Individual Medical Record Research Articles

Patient Characteristics at Prostate Cancer Diagnosis in Different Races at an Academic Center Serving a Diverse Population.

In the United States, the prostate cancer (PCa) incidence and death rate has been greater in non-Hispanic black (NHB) men than in non-Hispanic white (NHW) men and slightly lower in Hispanic men than in NHW men. We compared the sociodemographic and baseline prognostic factors at the diagnosis of PCa in different races/ethnicities at a large, academic center serving an ethnically diverse population. The Montefiore Medical Center Cancer Registry was used to generate a comprehensive list of all patients with PCa diagnosed from 2004 to 2014. The clinical Looking Glass (a proprietary searchable database of patient information) and individual patient medical record review were used to obtain data, including age at diagnosis, socioeconomic status (SES), clinical Gleason score, clinical stage, and prostate-specific antigen level at diagnosis. The patients were classified by self-identified race/ethnicity as Hispanic, NHB, NHW, or other. The χ2 test was used for categorical variables, and analysis of variance or the Kruskal-Wallis test was used for continuous variables. We identified 2352 patients with newly diagnosed PCa during the study period, including 778 Hispanic, 1046 NHB, 486 NHW, and 42 other. The NHW men were significantly older at diagnosis (Hispanic, 63.2 years; NHB, 63.4 years; NHW, 67 years; other, 63.0 years; P< .0001). The mean SES for the Hispanic and NHB men was significantly lower (SES below average: Hispanic, 92.8%; NHB, 91.3%; NHW, 56.6%; other, 75%; P<.0001). The Gleason score at diagnosis differed among these race groups (Gleason score≤6 PCa: Hispanic, 42.8%; NHB, 39.1%; NHW, 52.2%; other, 50%; Gleason score 8-10: Hispanic, 15.8%; NHB, 17.6%; NHW, 14.3%; other, 16.7%; P= .0005). The proportion of men with metastatic disease at diagnosis also differed significantly among the groups (Hispanic, 7.5%; NHB, 9.0%; NHW, 4.3%; other, 9.5%; P=.0139). Using pairwise comparisons, the odds ratio for a higher Gleason score at presentation between NHB and NHW was 1.592 (P< .001) and was 1.378 for Hispanic versus NHW (P= .0200). The pairwise comparison for metastatic disease at diagnosis showed an odds ratio of 2.186 for NHB versus NHW (P= .0087). After adjusting for SES, the odds ratio for a higher Gleason score comparing NHB and NHW was 1.55 (P= .001). Although the odds of metastatic disease were greater in Hispanic men than in NHW men (odds ratio, 1.784), the differences were not statistically significant (P=.1197). At our center, the clinical features of men from different racial groups differed significantly at the time of newly diagnosed PCa. Differences included age at diagnosis, SES, Gleason score, and proportion with metastatic disease. Our pairwise comparisons between different ethnic groups suggested that PCa in Hispanic men might be more similar to that in NHB than to that in NHW patients and are generally more aggressive at diagnosis.

Акушерские и перинатальные исходы беременностей, полученных после лечения бесплодия методами вспомогательных репродуктивных технологий после переноса криоконсервированного эмбриона

The paper presents an analysis of the data on obstetric and perinatal outcomes of pregnancies after infertility treatment by the methods of assisted reproductive technologies (ART) using the transfer of one selected cryopreserved embryo, particularly the outcomes of spontaneous and induced singleton pregnancies. The clinical and anamnestic data of patients were analyzed. The course of pregnancy, childbirth and the state of the newborn were assessed using the data of individual medical record of the pregnant woman and discharge report from the maternity hospital. The criteria for assessing obstetric and perinatal outcomes included: the frequency of normal physiological and preterm delivery, the method of delivery and the weight of children at birth. Factors influencing the course of pregnancy and the condition of children born after natural conception and the use of ART have been determined. It was found that in a group of patients with transfer of a cryopreserved embryo of delivery by cesarean section are performed more often. The body mass index of newborns was statistically and significantly higher than in the groups with spontaneous and induced pregnancies: (3,653.3 ± 550.5) (3,420.2± 547.1) and (3,087.1 ± 704.7) g, respectively. Probl Cryobiol Cryomed 2018; 28(3): 249–257

