Minnesota Residents Research Articles

Care in the last year of life for community patients with heart failure.

Healthcare utilization peaks at the end of life (EOL) in patients with heart failure. However, it is unclear what factors affect end of life utilization in patients with heart failure and if utilization has changed over time. Southeastern Minnesota residents with heart failure were prospectively enrolled into a longitudinal cohort study from 2003 to 2011. Patients who died before December 31, 2012, were included in the analysis. Information on hospitalizations and outpatient visits in the last year of life was obtained using administrative sources. Negative binomial regression was used to assess the association between patient characteristics and utilization. The 698 decedents (47.3% men; 53.4% preserved ejection fraction) experienced 1528 hospitalizations (median 2 per person; range, 0-12; 37.6% because of cardiovascular causes) and 12 927 outpatient visits (median 14 per person; range, 0-119) in their last year of life. Most patients (81.5%) were hospitalized at least once and 28.4% died in the hospital. Patients who were older and those with dementia had lower utilization. Patients who were married, resided in a skilled nursing facility, and had more comorbidities had higher utilization. Patients with preserved ejection fraction had higher rates of noncardiovascular hospitalizations although other utilization was similar. Over time, rates of hospitalizations and outpatient visits decreased, whereas palliative care consults and enrollment in hospice increased. Although patient factors remain associated with differential healthcare utilization at the end of life, utilization declined over time and use of palliative care services increased. These results are encouraging given the high resource use in patients with heart failure.

Abstract P380: Coronary Artery Disease Extent is Predictive of Heart Failure Incidence After Myocardial Infarction

Background: Little is known about the association between coronary artery disease (CAD) and the risk of heart failure (HF) after myocardial infarction (MI), and whether it differs by reduced (HFrEF) or preserved (HFpEF) ejection fraction (EF) has yet to be determined. Subjects and Methods: Olmsted County, Minnesota residents (n=1,924; mean age, 64 years; 66% male) with first MI diagnosed in 1990-2010 and no prior HF were followed through 2013. Framingham Heart Study criteria were used to define HF, which was further classified according to EF (applying a 50% cutoff). The extent of angiographic CAD was defined at index MI according to the number of major epicardial coronary arteries with ≥50% lumen diameter obstruction. Fine & Gray and Cox proportional hazards regression models were used to assess the association of CAD categories with incidence of HF, and multiple imputation methodology was applied to account for the 19% with missing EF data. Results: During a mean (SD) follow-up of 6.7 (5.9) years, 594 patients developed HF. Adjusted for age and sex, with death considered a competing risk, the cumulative incidence rates of HF among patients with 1- (n=581), 2- (n=622), and 3-vessel disease (n=721) were 11.2%, 14.6% and 20.5% at 30 days; and 18.1%, 22.3% and 29.4% at 5 years after MI, respectively. The increased risk of HF with greater number of occluded vessels was only modestly attenuated after further adjustment for patient and MI characteristics, and did not differ materially by EF (Table). Conclusions: The extent of angiographic CAD expressed by the number of diseased vessels is independently associated with HF incidence after MI. The association is evident promptly after MI and applies to both HFrEF and HFpEF.

Activities of daily living and outcomes in heart failure.

