.1; p = 0.002). The proportional mortality from SSc was not elevated among men (PMR = 1.0; p = 0.90) and was lower than expected among women (PMR = 0.8; p = 0.39). CONCLUSION: When cited on death certificates, the non-mining occupational categories identified by NIOSH reflect prior silica exposure; however, no evidence of excess mortality from SSc was observed in these occupations. The reported increased frequency of SSc among miners may depend on a level or mode of silica exposure unique to the mining industry.
Evaluation Studies as Topic↗
Diminished socioeconomic and racial disparity in the detection of early-stage breast cancer, Connecticut, 1986-1995.
Annual counts, proportional distributions, and age-adjusted incidence rates of disease by stage at diagnosis are reported for 27,970 in situ and invasive breast cancers from the Connecticut Tumor Registry, 1986-1995. Odds ratios for the likelihood of late-stage disease by year of diagnosis, age category, race/ethnicity, and the socioeconomic level of community of residence are presented. More breast cancer is diagnosed today at earlier, treatable stages than was previously the case. Nonetheless, young women, non-whites, and residents of low-to-moderate income census tracts were all at increased risk of being diagnosed with late-stage disease than were their respective reference groups. From 1986 through 1990, there was little change in the greater likelihood that non-whites and disadvantaged women would be diagnosed with late-stage disease. For 1990-95, however, the disparity in late-stage diagnosis by race/ethnicity and socioeconomic standing was greatly decreased.
Adult↗
Symptomatic cholelithiasis: a different disease in men? Connecticut Laparoscopic Cholesystectomy Registry.
OBJECTIVE: To determine the importance of gender in the clinical presentation and subsequent clinical outcome (risk of conversion from laparoscopic to open technique and risk of postoperative mortality) for patients undergoing cholecystectomy. SUMMARY BACKGROUND DATA: Age and clinical presentation have consistently been found to be important predictors of cholecystectomy outcomes; male gender has been cited in disparate studies as possibly having prognostic significance. METHOD: A statewide cholecystectomy registry (30,145 cases between 1989-1993) was analyzed. Hierarchical log-linear modeling was used to identify associations between characteristics of clinical presentation. Multivariate logistic regression analysis was used to determine predictions of conversion and mortality. RESULTS: Male gender was associated with twice the expected incidence of acute cholecystitis and pancreatitis in the elderly (> or = 65 years). Males had a significantly increased risk for conversion to open technique, but this decreased during the time frame of the study. Mortality was twice as high among males (confidence interval, 1.4-2.9, p = 0.0001). CONCLUSIONS: Males presenting for cholecystectomy are more likely to have severe disease. Independent of clinical presentation, they face increased risks of conversion to open technique and of postoperative mortality.
Aged↗
Limitations to the robustness of binormal ROC curves: effects of model misspecification and location of decision thresholds on bias, precision, size and power.
This paper concerns robustness of the binormal assumption for inferences that pertain to the area under an ROC curve. I applied the binormal model to rating method data sets sampled from bilogistic curves and observed small biases in area estimates. Bias increased as the range of decision thresholds decreased. The variance of area estimates also increased as the range of decision thresholds decreased. Together, minor bias and inflated variance substantially altered the size and power of statistical tests that compared areas under bilogistic ROC curves. I repeated the simulations by applying the binormal assumption to data sampled from binormal curves. Biases in area estimates were minimal for the binormal data, but the variance of area estimates was again higher when the range of decision thresholds was narrow. The size of tests that compared areas did not vary from the chosen significance level. Power fell, however, when the variance of area estimates was inflated. I conclude that inferences derived from the binormal assumption are sensitive to model misspecification and to the location of decision thresholds. A narrow span of decision thresholds increases the variability of area estimates and reduces the power of area comparisons. Model misspecification produces bias that alters test size and can exaggerate the loss of power that accompanies increased variability.
Bias↗
Changes in size of melanocytic nevi during pregnancy.