Otolaryngologic Manifestations of Klippel-Feil Syndrome in Children

Children with Klippel-Feil syndrome (KFS), characterized principally by abnormal fusion of 2 or more cervical vertebrae, may have many additional congenital anomalies. The overall prevalence of otolaryngologic manifestations among patients with KFS has not been previously characterized. To define the otolaryngologic diagnoses made and procedures performed in 95 patients with KFS, which, to our knowledge, is the largest series of this challenging patient population published to date. For this retrospective review, all patients with KFS who underwent otolaryngology consultation at our institution over a 26-year period (January 1989 to December 2015) were included. Patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and were confirmed through individual medical record review. Relevant otolaryngologic diagnoses and procedures were extracted using ICD-9 and Current Procedural Terminology codes, respectively. Selected demographics included age, sex, number of clinic visits, and number of procedures. The primary outcomes were the otolaryngologic diagnoses and procedures associated with the KFS patient population; the secondary outcome was Cormack-Lehane classification documented during airway procedures. Overall, 95 patients with KFS were included in this study (55 males [58%] and 40 females [42%]); mean (range) age at time of presentation to the otorhinolaryngology clinic was 5.8 (birth-23.0) years. Each patient with KFS averaged 8 visits to the otorhinolaryngology office and 5 otolaryngologic diagnoses. The most common diagnosis was conductive hearing loss (n = 49 [52%]), followed by sensorineural hearing loss (n = 38 [40%]), and dysphagia (n = 37 [39%]). Sixty-two (65%) patients underwent otolaryngologic procedures, with 44 (46%) undergoing multiple procedures. The most common procedure was tympanostomy tube placement (n = 36 [38%]), followed by office flexible endoscopy (n = 23 [24%]). Twelve of the 20 patients who underwent direct laryngoscopy had documented Cormack-Lehane classification; 5 of 12 patients (42%) had a compromised view (grade 2, 3, or 4) of the larynx. Three patients required tracheotomies at this institution for airway stabilization purposes; each had severe upper airway obstruction leading to respiratory failure. Patients with KFS require consultation for a variety of otolaryngologic conditions. Among these, hearing loss is the most common, but airway issues related to cervical spine fusion are the most challenging. Formulating an appropriate care plan in advance is paramount, even for routine otolaryngology procedures.

Efficacy of a type 2 diabetes self-management model with family doctor team support in southern China: a randomised controlled trial

BackgroundChina has the highest number of people with diabetes in the world, with a diabetes prevalence of 11·6% and prediabetes prevalence of 50·1%. In China, diabetes self-management support is poorly implemented, with low adherence to self-care recommendations. Effective strategies to assist patients in managing diabetes are therefore urgently needed. The purpose of this study was to investigate the efficacy of a novel self-management model plus family doctor team support for patients with type 2 diabetes. MethodsThis randomised controlled trial was done in Longfeng Street Community Health Service Center (LSCHSC) in Guangdong province, southern China. Patients with type 2 diabetes with no hepatic or renal dysfunction, mental illness, or language disorders were eligible. Patients were randomly selected (using computer-generated randomisation numbers) from the diabetic archives in LSCHSC, and assigned (1:1) to either the intervention or control group, also using a computer-generated randomisation list. Participants, investigators, and those assessing outcomes were not masked to group assignment. Each patient in the intervention group signed a contract with the family doctor team of LSCHSC. Standard operating procedures for follow-up management were developed for patients in the intervention group, and an individual medical record system was established to monitor lifestyle interventions. Additionally, patients' family doctor teams provided training on healthy lifestyle self-management for the patients and their family members (eg, lectures and consultations, in-person interviews, diabetic clubs, and diabetes outreach activities), which is ongoing. Patients in the control group were provided with regular health education. The primary endpoint was laboratory measures and fundus disorders at 18 months after initiation of the intervention, analysed in the per-protocol population. The study was approved by the ethics committee of LSCHSC, and informed consent was obtained from each participant. FindingsBetween March 1, 2015, and May 31, 2015, 600 adults with type 2 diabetes were enrolled (300 to the intervention group and 300 to the control group). Baseline demographic, clinical characteristics, and laboratory measures were similar between groups. After 18 months of follow-up, 263 participants in the intervention group and 278 in the control group remained in the study and were analysed. Concentrations of several laboratory measures were significantly lower in intervention group than the control group (triglyceride, p=0·0082; total cholesterol, p=0·001; low-density lipoprotein, p=0·002; urinary creatinine, p=0·001; fasting blood glucose, p<0·0001; and post-prandial blood glucose, p=0·008), whereas high-density lipoprotein concentrations were significantly higher in the intervention group (p=0·019). No significant differences in HbA1c (p=0·10), urinary albumin (p=0·30), and the ratio of urinary albumin to urinary creatinine (p=0·24) were noted between the two groups. The proportion of patients with diabetic retinopathy (stage R0) did not significantly differ between the two groups (37 [11%] of 346 eyes in the intervention group vs 50 [12%] of 432 eyes in the control group; p=0·75). InterpretationType 2 diabetes self-management with support from a family doctor team in a community health service centre might be an effective strategy to control disease progression and improve patients' quality of life. Benefits to ocular complication of diabetes need further investigation. FundingNational Nature Science Foundation of China (81570843) and National Natural Science Foundation of China for Young Scholar (81600707).