Chronic disease can contribute to functional disability, which can degrade quality of life. However, the prevalence of functional disability and its association with outcomes among patients with heart failure requires further study. Southeastern Minnesota residents with heart failure were enrolled from September 2003 through January 2012 into a cohort study with follow-up through December 2012. Difficulty with 9 activities of daily living (ADLs) was assessed by a questionnaire. Patients were divided into 3 categories of ADL difficulty (no/minimal, moderate, severe). The associations of ADL difficulty with mortality and hospitalization were assessed using Cox and Andersen-Gill models. Among 1128 patients (mean age, 74.7 years; 49.2% female), a majority (59.4%) reported difficulty with one or more ADLs at enrollment, with 272 (24.1%) and 146 (12.9%) experiencing moderate and severe difficulty, respectively. After a mean (SD) follow-up of 3.2 (2.4) years, 614 patients (54.4%) had died. Mortality increased with increasing ADL difficulty; the hazard ratio (95% confidence interval) for death was 1.49 (1.22-1.82) and 2.26 (1.79-2.86) for those with moderate and severe difficulty, respectively, compared to those with no/minimal difficulty (Ptrend<0.001). Patients with moderate and severe difficulty were at an increased risk for all-cause and noncardiovascular hospitalization. In a second assessment, 17.7% of survivors reported more difficulty with ADLs and patients with persistently severe or worsening difficulty were at an increased risk for death (hazard ratio, 2.10; 95% confidence interval, 1.71-2.58; P<0.001) and hospitalization (hazard ratio, 1.51; 95% confidence interval, 1.31-1.74; P<0.001). Functional disability is common in patients with heart failure, can progress over time, and is associated with adverse prognosis.

Cardiovascular risk and acute coronary syndrome in giant cell arteritis: a population-based retrospective cohort study.

To assess the occurrence of acute coronary syndrome (ACS) in patients with giant cell arteritis (GCA) compared to subjects without GCA. We retrospectively reviewed a population-based incidence cohort of Olmsted County, Minnesota residents with GCA diagnosed in 1950-2009. We compared this cohort with a cohort of patients without GCA of similar age, sex, and calendar year from the same population. The study included 245 patients with GCA and 245 non-GCA subjects. The mean ± SD Framingham cardiovascular risk score was 30% ± 19% in GCA patients and 34% ± 23% in non-GCA subjects (P = 0.096) at the incidence/index date. Diabetes mellitus was significantly less common in GCA patients than non-GCA subjects at the index date. The mean high-density lipoprotein was higher and triglycerides were lower, with fewer patients taking lipid-lowering medications in the GCA cohort compared to the non-GCA cohort at the index date. During followup, no difference between the 2 cohorts was noted in the overall rate of ACS events (hazard ratio 0.74, 95% confidence interval 0.44-1.26). Overall thrombosis in myocardial infarction scores were similar in both cohorts. Revascularization procedures were done less frequently in GCA than in non-GCA subjects (19% versus 50%; P = 0.015). Post-ACS hospital length of stays and complications were similar in both cohorts. Multiple cardiovascular risk factors are less atherogenic at incidence of GCA. There is no overall increased risk of ACS in patients with GCA.

The incidence of giant cell arteritis in Olmsted County, Minnesota, over a 60-year period 1950–2009

Objective: To assess the incidence of giant cell arteritis (GCA) in the era from 2000 to 2009.Method: We extended the previously identified population-based cohort of Olmsted County, Minnesota residents who fulfilled 1990 American College of Rheumatology (ACR) criteria for GCA for earlier decades during 1950–1999.Results: In 2000–2009, 74 cases of GCA were identified (mean age 78.1 years; 80% women; 79% temporal artery biopsy positive; seven included based on radiological criteria). The incidence of GCA was 19.8 per 100 000 population.Conclusions: The GCA incidence rates have remained steady since 1970 and the age at incidence, which was progressively increasing, seems to have reached a plateau.

Updated Incidence and Prevalence of Crohn’s Disease and Ulcerative Colitis in Olmsted County, Minnesota (1970-2010): ACG IBD Research Award

