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Biomedical subjects

E R Delong

Publications and source records attributed to E R Delong.

12 recordsLinked to original sources

A diagnostic for Cox regression with discrete failure-time models.

Changes in maximum likelihood parameter estimates due to deletion of individual observations are useful statistics, both for regression diagnostics and for computing robust estimates of covariance. For many likelihoods, including those in the exponential family, these delete-one statistics can be approximated analytically from a one-step Newton-Raphson iteration on the full maximum likelihood solution. But for general conditional likelihoods and the related Cox partial likelihood, the one-step method does not reduce to an analytic solution. For these likelihoods, an alternative analytic approximation that relies on an appropriately augmented design matrix has been proposed. In this paper, we extend the augmentation approach to explicitly deal with discrete failure-time models. In these models, an individual subject may contribute information at several time points, thereby appearing in multiple risk sets before eventually experiencing a failure or being censored. Our extension also allows the covariates to be time dependent. The new augmentation requires no additional computational resources while improving results.

Biometry↗

Value of exercise treadmill testing in women.

OBJECTIVES: We sought to determine the ability of a treadmill score to provide accurate diagnostic and prognostic risk estimates in women. BACKGROUND: Treadmill testing has been reported to have a lower accuracy for diagnosis of chest pain in women. The diagnostic and prognostic value of the Duke Treadmill Score (DTS) in women is unknown. METHODS: We determined the diagnostic and prognostic value of the DTS in 976 women and 2,249 men who underwent both treadmill testing and cardiac catheterization in a single institution from 1984 to 1994. RESULTS: Women and men differed significantly in DTS (1.6 vs. -0.3, p < 0.0001), disease prevalence (32% vs. 72% significant coronary artery disease [CAD], p < 0.001), and 2-year mortality (1.9% vs. 4.9%, p < 0.0001). The DTS provided information beyond clinical predictors of both coronary disease and survival in women and men. Although overall women had better survival, the DTS performed equally well in stratifying both genders into prognostic categories. The DTS actually performed better in women than in men for excluding disease, with fewer low risk women having any significant coronary disease (> or = 1 vessel with > or =75% stenosis) (20% vs. 47%, p < 0.001), or severe disease (3-vessel disease or > or =75% left main stenosis) (3.5% vs. 11.4%, p < 0.001). CONCLUSIONS: By combining several aspects of treadmill testing, the DTS effectively stratifies women into diagnostic and prognostic risk categories.

Coronary Disease↗

Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project.

OBJECTIVES: The purpose of this consensus effort was to define and prioritize the importance of a set of clinical variables useful for monitoring and improving the short-term mortality of patients undergoing coronary artery bypass graft surgery (CABG). BACKGROUND: Despite widespread use of data bases to monitor the outcome of patients undergoing CABG, no consistent set of clinical variables has been defined for risk adjustment of observed outcomes for baseline differences in disease severity among patients. METHODS: Experts with a background in epidemiology, biostatistics and clinical care with an interest in assessing outcomes of CABG derived from previous work with professional societies, government or academic institutions volunteered to participate in this unsponsored consensus process. Two meetings of this ad hoc working group were required to define and prioritize clinical variables into core, level 1 or level 2 groupings to reflect their importance for relating to short-term mortality after CABG. Definitions of these 44 variables were simple and specific to enhance objectivity of the 7 core, 13 level 1 and 24 level 2 variables. Core and level 1 variables were evaluated using data from five existing data bases, and core variables only were examined in an additional two data bases to confirm the consensus opinion of the relative prognostic power of each variable. RESULTS: Multivariable logistic regression models of the seven core variables showed all to be predictive of bypass surgery mortality in some of the seven existing data sets. Variables relating to acuteness, age and previous operation proved to be the most important in all data sets tested. Variables describing coronary anatomy appeared to be least significant. Models including both the 7 core and 13 level 1 variables in five of the seven data sets showed the core variables to reflect 45% to 83% of the predictive information. However, some level 1 variables were stronger than some core variables in some data sets. CONCLUSIONS: A relatively small number of clinical variables provide a large amount of prognostic information in patients undergoing CABG.

Coronary Artery Bypass↗

Natural history of androgenetic alopecia.