Increased Risk of Multimorbidity in Patients With Sarcoidosis: A Population-Based Cohort Study 1976 to 2013

ObjectiveTo evaluate the risk and pattern of multimorbidity in patients with sarcoidosis. Patients and MethodsA cohort of all residents of Olmsted County, Minnesota, first diagnosed with sarcoidosis between January 1, 1976, and December 31, 2013, was identified through the medical record linkage system of the Rochester Epidemiology Project. Diagnosis was verified by individual medical record review. A cohort of sex- and age-matched comparators without sarcoidosis was assembled from the same population. Data on 18 chronic conditions recommended by the US Department of Health and Human Services for both cases and comparators were retrieved and compared. ResultsThe prevalence of multimorbidity (ie, the presence of ≥2 chronic conditions) was similar between the 2 groups: 111 of 345 cases (32.2%) and 110 of 345 comparators (31.9%) (P=.99). After the index date, 156 cases (43.8%) and 142 comparators (41.2%) developed multimorbidity, corresponding to a hazard ratio of 1.60 (95% CI, 1.27-2.01; P<.001). The cumulative incidence of the presence of ≥3, 4, and 5 chronic conditions was also consistently significantly higher in cases than in comparators (P value=.01, .004 and .002, respectively). Analysis by specific type of chronic condition revealed a significantly higher cumulative incidence of coronary artery disease, congestive heart failure, arrhythmia, stroke or transient ischemic attack, arthritis, depression, diabetes, and major osteoporotic fracture. ConclusionIn this population, patients with sarcoidosis had a significantly higher risk of developing multimorbidity than did sex- and age-matched individuals without sarcoidosis.

Clinical Characteristics of Ocular Sarcoidosis: A Population-Based Study 1976–2013

ABSTRACTPurpose: To characterize the epidemiology and clinical characteristics of ocular involvement in patients with systemic sarcoidosis.Methods: An inception cohort of patients with systemic sarcoidosis in 1976–2013 in Olmsted County, Minnesota, was identified based on comprehensive individual medical record review. Medical records of those patients were then reviewed for ocular involvement.Results: A total of 345 incident cases of systemic sarcoidosis were identified. Ocular involvement occurred in 23 patients (7%). The most common ocular disease was uveitis (61%) followed by dry eye disease, conjunctival nodule, episcleritis, anterior scleritis, and conjunctivitis. Anterior uveitis was the most common type of uveitis (71%). The visual outcome of uveitis was favorable with only one patient lost three or more lines of VA during follow-up and had VA of less than 20/200 at last visit.Conclusion: Ocular involvement occurred in 7% of sarcoidosis patients. Uveitis was the most common type of ocular disease.

Clinical Characteristics and Outcome of Hepatic Sarcoidosis: A Population-Based Study 1976-2013.

Data on clinical manifestations and outcome of hepatic sarcoidosis are scarce. This study aimed to use a population-based cohort of patients with incident sarcoidosis to better describe the characteristics of hepatic sarcoidosis. A cohort of incident cases of sarcoidosis in Olmsted County, MN, USA, from 1976 to 2013 was identified from the database. Diagnosis was verified by individual medical record review. Confirmed cases of sarcoidosis were then reviewed for liver involvement. Data on clinical manifestations, imaging study, liver biochemical tests, treatment, and outcome were collected. Cumulative incidence of cirrhosis adjusted for the competing risk of death was estimated. A total of 345 cases of incident sarcoidosis were identified. Of these, 19 cases (6%) had liver involvement (mean age 46.1 years, 53% female and 79% Caucasian). Most patients had asymptomatic liver disease and were discovered in pursuit of abnormal biochemical tests and imaging studies. Alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were elevated in the majority of patients (88 and 90%, respectively). Elevated transaminases were less common and less severe. About half of patients had abnormal imaging study with hypodense nodular lesions being the most common abnormality (six patients) followed by hepatomegaly (three patients). Liver biopsy revealed non-caseating granuloma in 88% (14 of 16 patients). A total of four patients developed cirrhosis. Involvement of the liver by sarcoidosis was seen in 6% of patients with sarcoidosis. The majority of patients were asymptomatic. Elevated ALP and GGT were the most common abnormal biochemical tests. Liver biopsy revealed non-caseating granuloma in almost all cases. Cirrhosis was seen in a significant number of patients. Generalizability of the observations to other populations may be limited, as the studied population was predominantly Caucasian. The prevalence of liver disease may be higher in more diverse populations.

