Timothy L Lash

Emory University, Atlanta, Georgia, United States

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Publications (200)983.44 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Quantitative bias analysis serves several objectives in epidemiological research. First, it provides a quantitative estimate of the direction, magnitude and uncertainty arising from systematic errors. Second, the acts of identifying sources of systematic error, writing down models to quantify them, assigning values to the bias parameters and interpreting the results combat the human tendency towards overconfidence in research results, syntheses and critiques and the inferences that rest upon them. Finally, by suggesting aspects that dominate uncertainty in a particular research result or topic area, bias analysis can guide efficient allocation of sparse research resources. The fundamental methods of bias analyses have been known for decades, and there have been calls for more widespread use for nearly as long. There was a time when some believed that bias analyses were rarely undertaken because the methods were not widely known and because automated computing tools were not readily available to implement the methods. These shortcomings have been largely resolved. We must, therefore, contemplate other barriers to implementation. One possibility is that practitioners avoid the analyses because they lack confidence in the practice of bias analysis. The purpose of this paper is therefore to describe what we view as good practices for applying quantitative bias analysis to epidemiological data, directed towards those familiar with the methods. We focus on answering questions often posed to those of us who advocate incorporation of bias analysis methods into teaching and research. These include the following. When is bias analysis practical and productive? How does one select the biases that ought to be addressed? How does one select a method to model biases? How does one assign values to the parameters of a bias model? How does one present and interpret a bias analysis?. We hope that our guide to good practices for conducting and presenting bias analyses will encourage more widespread use of bias analysis to estimate the potential magnitude and direction of biases, as well as the uncertainty in estimates potentially influenced by the biases.
    International journal of epidemiology. 07/2014;
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    ABSTRACT: Five-year breast cancer survivors, diagnosed after 65 years of age, may develop more incident comorbidities than similar populations free of cancer. We investigated whether older breast cancer survivors have a similar comorbidity burden 6-15 years after cancer diagnosis to matched women free of breast cancer at start of follow-up and whether incident comorbidities are associated with all-cause mortality. In this prospective cohort study, 1,361 older 5-year early-stage breast cancer survivors diagnosed between 1990 and 1994 and 1,361 age- and health system-matched women were followed for 10 years. Adjudicated medical record review captured prevalent and incident comorbidities during follow-up or until death as collected from the National Death Index. Older 5-year breast cancer survivors did not acquire incident comorbidities more often than matched women free of breast cancer in the subsequent 10 years [hazard ratio (HR) 1.0, 95 % confidence interval (95 % CI) 0.93, 1.1]. Adjusted for cohort membership, women with incident comorbidities had a higher mortality rate than those without incident comorbidities (HR 4.8, 95 % CI 4.1, 5.6). A breast cancer history continued to be a hazard for mortality 6-15 years after diagnosis (HR 1.3, 95 % CI 1.1, 1.4). We found that older breast cancer survivors who developed comorbidities had an increased all-cause mortality rate even after adjusting for age and prevalent comorbidity burden. Additionally, survivors acquire comorbidities at a rate similar to older women free of breast cancer. These results highlight the association between comorbidity burden and long-term mortality risk among older breast cancer survivors and their need for appropriate oncology and primary care follow-up.
    Breast Cancer Research and Treatment 06/2014; · 4.47 Impact Factor
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    ABSTRACT: We created a registry of Danish-born citizens of Denmark with incident International Classification of Diseases (10th ed.; ICD-10) severe stress and adjustment disorder diagnoses between 1995 and 2011. A unique personal identifier was used to retrieve and merge data on demographic characteristics and diagnoses (ICD-10 codes F43.x). Here we report on the incidence of these disorders and the demographic characteristics of the subset of the Danish population who have received 1 of these diagnoses: 111,844 adults and children received a first diagnosis between 1995 and 2011. More women than men (60.1% vs. 39.9%) received a diagnosis. Diagnoses increased during the late teens through early 30s. Adjustment disorder was the most common diagnosis (65.7% of adults and 64% of children). Reaction to severe stress unspecified was the second most common (19.8% of adults and 23.8% of children), and there was a large increase in both, as well as acute stress reaction diagnoses, in 2007 (3,717-5,141, 1,248-2,520, and 348-1,024 in 2006 to 2007, respectively). Findings regarding gender and age of onset are similar to other westernized countries. This registry can be used for future research programs, contributing to the study of stress and trauma.