Twenty-two men with patterns III-Va androgenetic alopecia were entered into a 10-month study aimed at establishing information on the natural progression of hair loss over a period of time typical of studies of hair growth promoters. The methodology employed was the same as that in published clinical trials of topical minoxidil, but the men refrained from application of either active drug or vehicle to their scalps. As one of the potential explanations for the observed 'placebo-effect' seen in non-vellus hair counts in the topical minoxidil trials was a learning curve of novice hair counters, we were particularly interested in evaluating this in our 'no-treatment' trial. To that end, both a novice (Observer I) and an experienced (Observer II) hair counter independently performed the hair counts. There was a mean decline in the number of vertex target area non-vellus hairs (-17.2 +/- 80.3 for Observer I and -26.6 +/- 63.5 for Observer II) at the end of 10 months; this was not significant. The novice's hair counts were lower than the experienced observer's counts at baseline, and the difference remained relatively constant during the study. Without the application of a placebo, there was no increase in hair growth, making it unlikely that the methods of hair counting led to the 'placebo-effect' seen in prior topical minoxidil studies.

Adult↗

Inter-examiner reproducibility of probing pocket depths in molar furcation sites.

This investigation was designed to determine the reproducibility of probing pocket depths in maxillary facial and mandibular facial and lingual grade II and III molar furcation sites. 80 untreated molar teeth with 102 furcation invasions due to periodontitis were probed with a pressure-sensitive periodontal probe by 3 examiners. 8 sites per furcation were measured by each examiner at a single examination. The sequence of examiner probing was rotated in order to evaluate the effect of sequential probing. Tracings were made from radiographs of the inter-root separations in order to classify the interradicular space and to determine the effect of root separation on reproducibility. Data was analyzed by regression analysis. Pearson correlations, intraclass correlations, and the Student-Newman-Keuls test. Analysis indicated a high reproducibility of the maxillary facial and mandibular facial and lingual furcation sites in this untreated adult sample. No effect was due to probing sequence. The mid-root prominences, the line angles, and the internal surface sites of the furcation roots were recordable and reproducible, while the horizontal measurements were not consistently recordable. The reproducibility of the facial and lingual furcation sites that were probed decreased with an increase in probing pocket depth and an increased degree of root separation.

Clinical Competence↗

Effect of ultraviolet light on topical minoxidil-induced hair growth in advanced male pattern baldness.

Nine healthy men with type IVa or Va male pattern baldness completed a 4-month single-blinded controlled pilot study designed to assess the effect of ultraviolet light (UVL) on topical minoxidil-induced hair growth. Subjects applied 2% topical minoxidil solution twice daily to their balding scalps and to one target area on the upper arm. These men, all of whom had either skin type II or III, were randomized to also receive either incremental doses of UVB or PUVA (topical psoralen) twice weekly to one side of their scalp and to a 2.5 cm target area on the nonminoxidil-treated upper ipsilateral arm. Vellus, nonvellus, and total hair counts were done in two 1-inch in diameter circular target areas in symmetric regions of the scalp and on each upper arm at regular intervals. All nine subjects had an increase in target nonvellus hair and a net loss of vellus hair in scalp target area treated with topical minoxidil. Concomitant UVL did not have a significant synergistic nor adverse effect on topical minoxidil-induced hair growth.

Adult↗

Tumor-associated antigen TAG-72: correlation of expression in primary and metastatic breast carcinoma lesions.

Variability of tumor-associated antigens among and within human tumor cell groups presents a potential problem in the development and optimization of immunodiagnostic and therapeutic procedures for cancer. We determined the degree of expression of a tumor-associated antigen in the primary and metastatic lesions of 23 patients with infiltrating ductal carcinoma; this was accomplished using monoclonal antibody B72.3, an IgG1 generated against membrane-enriched fractions of human metastatic breast carcinomas and reactive with a 220,000-400,000 d glycoprotein complex, termed TAG-72, and the avidin-biotin complex immunoperoxidase method on fixed tissue sections. Sixteen of the 23 breast carcinomas (70%) demonstrated MAb B72.3 reactivity (range 5% to 100% of tumor cells staining). Reactivity of lymph node metastases was present in 14 of 21 patients (67%). MAb reactivity in metastases to distant sites, including bone, adrenals, liver, skin and effusions, was present in 10 of 18 patients (56%). In one patient, neither the primary carcinoma nor the metastasis to the lymph node demonstrated reactivity. There was a statistically significant positive correlation between MAb B72.3 reactivity in both primary and lymph node metastases (Kendall's Correlation Coefficient = 0.60, p = 0.0006) and between lymph node and distant metastases (Kendall's Correlation Coefficient = 0.48, p = 0.02) of the same patient. No correlation existed between antibody reactivity seen in the primary and that found in the distant lesions of that patient. These studies thus demonstrate that monoclonal antibody B72.3 can detect expression of a tumor-associated antigen in both primary and metastatic infiltrating ductal carcinoma lesions, and may prove valuable in the understanding of tumor biology of metastases and as a means for diagnosing occult disease.