2061

OBJECTIVES/SPECIFIC AIMS: Aim 1—estimate prevalence and associated characteristics of nonfatal, non-self-inflicted strangulation among women ages 18 and older who presented to a US emergency department between 2006 and 2013. Aim 2—explore care-seeking behaviors, the context of the care seeking, treatment expectations and perceived diagnosis in a sample of women ages 18 and older who present to a US emergency department and report being strangled by an intimate partner. Aim 3—merge and synthesize findings from both the quantitative and qualitative strands to provide a more complete understanding of post-strangulation emergency care of women. METHODS/STUDY POPULATION: This mixed-methods study will use a convergent parallel design, with a single phase of concurrent and independent data collection. Analysis of quantitative and qualitative data will be performed separately then compared, with main findings integrated during the interpretation phase and presented in a merged data analysis display. IRB review and approval will be obtained before initiating this study. Aim 1 will include a cross-sectional analysis of 2006–2013 Nationwide Emergency Department Sample (NEDS) data, from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP). NEDS is the US’s largest all-payer emergency department (ED) database, providing national estimates of hospital-based ED visits from ~120 to 135 million ED visits/year (weighted). For this study, we will examine data from patients meeting inclusion criteria with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM; Medicode, 1996) code of strangulation. For this strand, females aged 18 years or older who presented to a US emergency department between 2006 and 2013 will be included. The outcome variable will be non-fatal, non-self-inflicted strangulation, defined using at least one of the ICD-9-CM codes for strangulation. These codes are: 994.7 (“asphyxiation and strangulation”), E963 (“assault by hanging and strangulation”), E983.8 (“strangulation or suffocation by other specified means undetermined whether accidentally or purposely inflicted”), and E983.9 (“strangulation or suffocation by unspecified means undetermined whether accidentally or purposely inflicted”). Patients with a concurrent ICD-9-CM code for suicide attempt (E953, “Suicide and self-inflicted injury by hanging, strangulation and suffocation”) will be excluded, to minimize self-inflicted assault events. Aim 2 will employ a narrative descriptive approach, with semistructured individual interviews to gather more information about women’s experiences when engaging the health care system after being strangled. Medical records related to the strangulation event will also be reviewed for diagnostic codes and other nursing and/or medical notes that may relate to diagnoses, treatment and referrals. For this strand, women aged 18 years or older who present for care to an urban, academic ED will be recruited, purposely sampling those reporting strangulation as a reason for their visit. We anticipate interviewing ~20–30 women to achieve saturation of information. RESULTS/ANTICIPATED RESULTS: Data from the NEDS from 2006 to 2013 will be analyzed for prevalence and associated characteristics of women seeking care after being strangled. Individual interviews and medical record reviews of a small sample of adult women will be conducted to explore women’s in-depth experiences within the health care system. Results from both the quantitative and qualitative analyses will then be collectively compared and interpreted to better synthesize the evidence from this work. Convergent and divergent findings will be presented in a merged data analysis display (Creswell and Plano Clark, 2011). Qualitative data will be used to fill the knowledge gap remaining from the quantitative analysis, and to explain and contextualize some of the findings. Such integration will help expand the current limited evidence on care of strangled women, and will identify additional research questions that will guide future research in this area. DISCUSSION/SIGNIFICANCE OF IMPACT: To our knowledge, this study will be the first to explore this issue using a nationally representative sample of adult women who sought emergency medical care for strangulation analyzed in conjunction with a detailed qualitative analysis of strangled women’s experiences with the health care system. The resulting knowledge will be critical to informing clinical assessment, intervention and prevention efforts for this vulnerable population, as well as public policy and future research regarding this specific violence tactic.

Reliability of Cardiovascular Risk Calculators to Estimate Accurately the Risk of Cardiovascular Disease in Patients With Sarcoidosis

Chronic inflammation is an independent risk factor for cardiovascular disease (CVD), but most risk calculators, including the Framingham risk score (FRS) and the American College of Cardiology (ACC)/American Heart Association (AHA) risk score do not account for it. These calculators underestimate cardiovascular risk in patients with rheumatoid arthritis and systemic lupus erythematosus. To date, how these scores perform in the estimation of CVD risk in patients with sarcoidosis has not been assessed. In this study, the FRS and the ACC/AHA risk score were calculated for a previously identified cohort of patients with incident cases of sarcoidosis in Olmsted County, Minnesota, United States, from 1989 to 2013 as well as their gender- and age-matched comparators. The standardized incidence ratio (SIR) was estimated as the ratio of the predicted and observed numbers of CVD events. All CVD events were identified by diagnosis codes and were verified by individual medical record reviews. The predicted number of CVD events among 188 cases by FRS was 11.8 and the observed number of CVD events was 34, which corresponded to an SIR of 2.88 (95% confidence interval 2.06 to 4.04). FRS underestimated the risk of CVD events in patients with sarcoidosis by gender, age and severity of sarcoidosis. The predicted number of CVD events among cases by ACC/AHA risk score was 4.6 and the observed number of CVD events was 19, corresponding to an SIR of 4.11 (95% confidence interval 2.62 to 6.44). In conclusion, the FRS and the ACC/AHA risk score underestimate the risk of CVD in patients with sarcoidosis.