    Journal of Traumatic Stress 06/2014; 27(3):370-4. · 2.72 Impact Factor
  • American journal of epidemiology. 05/2014;
  • Timothy L Lash, Barbara Abrams, Lisa M Bodnar
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    ABSTRACT: Epidemiologic data sets continue to grow larger. Probabilistic-bias analyses, which simulate hundreds of thousands of replications of the original data set, may challenge desktop computational resources. We implemented a probabilistic-bias analysis to evaluate the direction, magnitude, and uncertainty of the bias arising from misclassification of prepregnancy body mass index when studying its association with early preterm birth in a cohort of 773,625 singleton births. We compared 3 bias analysis strategies: (1) using the full cohort, (2) using a case-cohort design, and (3) weighting records by their frequency in the full cohort. Underweight and overweight mothers were more likely to deliver early preterm. A validation substudy demonstrated misclassification of prepregnancy body mass index derived from birth certificates. Probabilistic-bias analyses suggested that the association between underweight and early preterm birth was overestimated by the conventional approach, whereas the associations between overweight categories and early preterm birth were underestimated. The 3 bias analyses yielded equivalent results and challenged our typical desktop computing environment. Analyses applied to the full cohort, case cohort, and weighted full cohort required 7.75 days and 4 terabytes, 15.8 hours and 287 gigabytes, and 8.5 hours and 202 gigabytes, respectively. Large epidemiologic data sets often include variables that are imperfectly measured, often because data were collected for other purposes. Probabilistic-bias analysis allows quantification of errors but may be difficult in a desktop computing environment. Solutions that allow these analyses in this environment can be achieved without new hardware and within reasonable computational time frames.
    Epidemiology (Cambridge, Mass.) 05/2014; · 5.51 Impact Factor
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    ABSTRACT: Venous thromboembolism (VTE) is associated with renal cell carcinoma (RCC), but data on the effect of comorbidities are limited. Therefore, our purpose was to determine the effect of comorbidity on VTE risk among patients with RCC. A population-based cohort of all patients with RCC (n = 8,633) diagnosed in Denmark between 1995 and 2010 and a comparison cohort selected from the general population and matched on age, sex, and comorbidities (n = 83,055) were identified. Risk of subsequent VTE was estimated with 95% CI for the first 3 months, 1 year, and 5 years following cancer diagnosis. We stratified by Charlson comorbidity index (CCI) scores to estimate excess risk in patients with RCC vs. the comparison cohort within comorbidity strata. We also performed subanalyses for postoperative VTE and metastases. VTE risk was higher in the RCC compared with comparison cohort, particularly during the initial year following diagnosis (risk difference = 9.9 per 1,000 persons [95% CI: 7.7-12.2]). After stratifying by CCI, excess risk declined with increasing comorbidities. The risk difference was 12.3 per 1,000 persons (95% CI: 9.1-15.5) for CCI = 0 and 0.5 (95% CI: 6.0-7.0) for CCI = 4. Excess risk also declined with increasing comorbidities among patients with postoperative VTE and among those with metastases. RCC is associated with increased risk of VTE when compared with a matched general population cohort. Risk did not appear to increase with added comorbidity burden. Clinical attention to VTE risk in patients with RCC is appropriate regardless of the presence or absence of comorbidities.