BACKGROUND: The relation between pregnancy, melanocytic nevi, and malignant melanoma is ambiguous. It has been reported that nevi grow and darken during pregnancy. Several recent studies have shown that malignant melanomas diagnosed during pregnancy are thicker than those not associated with pregnancy. This may be partially due to a delay in diagnosis because of the opinion that benign nevi change during pregnancy. OBJECTIVE: Our purpose was to photographically document any change in size of melanocytic nevi during pregnancy. METHODS: Twenty-two women were entered into the study during the first trimester of pregnancy and examined again in the third trimester. All nevi 2 mm or larger on their back were documented and photographed. Photographs were then compared and nevi measured for change in diameter. RESULTS: Of 129 nevi, only eight nevi (6.2%) changed in diameter from the first to the third trimester. The mean change in size of all nevi studied was zero. Of the eight nevi that did change in size, four increased by 1 mm and four decreased by 1 mm. CONCLUSION: Our study suggests that pregnancy is not associated with any significant change in size of melanocytic nevi. Patient characteristics (age, pregnancy number, skin type) and nevi characteristics (location, number) did not correlate with any change in size.
Adult↗
The effects of occupation-based social position on mortality in a large American cohort.
OBJECTIVES: Four occupation-based measures were used to derive estimates of social position's effect on all-cause mortality among men and women in a large national cohort. METHODS: The National Longitudinal Mortality Study provided information on principal occupation and 9-year follow-up for 229,851 persons aged 25 through 64 years. Cox's proportional hazards model was used to estimate the age-adjusted risk of death relative to six ordinal categories of social position. The Slope Index of Inequality described average change in death rates across categories. RESULTS: Risk of death was consistently elevated among persons at lower positions in the social hierarchy. Estimates comparing lowest with highest categories varied within a narrow range (1.47-1.92 for men and 1.23-1.55 for women). However, several discrepancies among analyses were noted. The analysis by US census groups revealed nonlinear associations, whereas those using other scales found incremental increases in risk. Effect modification by sex was observed for analyses by two of the four measures. Race/ ethnicity did not modify the underlying association between variables. CONCLUSIONS: Our analysis complements previous findings and supports, with few qualifications, the interchangeability of occupation-based measures of social position in mortality studies. Explanations for why relative risk estimates were modified by sex are offered.
Adult↗
Geographic information systems, spatial network analysis, and contraceptive choice.
How does family planning accessibility affect contraceptive choice? In this paper we use techniques of spatial analysis to develop measures of family planning accessibility, and evaluate the effects of these geographically derived measures in a multilevel statistical model of temporary method choice in Nang Rong, Thailand. In our analyses we combine spatial data obtained from maps and Global Positioning System (GPS) readings with sociodemographic data from surveys and administrative records. The new measures reveal (1) important travel time effects even when family planning outlets are close by; (2) independent effects of road composition; (3) the relevance of alternative sources of family planning supply; and (4) the importance of the local history of program placement.
Choice Behavior↗
Normative models and healthcare planning: network-based simulations within a geographic information system environment.
OBJECTIVES: Network analysis to integrate patient, transportation and hospital characteristics for healthcare planning in order to assess the role of geographic information systems (GIS). A normative model of base-level responses of patient flows to hospitals, based on estimated travel times, was developed for this purpose. DATA SOURCES/STUDY SETTING: A GIS database developed to include patient discharge data, locations of hospitals, US TIGER/Line files of the transportation network, enhanced address-range data, and U.S. Census variables. The study area included a 16-county region centered on the city of Charlotte and Mecklenburg County, North Carolina, and contained 25 hospitals serving nearly 2 million people over a geographic area of nearly 9,000 square miles. STUDY DESIGN: Normative models as a tool for healthcare planning were derived through a spatial Network analysis and a distance optimization model that was implemented within a GIS. Scenarios were developed and tested that involved patient discharge data geocoded to the five-digit zip code, hospital locations geocoded to their individual addresses, and a transportation network of varying road types and corresponding estimated travel speeds to examine both patient discharge levels and a doubling of discharge levels associated with total discharges and DRG 391 (Normal Newborns). The Network analysis used location/allocation modeling to optimize for travel time and integrated measures of supply, demand, and impedance. DATA COLLECTION/EXTRACTION METHODS: Patient discharge data from the North Carolina Medical Database Commission, address-ranges from the North Carolina Institute for Transportation Research and Education, and U.S. Census TIGER/Line files were entered-into the ARC/INFO GIS software system for analysis. A relational database structure was used to organize the information and to link spatial features to their attributes. PRINCIPAL FINDINGS: Advances in healthcare planning can be achieved by examining baseline responses of patient flows to distance optimization simulations and healthcare scenarios conducted within a spatial context that uses a normative model to integrate characteristics of population, patients, hospitals, and transportation networks. Model runs for the defined scenarios indicated that a doubling of the 1991 patient discharge levels resulted in an areal constriction of the service areas to those zip codes immediately adjacent to the hospitals, thereby leaving substantial areas unassigned to hospitals during the allocation process, but that doubling the demand for obstetrics care (DRG 391) resulted in little change in the pattern of accessibility to care as indicated by the size, orientation, and pattern of the service areas. CONCLUSIONS: The GIS-Network system supported "what if" simulations, portrayed service areas within a spatial context, integrated disparate data in the execution of the location/allocation model, and used estimated travel time along a transportation network instead of Euclidean distance for calculating accessibility. The results of the simulations suggest that the GIS-Network system is an effective approach for exploring a variety of healthcare scenarios where changes in the supply, demand, and impedance variables can be examined within a spatial context and where variations in system trajectories can be simulated and observed.