Characteristics and Long-Term Outcome of Neurosarcoidosis: A Population-Based Study from 1976-2013

Background/Aims: Neurosarcoidosis is a rare condition with serious health consequences. However, little is known about clinical characteristics and outcome of neurosarcoidosis in the community setting. Methods: Patients with neurosarcoidosis were identified from a previously described cohort of patients with incident sarcoidosis from Olmsted County, Minnesota, United States from 1976 to 2013 using individual medical record review. Data on clinical characteristics, treatment, and outcome were collected. Results: Neurological involvement by sarcoidosis occurred in 11 patients (3% of all patients with sarcoidosis). Cranial neuropathy was the most common type of neurological disease (5 patients; 45%) followed by peripheral neuropathy (3 patients; 27%), and meningitis (3 patients; 27%). Cerebrospinal fluid (CSF) pleocytosis and elevated CSF protein levels were observed in patients with meningitis, intramedullary spinal cord sarcoidosis, intracranial mass lesion and some patients with cranial neuropathy but were normal in patients with peripheral neuropathy. All patients received high-dose glucocorticoids as initial treatment and almost all responded to this therapy. Relapse after glucocorticoid dose reduction necessitated subsequent treatment with steroid-sparing agents in 4 patients. Conclusion: Neurosarcoidosis is an uncommon manifestation of sarcoidosis. Neurosarcoidosis manifestations generally responded well to high-dose glucocorticoids in the majority of patients, but relapse was common.

Association Between Thyroid Disease and Uveitis

ImportanceCommon pathophysiological mechanisms may be responsible for immune dysregulation in both thyroid disease and uveitis. Studies investigating a possible association are limited.ObjectiveTo determine the association between thyroid disease and uveitis.Design, Setting, and ParticipantsA retrospective, population-based case-control study was conducted from January 1, 2006, to December 31, 2007, among 217 061 members of the Kaiser Permanente Hawaii health system during the study period. A clinical diagnosis of uveitis was determined through a query of the electronic medical record followed by individual medical record review for confirmation by a uveitis specialist. Thyroid disease was determined based on International Classification of Diseases, Ninth Revision, coding. Two control groups were chosen at a 4:1 ratio for comparison with patients with uveitis. A logistic regression analysis was performed with uveitis as the main outcome variable and thyroid disease as the main predictor variable, while adjusting for age, sex, race, smoking status, and history of autoimmune disease. Data analysis was conducted between 2014 and 2016.Main Outcomes and MeasuresA diagnosis of thyroid disease among patients with uveitis and respective controls.ResultsOf the 224 patients with uveitis (127 women and 97 men; mean [SD] age, 54.1 [17.8] years) identified during the study period, 29 (12.9%) had a diagnosis of thyroid disease, compared with 62 of 896 patients (6.9%) in the control group (P = .01) and 78 of 896 patients (8.7%) in the ophthalmology clinic control group (P = .06). Using the general Kaiser Permanente Hawaii population control group, patients who had thyroid disease had a 1.7-fold (95% CI, 1.03-2.80; P = .04) higher odds of having uveitis compared with patients who did not have thyroid disease when controlling for age, sex, race, smoking status, and autoimmune disease. A similar association was found using the ophthalmology clinic control group (odds ratio, 1.8; 95% CI, 1.1-2.9; P = .02) while adjusting for these factors.Conclusions and RelevanceThese findings suggest that a history of thyroid disease has a weak to moderate association with uveitis. Similar autoimmune mechanisms could explain the pathogenesis of both conditions. If future studies corroborate these findings, they may have further clinical implications in the laboratory workup of uveitis.

Sarcoidosis Increases Risk of Hospitalized Infection. A Population-based Study, 1976-2013.

Patients with sarcoidosis may have an increased risk of infection similar to other immune-mediated disorders. However, the data are still limited. To investigate the risk of hospitalized infection among patients with sarcoidosis, using a population-based cohort. Using the Rochester Epidemiology Project record-linkage system, a cohort of incident cases of sarcoidosis in Olmsted County, Minnesota from 1976 to 2013 was identified. Diagnosis was confirmed by individual medical record review. For each patient with sarcoidosis, a sex- and age-matched comparator without sarcoidosis was randomly selected from the same population. Medical records of cases and comparators were individually reviewed for hospitalized infection that occurred after the index date. The cumulative incidence of hospitalized infection overall and by type of infection, adjusted for the competing risk of death, was estimated. Cox models were used to compare the rate of first hospitalized infection between cases and comparators and to evaluate the association between use of immunosuppressive agents and hospitalized infection among cases. Three hundred and forty-five cases and 345 comparators were identified. Patients with sarcoidosis had a higher risk of a hospitalized infection with a hazard ratio (HR) of 2.00 (95% confidence interval [CI], 1.41-2.84), adjusted for age, sex, and calendar year of index date. Use of oral glucocorticoids was a significant predictor of hospitalized infection with an HR of 3.03 (95% CI, 1.33-6.90) for oral glucocorticoids not exceeding 10 mg/day and an HR of 4.48 (95% CI, 1.54-13.03) for oral glucocorticoids greater than 10 mg/day. Patients with sarcoidosis are at increased risk of hospitalized infection. Glucocorticoid therapy is strongly associated with this increased risk.