    Urologic Oncology 05/2014; 32(4):466-72. · 3.65 Impact Factor
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    ABSTRACT: Studies using vital records-based maternal weight data have become more common, but the validity of these data is uncertain. We evaluated the accuracy of prepregnancy body mass index (BMI) and gestational weight gain (GWG) reported on birth certificates using medical record data in 1204 births at a teaching hospital in Pennsylvania from 2003 to 2010. Deliveries at this hospital were representative of births statewide with respect to BMI, GWG, race/ethnicity, and preterm birth. Forty-eight strata were created by simultaneous stratification on prepregnancy BMI (underweight, normal weight/overweight, obese class 1, obese classes 2 and 3), GWG (<20th, 20-80th, >80th percentile), race/ethnicity (non-Hispanic white, non-Hispanic black), and gestational age (term, preterm). The agreement of birth certificate-derived prepregnancy BMI category with medical record BMI category was highest in the normal weight/overweight and obese class 2 and 3 groups. Agreement varied from 52% to 100% across racial/ethnic and gestational age strata. GWG category from the birth registry agreed with medical records for 41-83% of deliveries, and agreement tended to be the poorest for very low and very high GWG. The misclassification of GWG was driven by errors in reported prepregnancy weight rather than maternal weight at delivery, and its magnitude depended on prepregnancy BMI category and gestational age at delivery. Maternal weight data, particularly at the extremes, are poorly reported on birth certificates. Investigators should devote resources to well-designed validation studies, the results of which can be used to adjust for measurement errors by bias analysis.
    Paediatric and Perinatal Epidemiology 03/2014; · 2.16 Impact Factor
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    ABSTRACT: Late effects of breast cancer affect the quality of survivorship. Using administrative data, we compared the occurrence of almost all ICD9 codes among older breast cancer survivors to that among a matched comparison cohort to generate new hypotheses. Breast cancer patients 65 years or older diagnosed 1990-1994 in 6 integrated care settings and who survived at least 5 years were matched with a cohort of women without a history of breast cancer on care setting, age, and calendar time. We collected data on the occurrence of incident ICD9 codes beginning 6 years after the breast cancer diagnosis date and continuing to year 15, and comparable data for the matched woman. We calculated hazard ratios (HRs) and 95 % confidence intervals associating breast cancer survivorship with incidence of each ICD9 code. We used semi-Bayes methods to address multiple comparisons. Older breast cancer survivors had about the same occurrence of diseases and conditions 6-15 years after breast cancer diagnosis as comparable women. The median of 564 adjusted HRs equaled 1.06, with interquartile range 0.92-1.3. The distribution of HRs pertaining to cancer-related ICD codes was shifted toward positive associations, and the distribution pertaining to cardiovascular-related ICD codes was shifted toward negative associations. In this hypothesis-scanning study, we observed little difference in the occurrence of non-breast cancer-related diseases and conditions among older, long-term breast cancer survivors, and comparable women without a history of breast cancer.
    Breast Cancer Research and Treatment 03/2014; · 4.47 Impact Factor
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    ABSTRACT: Tamoxifen reduces the rate of breast cancer recurrence by approximately a half. Tamoxifen is metabolized to more active metabolites by enzymes encoded by polymorphic genes, including cytochrome P450 2D6 (CYP2D6). Tamoxifen is a substrate for ATP-binding cassette transporter proteins. We review tamoxifen's clinical pharmacology and use meta-analyses to evaluate the clinical epidemiology studies conducted to date on the association between CYP2D6 inhibition and tamoxifen effectiveness. Our findings indicate that the effect of both drug-induced and/or gene-induced inhibition of CYP2D6 activity is likely to be null or small, or at most moderate in subjects carrying two reduced function alleles. Future research should examine the effect of polymorphisms in genes encoding enzymes in tamoxifen's complete metabolic pathway, should comprehensively evaluate other biomarkers that affect tamoxifen effectiveness, such as the transport enzymes, and focus on subgroups of patients, such as premenopausal breast cancer patients, for whom tamoxifen is the only guideline endocrine therapy.
    Future Oncology 01/2014; 10(1):107-122. · 3.20 Impact Factor
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    ABSTRACT: To assess the interaction between comorbidity and breast cancer (BC) on the rate of venous thromboembolism (VTE) beyond what can be explained by the independent effects of BC and comorbidity.