Introduction: The incidence and prevalence of Crohn’s disease (CD) and ulcerative colitis (UC) in a population-based cohort of Olmsted County, Minnesota residents was last updated through the year 2000. We sought to update these rates through 2010. Methods: The resources of the Rochester epidemiology project, a linked diagnostic index, were used to identify potential cases of Olmsted County residents who were diagnosed with CD or UC. Diagnosis was based on previously set criteria. Residents of Olmsted County with new diagnoses of CD or UC between 1970 and 2010 were identified as incidence cases, and residents who met diagnostic criteria on the preset date of January 1, 2011 were identified as prevalence cases. Rates were age- and sex-adjusted to the 2010 U.S. Census for whites. Poisson regression was used to examine whether incidence rates were associated with age, gender, or year of diagnosis. Results: The incidence cohort included 410 patients with CD and 483 patients with UC. The median age of diagnosis was 29.5 years (range, 4-93) for CD and 34.9 (1-91) for UC. In 2000-2010, the adjusted annual incidence rates for CD and UC were 10.7 cases per 100,000 person-years (95% confidence interval [CI], 9.1-12.3) and 12.2 (95% CI, 10.5-14.0), respectively. On January 1, 2011, there were 380 residents with CD, with an adjusted prevalence of 246.7 cases per 100,000 persons (95% CI, 221.7-271.8), and 435 residents with UC, with an adjusted prevalence of 286.3 (95% CI, 259.1-313.5). In the Poisson regression analysis, male gender was significantly associated with a higher incidence rate of UC (p<0.001); the association between year of diagnosis and UC incidence rate was of borderline significance (p=0.06). Younger age at diagnosis (p<0.001) and year of diagnosis (p=0.003) were significantly associated with higher incidence rates of CD. Conclusion: The estimated UC and CD incidence rates we estimated in Olmsted County are amongst the highest in the U.S. Extrapolating the adjusted prevalence rates to the current U.S. Census, there are approximately 785,000 Americans with CD and 910,000 with UC, for a total of approximately 1.6 million Americans with IBD.Figure 1: Age- and sex-adjusted incidence rate of Crohn’s disease (CD) and ulcerative colitis (UC) in a population-based cohort of Olmsted County patients between 1970 and 2010.

The Changing Epidemiology of Myocardial Infarction in Olmsted County, Minnesota, 1995-2012

BackgroundContemporary data on the epidemiology of myocardial infarction in the population are limited and derived primarily from cohorts of hospitalized myocardial infarction patients. We assessed temporal trends in incident and recurrent myocardial infarction, with further partitioning of the rates into prehospital deaths and hospitalized events, in a geographically defined community. MethodsAll myocardial infarction events recorded among Olmsted County, Minnesota residents aged 25 years and older from 1995-2012, including prehospital deaths, were classified into incident and recurrent. Standardized rates were calculated and temporal trends compared. ResultsAltogether, 5258 myocardial infarctions occurred, including 1448 (27.5%) recurrences; 430 (8.2%) prehospital deaths were recorded. Among hospitalized events, recurrent myocardial infarction was associated with greater mortality risk than incident myocardial infarction (age-, sex-, and year-adjusted hazard ratio, 1.49; 95% confidence interval, 1.37-1.61). Although the overall rate of myocardial infarction declined over time (average annual percent change, −3.3), the magnitude of the decline varied widely. Incident hospitalized myocardial infarction rate fell 2.7%/y, compared with decreases of 1.5%/y in recurrent hospitalized myocardial infarction, 14.1%/y in prehospital fatal incident myocardial infarction, and 12.3%/y in prehospital fatal recurrent myocardial infarction (all P for diverging trends < .05). These trends resulted in an increasing proportion of recurrences among hospitalized myocardial infarctions (25.3% in 1995-2000, 26.8% in 2001-2006, and 29.0% in 2007-2012, Ptrend = .02). ConclusionsOver the past 18 years, a heterogeneous decline in myocardial infarction rates occurred in Olmsted County, resulting in transitions from incident to recurrent events and from prehospital deaths to hospitalized myocardial infarctions. Recurrent myocardial infarction confers a worse prognosis, thereby stressing the need to optimize prevention strategies in the population.