Hospitalization Among Patients with Sarcoidosis: A Population-Based Cohort Study 1987-2015.

There is little information about healthcare utilization for sarcoidosis. This study examined need for hospitalization as a measure of healthcare burden in this disease. A cohort of Olmsted County, Minnesota residents diagnosed with sarcoidosis between January 1, 1976 and December 31, 2013 was identified using the resources of the Rochester Epidemiology Project. Diagnosis was made based on individual medical record review. For each sarcoidosis subject, one sex- and age-matched comparator without sarcoidosis was randomly selected from the same population. Data on hospitalizations were retrieved electronically from billing data of the Mayo Clinic, the Olmsted Medical Center, and their affiliated hospitals. These data were available from 1987 to 2015. Subjects who died or emigrated from Olmsted County prior to 1987 were excluded. 332 incident cases of sarcoidosis and 342 comparators were included. Hospitalization rates were significantly higher among patients with sarcoidosis than comparators [rate ratio (RR) 1.37; 95% confidence interval (CI) 1.24-1.52]. Analysis based on sex revealed a significantly increased rate among females (RR 1.60; 95% CI 1.40-1.82) but not among males (RR 1.06; 95% CI 0.91-1.25). The overall age- and sex-adjusted rates of hospitalization were stable from 1987 to 2015 for both cases and comparators. The average length of stay was similar (4.6 and 4.4days for sarcoidosis and non-sarcoidosis hospitalizations, respectively, p=0.87). In this population, patients with sarcoidosis had a significantly higher rate of hospitalization than patients without sarcoidosis, driven by higher rates in females.

Obesity as an independent risk factor for group B streptococcal colonization

Objective: Approximately 25% of women are colonized with group B streptococcus (GBS). We assessed whether body mass index (BMI) is an independent risk factor for GBS colonization.Study design: We performed a retrospective cohort study using a previously collected database of women who delivered singleton gestations at term. Individual patient medical record review was undertaken to add GBS-related information to the database. Univariable logistic regression was used to assess the relationship between GBS colonization and BMI. Multivariable logistic regression was used to adjust for confounders.Results: A total of 2045 patients met enrollment criteria. The prevalence of GBS colonization was 29%. In the unadjusted analysis, there was a statistically significant increase in GBS colonization per unit increase in BMI (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.04). This relationship remained significant after adjusting for confounders (race, marital status, payer, chronic hypertension, concomitant genital infections) (OR 1.01, 95% CI 1.00–1.03; p = 0.04). By BMI category, there were no differences in antibiotic susceptibilities or mode of ascertainment of GBS colonization.Conclusion: Obesity is an independent risk factor for GBS colonization; however, this association is weak.

Risk of Malignancy Among Patients With Sarcoidosis: A Population-Based Cohort Study.

To investigate the risk of malignancy in patients with sarcoidosis in a population-based cohort. A cohort of Olmsted County, Minnesota, residents diagnosed with sarcoidosis between January 1, 1976 and December 31, 2013 was identified based on individual medical record review. For each sarcoidosis subject, 2 sex- and age-matched comparator subjects without sarcoidosis were randomly selected. Cases and comparators were then cross-indexed with the Mayo Clinic Cancer Registry, which collected data on every type of malignancy except for nonmelanoma skin cancer, for malignancy ascertainment. A total of 345 incident cases of sarcoidosis and 690 comparators were identified. There was no difference in the prevalence of malignancy at the index date between the 2 groups (4.3% among cases and 4.3% among comparators; P = 1.0). During followup, 36 patients with sarcoidosis and 91 subjects without sarcoidosis developed malignancy, with a cumulative incidence at 10 years of 3.8% and 7.1%, respectively. The difference corresponded to a hazard ratio (HR) of 0.72 (95% confidence interval [95% CI] 0.49-1.06). The cumulative incidences at 10 years for individual types of malignancy were also similar between the 2 groups, with nonsignificant HRs. However, subgroup analysis found that cases with extrathoracic involvement were at higher risk of incident hematologic malignancy compared with cases without extrathoracic involvement (HR 1.87 [95% CI 1.09-3.22]). Risk of malignancy was similar among patients with sarcoidosis compared to nonsarcoidosis subjects. However, the risk of incident hematologic malignancy was significantly higher among patients with sarcoidosis with extrathoracic involvement compared to patients without extrathoracic disease.