    BMJ Open 01/2014; 4(6):e005082. · 1.58 Impact Factor
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    ABSTRACT: This study examined the association between prenatal exposure to pandemic influenza and cardiovascular events in adulthood. Using Danish surveillance data to identify months when influenza activity was highest during three previous pandemics (1918, 1957, and 1968), persons were defined as exposed/unexposed based on whether they were in utero during peak months of one of the pandemics. Episodes of acute myocardial infarction (MI) and stroke were identified in the Danish National Registry of Patients covering all Danish hospitals since 1977. Information from Danish national registries on all persons with a Civil Personal Registry number and birthdates in 1915 through 1922, 1954 through 1960, and 1966 through 1972 was collected. Crude incidence rate ratios (IRRs) were calculated per pandemic. Generalized linear models were fit to estimate IRRs adjusted for sex. For acute MI, sex-adjusted IRRs for persons in utero during peaks of the 1918, 1957, and 1968 pandemics, compared with those born afterward, were 1·02 (95% confidence interval (CI): 0·99, 1·05), 0·96 (95% CI: 0·87, 1·05), and 1·18 (95% CI: 0·96, 1·45), respectively. For stroke, the corresponding IRRs were 0·99 (95% CI: 0·97, 1·02), 0·99 (95% CI: 0·92, 1·05), and 0·85 (95% CI: 0·77, 0·94), respectively. There was generally no evidence of an association between prenatal influenza exposure and acute MI or stroke in adulthood. However, survivor bias and left truncation of outcomes for the 1918 pandemic are possible, and the current young ages of persons included in the analyses for the 1957 and 1968 pandemics may warrant later re-evaluation.
    Influenza and Other Respiratory Viruses 01/2014; 8(1):83-90. · 1.47 Impact Factor
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    ABSTRACT: Residential clusters of non-communicable diseases are a source of enduring public concern, and at times, controversy. Many clusters reported to public health agencies by concerned citizens are accompanied by expectations that investigations will uncover a cause of disease. While goals, methods and conclusions of cluster studies are debated in the scientific literature and popular press, investigations of reported residential clusters rarely provide definitive answers about disease etiology. Further, it is inherently difficult to study a cluster for diseases with complex etiology and long latency (e.g., most cancers). Regardless, cluster investigations remain an important function of local, state and federal public health agencies. Challenges limiting the ability of cluster investigations to uncover causes for disease include the need to consider long latency, low statistical power of most analyses, uncertain definitions of cluster boundaries and population of interest, and in- and out-migration. A multi-disciplinary Workshop was held to discuss innovative and/or under-explored approaches to investigate cancer clusters. Several potentially fruitful paths forward are described, including modern methods of reconstructing residential history, improved approaches to analyzing spatial data, improved utilization of electronic data sources, advances using biomarkers of carcinogenesis, novel concepts for grouping cases, investigations of infectious etiology of cancer, and "omics" approaches.
    International Journal of Environmental Research and Public Health 01/2014; 11(2):1479-99. · 2.00 Impact Factor
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    ABSTRACT: Manganese superoxide dismutase (MnSOD) inhibits oxidative damage and cancer therapy effectiveness. A polymorphism in its encoding gene (SOD2: Val16Ala rs4880) may confer poorer breast cancer survival, but data are inconsistent. We examined the association of SOD2 genotype and breast cancer recurrence (BCR) among patients treated with cyclophosphamide-based chemotherapy (Cyclo). We compared our findings with published studies using meta-analyses. We conducted a population-based case-control study of BCR among women in Jutland, Denmark. Subjects were diagnosed with non-metastatic breast cancer from 1990-2001, received adjuvant Cyclo, and were registered in the Danish Breast Cancer Cooperative Group. We identified 118 patients with BCR and 213 matched breast cancer controls. We genotyped SOD2 and used conditional logistic regression to compute the odds ratio (OR) and associated 95% confidence intervals (95% CI) of BCR. We used random-effects meta-analytic models to evaluate the association of SOD2 polymorphisms and BCR. The frequency of the SOD2-Ala allele was 70% in cases versus 71% in controls; 40% versus 44% were heterozygotes, and 30% versus 25% were homozygotes, respectively. Heterozygote and homozygote carriers of the Ala allele had no increased rate of BCR (OR = 1.1, 95%CI = 0.65, 2.0, and OR = 0.87, 95%CI = 0.47, 1.6, respectively). Five studies informed the meta-analytic models; summary estimates associating BCR for homozygote, or any inheritance of the variant Ala allele were 1.18 (95%CI = 0.74, 1.88), and 1.18, (95%CI = 0.91, 1.54), respectively. Our findings do not suggest that MnSOD enzymatic activity, as measured by SOD2 genotype, affects rates of BCR among patients treated with Cyclo.