Computer Communication Networks↗
Geographical clustering of mortality from systemic sclerosis in the Southeastern United States, 1981-90.
OBJECTIVE: To determine whether elevated rates of mortality from systemic sclerosis (SSc) in the Southeastern United States result from local, multicounty clusters of the disease. METHODS: Detection of spatial clusters of SSc mortality by applying the method of Kulldorff and Nagarwalla to death certificate data from 955 counties in 12 southeastern states. RESULTS: From 1981 to 1990, significant excess mortality from SSc in the Southeastern US occurred among white males [standardized mortality ratio (SMR) = 1.2; p = 0.0004] and black males (SMR = 1.2; p = 0.04), but not among white females (SMR = 0.98; p = 0.55) or black females (SMR = 1.1; p = 0.06). When the cluster detection algorithm was applied to data for white males, 3 significant clusters were identified. The primary cluster (p = 0.001) was centered around Coffee, Tennessee. Two smaller clusters overlapped the primary cluster -- one centered at Calhoun, Alabama, (p = 0.008) and another centered at Chattooga, Georgia, (p = 0.04). Analysis of data for black males resulted in a single significant cluster (p = 0.02) centered at Northampton, North Carolina. When data for white or black females were analyzed, no clusters reached statistical significance. In combination, excess SSc mortality in the detected clusters accounted for 79.0 and 66.2%, respectively, of the excess deaths among white and black males across the whole Southeast. CONCLUSION: Elevation of SSc mortality rates in the Southeastern US results from local clusters of concentrated mortality. These clusters may be artifacts of regional variation in death certificate quality. If not, distinctive environmental factors in these areas may provide new insights into the etiology of SSc.
Adolescent↗
Bile duct injuries, 1989-1993. A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry.
OBJECTIVE: To review the incidence of major bile duct injuries (MBDI) during the shift from open (OC) to laparoscopic cholecystectomy (LC). DESIGN: Cohort analysis; minimum 15-month patient follow-up. SETTING: Acute care Connecticut hospitals. PATIENTS: Medical records of 30211 patients with cholecystectomy (OC or LC) reviewed; 47 cases of MBDI confirmed. MAIN OUTCOME MEASURE: Rate of MBDI. RESULTS: The incidence of MBDI in Connecticut hospitals rose from 0.04% in 1989 to 0.24% in 1991, then decreased to 0.11% in 1993. The increase was due to increased numbers of cholecystectomies and the initial increased risk of injury with LC. The 1990-through-1993 trend of decreasing incidence of LC MBDI was statistically significant (P=.02). By 1993, the difference between LC and OC was no longer significant (P=.81). Acute cholecystitis (odds ratio, 3.3) and gallstone pancreatitis (odds ratio, 3.6) increased the risk of MBDI during LC (P<.001). The LC MBDI more commonly were ductal excision or transections and often were not diagnosed intraoperatively. Intraoperative cholangiography facilitated intraoperative recognition and repair. Most patients (89%) underwent definitive management of the MBDI at the hospital of origin; of those, 5% required further interventions. CONCLUSIONS: Surgeries for acute cholecystitis and gallstone pancreatitis are associated with an increased risk for MBDI. Ductal anatomy, the timing of recognition of injury, and the method of repair dictate patient outcomes. Most patients are successfully managed at the hospital of origin, with good long-term results. Late bile duct strictures appear rare.