Smoking, obesity and risk of sarcoidosis: A population-based nested case-control study

BackgroundSmoking and obesity might alter the risk of sarcoidosis. However, the data remained inconclusive. MethodsA cohort of Olmsted County, Minnesota residents diagnosed with sarcoidosis between January 1, 1976 and December 31, 2013 was identified based on individual medical record review. For each sarcoidosis subject, one sex and aged-matched control without sarcoidosis was randomly selected from the same underlying population. Medical records of cases and controls were reviewed for smoking status at index date and body mass index (BMI) within 1 year before to 3 months after index date. Results345 incident cases of sarcoidosis and 345 controls were identified. The odds ratio of sarcoidosis comparing current smokers with never smokers adjusted for age and sex was 0.34 (95% confidence interval (CI), 0.23–0.50). The odds ratio of sarcoidosis comparing current smokers with never smokers and former smokers adjusted for age and sex was 0.38 (95% CI, 0.26–0.56).The odds ratio of sarcoidosis comparing overweight subjects (BMI ≥ 25 kg/m2 but < 30 kg/m2) with subjects with normal/low BMI was 1.12 (95% CI, 0.72–1.75). The odds ratio of sarcoidosis comparing obese subjects (BMI ≥ 30 kg/m2) with subjects with normal/low BMI was 2.54 (95% CI, 1.58–4.06). The odds ratio of sarcoidosis comparing obese subjects with non-obese subjects was 2.38 (95% CI, 1.60–3.56). ConclusionIn this population, current smokers have a lower risk of developing sarcoidosis while subjects with obesity have a higher risk of developing sarcoidosis.

Polymyalgia rheumatica and cancer risk: the importance of the diagnostic set.

In the last few years, the relationship between polymyalgia rheumatica (PMR) and cancer has been considered with very different conclusions. In particular, in 2010, Ji et al examined the overall and specific cancer risks among Swedish subjects following hospitalization for PMR and giant cell arteritis and noted that the risk of cancer was highest in the first year after hospitalization (of 3941 total cancer diagnoses, 783 [19.1%] were in the first year). In 2013, Muller et al, using data from General Practice Research Database, highlighted that elderly patients with a PMR diagnosis were significantly more likely to receive a cancer diagnosis in the year after PMR diagnosis (313/667 cancer cases [69%]). In a series of 200 patients with PMR consecutively observed in our geriatric rheumatologic outpatient clinic from 2004 to 2014, we have observed 51 cancer cases; five of these were observed in the first year after diagnosis of PMR (percentage equal to 9.8%). In our article, we point out the importance of the diagnostic set. PMR is a disease that can be managed in a rheumatologic outpatient clinic without patients’ hospitalization. On the other hand, hospitalization of the elderly with PMR is useful when there are grounds for suspicion for a paraneoplastic syndrome, and this represents per se an important inclusion bias. The studies from institutional databases such as those of Ji et al and Muller et al have a very large series but diagnoses of the various diseases are based on coding and not always confirmed by individual medical record review. On the other hand, studies based on cohorts followed by single rheumatologic outpatient clinics can have much smaller data but have a higher diagnostic accuracy, because all patients are visited by rheumatologists and data are usually more accurate. The specificity of geriatric rheumatologic outpatient clinics with respect to elderly patients and to disease with an outpatient management (such as PMR) is often underestimated. In the health care organization of the geographic area that belongs to the hospital “Mariano Lauro”, the majority of patients for whom the general practitioner suspects a PMR are visited by a rheumatologist, as a consequence of an active collaboration between the general practitioner and the rheumatologist and thanks to the very short (5–7 days on average) waiting lists. In our cohort, diagnosis of PMR must be confirmed at least by a second rheumatologist. No change in the initial diagnosis was observed in any of our patients with PMR over the years and even after being examined by other colleagues from different centers. The repercussions of cancer risk in the elderly with PMR on health policies are easily understandable, and therefore the detection of all potential bias is mandatory. Data from other rheumatologic outpatient clinics are necessary.

Epidemiology of Mixed Connective Tissue Disease, 1985-2014: A Population-Based Study.