    PLoS ONE 01/2014; 9(1):e87450. · 3.73 Impact Factor
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    ABSTRACT: Purpose Venous thromboembolism (VTE) is associated with renal cell carcinoma (RCC), but data on the effect of comorbidities are limited. Therefore, our purpose was to determine the effect of comorbidity on VTE risk among patients with RCC. Materials and methods A population-based cohort of all patients with RCC (n = 8,633) diagnosed in Denmark between 1995 and 2010 and a comparison cohort selected from the general population and matched on age, sex, and comorbidities (n = 83,055) were identified. Risk of subsequent VTE was estimated with 95% CI for the first 3 months, 1 year, and 5 years following cancer diagnosis. We stratified by Charlson comorbidity index (CCI) scores to estimate excess risk in patients with RCC vs. the comparison cohort within comorbidity strata. We also performed subanalyses for postoperative VTE and metastases. Results VTE risk was higher in the RCC compared with comparison cohort, particularly during the initial year following diagnosis (risk difference = 9.9 per 1,000 persons [95% CI: 7.7–12.2]). After stratifying by CCI, excess risk declined with increasing comorbidities. The risk difference was 12.3 per 1,000 persons (95% CI: 9.1–15.5) for CCI = 0 and 0.5 (95% CI: 6.0–7.0) for CCI = 4. Excess risk also declined with increasing comorbidities among patients with postoperative VTE and among those with metastases. Conclusions RCC is associated with increased risk of VTE when compared with a matched general population cohort. Risk did not appear to increase with added comorbidity burden. Clinical attention to VTE risk in patients with RCC is appropriate regardless of the presence or absence of comorbidities.
    Urologic Oncology: Seminars and Original Investigations. 01/2014; 32(4):466–472.
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    ABSTRACT: Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.
    Breast Cancer Research and Treatment 10/2013; · 4.47 Impact Factor
  • Peter Jepsen, Hendrik Vilstrup, Timothy L Lash
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    ABSTRACT: & Aims: At least 40% of patients with cirrhosis have comorbidities, which increase mortality. We developed a cirrhosis-specific comorbidity scoring system (CirCom) to help determine how these comorbidities affect mortality, and compared it with the generic Charlson Comorbidity Index. We used data from nationwide healthcare registries to identify Danish citizens diagnosed with cirrhosis in 1999-2008 (n=12,976). They were followed through 2010 and characterized by 34 comorbidities. We used Cox regression to assign severity weights to comorbidities with an adjusted mortality hazard ratio ≥1.20. Each patient's CirCom score was based on at most 2 of these comorbidities. Performance was measured with Harrell's C statistic and the Net Reclassification Index (NRI), and results were compared with those obtained using the Charlson index (based on 17 comorbidities). Findings were validated in 2 separate cohorts of patients with alcohol-related cirrhosis or chronic hepatitis C. The CirCom score included chronic obstructive pulmonary disease, acute myocardial infarction, peripheral arterial disease, epilepsy, substance abuse, heart failure, non-metastatic cancer, metastatic cancer, and chronic kidney disease; 24.2% of patients had 1 or more of these, and mortality correlated with the CirCom score. Patients' CirCom score correlated with their Charlson Comorbidity Index (Kendall's τ = 0.57, P<.0001). Compared with the Charlson index, the CirCom score increased Harrell's C statistic by 0.6% (95% confidence interval, 0.3%-0.8%). The NRI for the CirCom score was 5.2% (95% confidence interval, 3.7%-6.9%), whereas the NRI for the Charlson index was 3.6% (95% confidence interval, 2.3%-5.0%). Similar results were obtained from the validation cohorts. We developed a scoring system to predict mortality among patients with cirrhosis, based on 9 comorbidities. This system had higher C statistic and NRI values than the Charlson Comorbidity Index, and is easier to use. It could therefore be a preferred method to predict death or survival of patients and for epidemiologic studies.