Acute Disease↗
Racial aspects of comorbidity in systemic lupus erythematosus.
OBJECTIVE: To investigate racial differences in the expression of systemic lupus erythematosus (SLE) by comparing comorbidity at death among individuals with SLE. METHODS: Proportional mortality rates were estimated for common contributing causes of death among white and black females in the United States, 1989-1991, whose death certificates listed SLE as an underlying or contributing cause. Logistic regression analysis was used to assess the effects of SLE and race on variation in proportional mortality using rates from non-SLE deaths as a comparison baseline. RESULTS: Common contributing causes of death listed with SLE included conditions that are known sequelae of the disease. Proportional mortality rates for these conditions varied with race and age. However, among black deaths that listed SLE, the rates of renal disease surpassed those of all other conditions regardless of age. When rates of renal disease among black SLE deaths or among white SLE deaths in any age group were compared to those among white non-SLE deaths, proportional mortality ratios were significantly greater than 1. This also held when rates of renal disease among black non-SLE deaths were compared to rates among white non-SLE deaths. However, across all ages, the proportional mortality ratios for renal disease in black SLE deaths significantly exceeded corresponding ratios for white SLE deaths and for black non-SLE deaths. CONCLUSION: Black females who die with SLE appear to experience a combination of the excess renal disease reported for persons with SLE and for all blacks. This combination may be a source of the elevated SLE mortality rates observed among US blacks.
Adolescent↗
A meningococcal vaccination campaign on a university campus: vaccination rates and factors in nonparticipation.
OBJECTIVES: This study was undertaken to determine an accurate vaccination rate and identify factors influencing nonvaccination in a meningococcal vaccination campaign on a Connecticut university campus in May 1993. METHODS: Vaccination and student data were merged to determine demographic factors associated with nonvaccination. A case-control study examined reasons for nonvaccination. RESULTS: The estimated vaccination rate for students returning to the campus was 93%. Lower rates occurred among older students, students living off campus, graduate and nondegree students, and married students. Perceived poor access to the vaccination center was the strongest predictor of nonvaccination. CONCLUSIONS: Higher vaccination rates may be achieved by specifically targeting students who live off campus and by providing multiple vaccination sites with extended hours.
Adolescent↗
Divergent racial trends in mortality from systemic lupus erythematosus.
OBJECTIVE: To compare trends in mortality from systemic lupus erythematosus (SLE) between black and white females in the United States. METHODS: Analysis of nationwide cause of death data collected by the National Center for Health Statistics, 1968 to 1991. RESULTS: During the latter half of the 1968-91 period, trends in SLE mortality for black and white women under age 45 diverged and racial differences in total mortality from SLE widened. Among white females, total SLE mortality has been stable since the late 1970s at a mean annual rate of 4.6 deaths per million. This stability results from a balance between declining risk among whites under age 45 and increasing in those beyond 55. Among blacks, total mortality has risen more than 30% since the late 1970s to a mean annual rate of 18.7 per million. This increase results from a combination of constant risk in black females under 45 and rising risk in women over 55. CONCLUSION: Trends for whites are consistent with a shift in mortality from younger to older women. This shift can be explained by longer postdiagnosis survival resulting from improved clinical management of SLE. The trends for blacks imply higher prevalence of SLE among black females than previously recognized and/or the existence of some impediment to young black females sharing in the full benefits of effective treatment.
Adolescent↗
Utility of magnetic resonance contrast agents in routine cranial imaging. Case study of an evaluative method.
Scientific studies that document the utility and value of MR imaging in routine clinical practice must differ from double-blind, randomized clinical trials. The case study in this article represents an effort to create pragmatic methods for these clinical environments. An independent, judicial panel reviewed blinded readings of unenhanced and enhanced MR images. This panel determined that Gd-DTPA enhancement improved the readings that were close enough for clinical purposes--called Diagnostic Merit. More importantly, clinical care was not disrupted, and statistically significant benefits were shown in routine practice. Such studies could lead to earlier reimbursement for useful imaging technologies.
Analysis of Variance↗
Diagnostic accuracy and deep venous thrombosis: a biostatistician's perspective.
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Biometry↗