Adult↗

Topical minoxidil in early male pattern baldness.

One-hundred twenty-six healthy men with early male pattern baldness completed a 12-month double-blind, controlled trial of 2% and 3% topical minoxidil. Subjects were initially randomly assigned to use placebo or 2% or 3% topical minoxidil. After 4 months of study, the placebo group was crossed over to 3% topical minoxidil. Both objective measurement of hair growth by counting of vellus, terminal, and total hairs in a vertex target balding area and subjective assessment by subject and investigator were done. Treatment of subjects with topical minoxidil for 4 months resulted in a statistically significant increase in terminal hair growth in comparison with placebo therapy. In addition, subjects initially treated with placebo, when crossed over to topical minoxidil, showed a significant increase in the number of terminal hairs. No subject had a net hair loss in the target area during the study. These results indicate that topical minoxidil can increase terminal hair growth in early male pattern baldness.

Administration, Topical↗

Socioeconomic status and risk of multiple myeloma.

A case control study was conducted to test the hypothesis that socioeconomic status is positively associated with multiple myeloma incidence. One hundred and fifty-three myeloma cases and 459 controls were identified at the Duke University Medical Center at Durham, North Carolina. Study members were interviewed regarding indicators of socioeconomic status. The association of myeloma with family income (current and highest), education, occupation, home ownership, dwelling size, and an index of crowding in the home was examined by estimating relative risks. Among these indicators, only home ownership showed any association with multiple myeloma incidence (RR = 1.6, 95% CI: 1.0-2.6). The association of multiple myeloma with socioeconomic status that has been seen in earlier studies may have been due to underascertainment of disease in less advantaged groups. This association is disappearing as access to health care becomes more uniform across socioeconomic groups.

Aged↗

An approach to conducting epidemiologic research within cooperative clinical trials groups.

Cooperative clinical trials groups offer exciting opportunities for conducting epidemiologic research for several reasons: they facilitate accrual of sufficient numbers of subjects in a short period of time, even for studies of rare diseases; they provide uniform pathologic review and uniform collection of subjects' entry data; and they provide a more representative sample of cases than a single-institution study. Despite these advantages, few epidemiologic studies of etiologic factors have been done through these groups because methods for selecting appropriate control subjects and for obtaining information from geographically scattered subjects have not been available. An approach that can serve as a model for this type of research has been developed. A collaborative case-control study of childhood rhabdomyosarcoma (RMS) with the Intergroup Rhabdomyosarcoma Study (IRS) was recently begun. The study, which is independently funded, evaluates the role of environmental factors in the etiology of RMS. Parents of subjects were interviewed by telephone and control subjects were selected from the same communities as patients by random digit dialing . Interview data are supplemented by information from birth certificates and, for patients, by IRS data. This new methodology permits a large study of a rare tumor in a relatively short period of time.

Child↗

Observer variability in the pulmonary examination.

Observer variability in the pulmonary examination was assessed by having four blindfolded observers (two medical students and two pulmonary physicians) twice examine 31 patients with abnormal pulmonary findings. Examiners were consistent in the repetitive detection of pulmonary abnormalities in 74-89% of the examinations; conversely, 11-26% of the time they disagreed with themselves. Although pulmonary specialists recorded fewer (55% of observations) abnormal findings than did medical students (74%), they were significantly (p = 0.008) less self-consistent than were the students. There was no clear trend in agreement between examiners (kappa = 0.20-0.49). Each examiner's findings were compared with those of physicians specially trained in pulmonary examination. Dichotomous variables (wheezes, crackles, rubs) were more reliably detected (kappa = 0.30-0.70) than graded variables (tympany, dullness, breath sound intensity), where kappa = 0.16-0.43. The authors suggest that dichotomous variables deserve greatest clinical reliance; that time in training, alone, does not improve clinical performance; and that there is a disconcertingly large amount of inter- and intraobserver disagreement in this fundamental clinical task.

Humans↗

The resident leaves the clinic: the effects of changing physicians on appointment-keeping behavior.

To understand the effect that termination of an established physician-patient relationship has on patient attendance patterns in a medical clinic, appointment scheduling and patient attendance were measured for 210 patients before and after 11 senior resident physicians left the clinic. There was no significant change in appointment scheduling, although the number of unscheduled or "drop-in" visits increased (p = 0.02). Likewise, patient attendance patterns did not differ between study periods. Overall the termination of an established relationship between an internist and a patient in this hospital-based general medicine clinic had no effect on appointment scheduling and patient attendance.

Adult↗