    Gastroenterology 09/2013; · 12.82 Impact Factor
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    ABSTRACT: Background:It is unknown whether comorbidity interacts with colorectal cancer (CRC) to increase the rate of mortality beyond that explained by the independent effects of CRC and comorbid conditions.Methods:We conducted a cohort study (1995-2010) of all Danish CRC patients (n=56 963), and five times as many persons from the general population (n=271 670) matched by age, gender, and specific comorbidities. To analyse comorbidity, we used the Charlson Comorbidity Index (CCI) scores. We estimated standardised mortality rates per 1000 person-years, and calculated interaction contrasts as a measure of the excess mortality rate not explained by the independent effects of CRC or comorbidities.Results:Among CRC patients with a CCI score=1, the 0-1 year mortality rate was 415 out of 1000 person-years (95% confidence interval (CI): 401, 430) and the interaction accounted for 9.3% of this rate (interaction contrast=39 out of 1000 person-years, 95% CI: 22, 55). For patients with a CCI score of 4 or more, the interaction accounted for 34% of the mortality (interaction contrast=262 out of 1000 person-years, 95% CI: 215, 310). The interaction between CRC and comorbidities had limited influence on mortality beyond 1 year after diagnosis.Conclusion:Successful treatment of the comorbidity is pivotal and may reduce the mortality attributable to comorbidity itself, and also the mortality attributable to the interaction.British Journal of Cancer advance online publication, 10 September 2013; doi:10.1038/bjc.2013.541 www.bjcancer.com.
    British Journal of Cancer 09/2013; · 5.08 Impact Factor
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    ABSTRACT: This Amicus Brief challenged the United States government's use of a questionable statistical orthodoxy to maintain a Wire Fraud Act prosecution and conviction against a scientist for describing the results of a body of empirical data as "demonstrating" causality. The Brief, filed in support of Dr. Harkonen's petition for writ of certiorari in the U.S. Supreme Court, shows that the government misrepresented factual and theoretical aspects of statistical significance testing, as well as how significance testing is used in practice by government, academic, and private sector scientists in biological and medical research.
