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The Impact of Bias in the Tri-State Toxic-Shock Syndrome Study

Michael T. Osterholm, PhD, MPH; Jack S. Mandel, PhD; Jeffrey P. Davis, MD; Robert W. Gibson, PhD
Arch Intern Med. 1985;145(4):763. doi:10.1001/archinte.1985.00360040203050.
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To the Editor.  —Horwitz et al1 presented a proposed assessment of the principle of temporal precedence and other problems of exposure-disease relationships relative to recent case-control studies regarding the association between tampon use and toxic shock syndrome (TSS). While we agree that the determination of those factors in establishing the validity of these studies is important, the authors base their assessment on an incorrect description of the study methodology used in at least one of the TSS studies, the Tri-State Toxic-Shock Syndrome Study (TSTSSS).2 All of the incorrect statements made regarding the study methodology of the TSTSSS have been previously addressed (written communication between M.T.O. and Mary R. Harvey, MD, Feb 2, 1982),3,4 yet Horwitz and colleagues continue to make such statements.Horwitz and colleagues fail to distinguish among the differences in the methods used for the five TSS case-c control studies. It is inappropriate to lump


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