To characterize the epidemiology of mixed connective tissue disease (MCTD) from 1983 to 2014. An inception cohort of patients with incident MCTD in 1985-2014 in Olmsted County, Minnesota was identified based on comprehensive individual medical record review. Diagnosis of MCTD required fulfillment of at least 1 of the 4 widely accepted diagnostic criteria without fulfillment of classification criteria for other connective tissue diseases. Data were collected on demographic characteristics, clinical presentation, laboratory investigations, and mortality. A total of 50 incident cases of MCTD were identified (mean age 48.1 years and 84% were female). The annual incidence of MCTD was 1.9 per 100,000 population. Raynaud's phenomenon was the most common initial symptoms (50%), followed by arthralgia (30%) and swollen hands (16%). The diagnosis was frequently delayed with the median time from first symptom to fulfillment of criteria of 3.6 years. At fulfillment of criteria, arthralgia was the most prevalent manifestation (86%), followed by Raynaud's phenomenon (80%), swollen hands (64%), leukopenia/lymphopenia (44%), and heartburn (38%). Evolution to other connective tissue occurred infrequently with a 10-year rate of evolution of 8.5% and 6.3% for systemic lupus erythematosus and systemic sclerosis, respectively. The overall mortality was not different from the general population with a standardized mortality ratio of 1.1 (95% confidence interval 0.4-2.6). This study was the first population-based study of MCTD to provide a complete picture of epidemiology and clinical characteristics of MCTD. MCTD occurred in about 2 persons per 100,000 per year. Evolution to other connective diseases occurred infrequently and the mortality was not affected.

Effectiveness of a multidisciplinary heart failure disease management programme on 1-year mortality: Prospective cohort study.

We performed a multicenter prospective observational cohort study (Epidémiologie et Pronostic de l'Insuffisance Cardiaque Aiguë en Lorraine, Epidemiology and Prognosis of Acute Heart Failure in Lorraine [EPICAL2]) to evaluate the effectiveness on mortality of a community-based multidisciplinary disease management programme (DMP) for heart failure (HF) patients.Between October 2011 and October 2012, 1816 patients, who were hospitalized for acute HF or who developed acute HF during a hospitalization, were included from 21 hospitals in a northeast region of France. At hospital admission, their mean age was 77.3 (standard deviation [SD] 11.6) years and mean left ventricular ejection fraction was 45.0 (SD 16.0)%. A subset of patients were enrolled in a multidimensional DMP for HF (n = 312, 17.2%), based on structured patient education, home monitoring visits by HF-trained nurses, and automatic alerts triggered by significant clinical and biological changes to the patient. The DMP involved general practitioners, nurses, and cardiologists collaborating via an individual web-based medical electronic record. The outcome was all-cause mortality from the 3rd to the 12th month after discharge. During the follow-up, a total of 377 (20.8%) patients died: 321 (21.3%) in the control group and 56 (17.9%) in the DMP group. In a propensity score analysis, DMP was associated with lower 1-year all-cause mortality (hazard ratio 0.65, 95% CI 0.46-0.92). Instrumental variable analysis gave similar results (hazard ratio 0.56, 0.27-1.16).In a real world setting, a multidimensional DMP for HF with structured patient education, home nurse monitoring, and appropriate physician alerts may improve survival when implemented after discharge from hospitalization due to worsening HF.

Unmet informational and supportive care needs of patients following cystectomy for bladder cancer based on age, sex, and treatment choices

PurposeAssessing the unmet needs of cancer patients can help providers tailor health care services to patients’ specific needs. This study examines whether the unmet informational and supportive care needs of the patients with muscle-invasive bladder cancer vary by the patients’ age, sex, or individual treatment choices. Methods and materialsParticipants (N = 30 survivors; 73.3% men) were recruited from the Mount Sinai Medical Center and through advertisements posted on a national Bladder Cancer Advocacy Network website between December 2011 and September 2012. Data were collected through individual interviews and electronic medical record review. A prior qualitative study of this cohort, using immersion/crystallization approach, confirmed the prevalence of unmet needs across the disease trajectory. This is a secondary quantitative analysis of the initial interview data we collected (i.e., quantitative analyses of transformed qualitative data using Chi-square and Fisher exact tests) to examine differences in unmet needs based on the patient’s age, sex, and treatment choices. ResultsYounger patients (<60y) were less satisfied with the treatment information received presurgery and more likely to report posttreatment complications, choose a neobladder, and seek and receive professional support regarding sexual function, than were older patients (P<0.05). More women than men reported difficulties with self-care and relied on themselves in disease self-management as opposed to relying on spousal support (P<0.05). Patients with neobladder were more likely to report difficulties with urinary incontinence and deterioration in sexual function, whereas patients with ileal conduit were more likely to require spousal help with self-care. Patients who received chemotherapy were significantly more likely to report changes in everyday life (P<0.05). Lastly, regardless of age, sex, or treatment choice, up to 50% of patients reported feeling depressed before or after treatment. ConclusionsUnmet informational and supportive needs of patients with muscle-invasive bladder cancer during survivorship, and vary by age, sex, and treatment choices. Educational and psychological assessments as well as clinical interventions should be tailored to a patient’s specific unmet needs, and to specific clinical and demographic characteristics.