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    ABSTRACT: Aims: Large inequalities in the use of primary percutaneous interventions (PPCI) for ST-elevation myocardial infarction (STEMI) are evident. In order to understand how we can help to implement best practice for STEMI patients, we investigated the variation in PPCI utilisation in 120 regions in 10 EU countries and the association with economic, organisational and demographic characteristics. Methods and results: We performed an ecological study using mixed effects regression models in the following 10 countries: Austria, Belgium, Denmark, England and Wales, Germany, Italy, Portugal, Spain, Sweden, and Northern Ireland. The main finding was the annual number of PPCI per million inhabitants from 2003 through 2008. Overall, the annual increase in PPCI utilisation was 1.15 (95% CI: 1.12, 1.19) per million per year. Regional-level rates varied from 0.74 (95% CI: 0.42, 1.30) to 1.90 (95 % CI: 1.01, 3.55) per million per year. At a regional level, significant positive associations with PPCI utilisation were the number of physicians per 100,000 inhabitants; the number of nurses and midwives per 100,000 inhabitants; and the proportion of the region's population aged 50 to <70 years. At a country level, significant positive associations with utilisation were the year of STEMI treatment, population density per km2; number of general hospital beds per 100,000 inhabitants; and the number of physicians per 100,000 inhabitants. Conclusions: Between 2003 and 2008, PPCI utilisation increased significantly in the ten European countries studied, but there was a great variation within country regions. Regional variation in PPCI rates were associated with both demographic and supply factors, revealing substantial opportunities to improve PPCI utilisation across Europe at national and regional levels.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 08/2013; 9(4):469-76. · 3.17 Impact Factor
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    ABSTRACT: Obesity was recognized as in independent risk factor for influenza during the 2009 H1N1 influenza pandemic. We evaluated the association between body mass index (BMI) and influenza-like illness (ILI) during two non-pandemic influenza seasons (2003-2004 and 2004-2005) and during the spring and fall waves of the 2009 H1N1 pandemic. Adults with severe (inpatient) and mild (outpatient) ILI were compared to those without ILI using a case-cohort design. The study was nested among those insured by a single health insurance company, receiving care from a large multispecialty practice. Data were collected from insurance claims and the electronic health record. The primary exposure was obesity (BMI ≥ 30·0 kg/m(2) ). Across three seasons, the crude and adjusted ORs for obesity and severe ILI were 1·65 (95% CI 1·31, 2·08) and 1·23 (95% CI 0·97, 1·57), respectively. An association was observed for those aged 20-59 years (adjusted OR 1·92, 95% CI 1·26, 2·90), but not for those 60 and older (adjusted OR 1·08, 95% CI 0·80, 1·46). The adjusted ORs for obesity and severe ILI in 2003-2004, 2004-2005, and during H1N1 were 1·14 (95% CI 0·80, 1·64), 1·24 (95% CI 0·86, 1·79), and 1·76 (95% CI 0·91, 3·42), respectively. Among those with a Charlson Comorbidity Index score of zero, the adjusted ORs for 2003-2004, 2004-2005, and H1N1 were 1·60 (95% CI 0·93, 2·76), 1·43 (95% CI 0·80, 2·56), and 1·90 (95% CI 0·68, 5·27), respectively. Our results suggest a small to moderate association between obesity and hospitalized ILI among adults.
    Influenza and Other Respiratory Viruses 08/2013; · 1.47 Impact Factor

Publication Stats

3k Citations
983.44 Total Impact Points

Institutions

  • 2014
    • Emory University
      • Department of Epidemiology
      Atlanta, Georgia, United States
  • 2005–2014
    • Aarhus University Hospital
      • Department of Clinical Epidemiology
      Aarhus, Central Jutland, Denmark
  • 2013
    • Group Health Cooperative
      • Group Health Research Institute
      Seattle, Washington, United States
  • 2010–2013
    • Aarhus University
      • Department of Clinical Epidemiology
      Aarhus, Central Jutland, Denmark
  • 2010–2012
    • Overton Brooks VA Medical Center
      Shreveport, Louisiana, United States
  • 2011
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, MA, United States
  • 2005–2011
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 1999–2011
    • Boston University
      • • Department of Medicine
      • • Department of Epidemiology
      • • School of Public Health
      Boston, MA, United States
    • University of Alabama at Birmingham
      • Department of Epidemiology
      Birmingham, AL, United States
  • 1999–2010
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 2009
    • Cornell University
      • Department of Public Health
      Ithaca, NY, United States
    • University of Rochester
      • Division of Epidemiology
      Rochester, NY, United States
  • 2001–2009
    • Boston Medical Center
      Boston, Massachusetts, United States
  • 2008
    • Worcester Polytechnic Institute
      Worcester, Massachusetts, United States
    • CSU Mentor
      Long Beach, California, United States
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2007–2008
    • Case Western Reserve University
      • Division of Hematology and Oncology
      Cleveland, OH, United States
    • Pennington Biomedical Research Center
      Baton Rouge, Louisiana, United States
  • 2006
    • Kaiser Permanente
      Oakland, California, United States
  • 2003
    • University of Southern California
      Los Angeles, California, United States