363 Characterization and Impact of a State Prescription Drug Monitoring Program by Emergency Department Providers

The Minnesota Prescription Monitoring Program (RxSentry) collects prescription data on all schedule II-IV controlled substances as well as federal schedule V substances. Reporting is from all in-state pharmacies and other dispensers as well as those out of state pharmacies that ship controlled substances to Minnesota residents. To determine if this program is used and its effect on controlled substance prescribing as perceived by emergency department (ED) providers. This was a prospective observational study conducted at an urban, Level 1 Trauma Center with 99,000 annual visits. Data collection was performed using trained research associates. We screened all adult patients in the ED during a randomized distribution of 10 8-hour shifts totaling 80 hours in November 2013. ED providers were approached to complete a survey if their patient received pain medication either in the ED or upon discharge, or if the provider used the RxSentry system. Data were analyzed using descriptive statistics. A total of 673 patients were screened and 235 were enrolled. Of 235 patients, 187 were prescribed a pain medication at discharge (80%), 137 were prescribed a controlled substance at discharge (58%). The RxSentry program was used in 37 patients (16%). Providers reported the RxSentry changed the decision to prescribe a controlled substance in 13 cases. In 3 cases, the provider did not prescribe a controlled substance and in 10 cases the provider did prescribe a controlled substance. Providers reported the RxSentry program changed their decision regarding quantity of controlled substances in 9 cases, in 4 of these cases the quantity of controlled substance was increased and in 5 cases it was decreased. In the majority of cases (30/34, 88%), the provider did not discuss the use of the program with the patient if it was used. The RxSentry system was only used 16% of the time a patient was given a pain medication. Of these, the provider reported the use of the system had an effect on prescription or quantity dispensed of controlled substance prescribed in 29% of these cases. It appears the system is under-utilized, and could potentially have a larger impact if it were used in more patients who were prescribed controlled substances.

The Dilemma of Antimicrobial Treatment of Shiga Toxin-producing Escherichia coli

The Dilemma of Antimicrobial Treatment of Shiga Toxin-producing Escherichia coli

Abstract 111: Independence in Activities of Daily Living and Death in Patients wtih Heart Failure

Background: Several chronic diseases can contribute to functional disability. However, little is known about functional disability and its progression overtime in chronic heart failure (HF). We aimed to investigate the prevalence and progression of difficulty with activities of daily living (ADLs) and its association with mortality in patients with HF. Methods: We enrolled Southeastern Minnesota residents with HF into a longitudinal study from September 2, 2003 through January 31, 2012. A patient’s difficulty with 9 ADLs (feeding themselves, dressing, toileting, housekeeping, climbing stairs, bathing, walking, using transportation, managing medications) was assessed by questionnaire. Patients were followed for all-cause mortality. Using Rasch analysis to determine the order of ADL difficulty, patients were divided into 3 categories (minimal, moderate, severe difficulty). Predictors of ADL difficulty were assessed using negative binomial regression and the association between ADL difficulty and death with Cox proportional hazard regression. Results: Among 1128 patients (mean age 74.7 years, 49.2% female), most (59.4%) reported difficulty with one or more ADLs at enrollment, with 272 (24.1%) and 146 (12.9%) reporting moderate and severe difficulty, respectively. The independent predictors of difficulty with ADLs were older age, female sex, diabetes, morbid obesity, cerebrovascular disease, dementia, anemia, and unmarried status. After a mean (SD) follow-up of 3.2 (2.4) years, 615 (54.5%) patients had died. There was a stepwise increase in the risk of death as difficulty with ADLs increased ( Figure ). After adjusting for age, sex, and comorbidity, the HR (95% CI) for mortality was 1.52 (1.25-1.83, p&lt;0.001) for patients with moderate and 2.28 (1.82-2.85, p&lt;0.001) for those with severe difficulty with ADLs compared to those with minimal difficulty (p for trend&lt;0.001). In most patients (73.5%), difficulty with ADLs was stable over time. However, survivors reporting persistently severe or worsening ADL difficulty in a second assessment (median 9 months later) were at an increased risk of subsequent mortality (adjusted HR 2.08, 95% CI 1.70-2.55, p&lt;0.001). Conclusions: Functional disability is common in patients with HF, can progress over time, and is independently associated with adverse prognosis.

Resuscitation preferences in community patients with heart failure.

Little is known about the resuscitation preferences of patients with heart failure, how they may change over the course of the disease, and their association with mortality. We enrolled consecutive Southeastern Minnesota residents with heart failure from October 2007 through September 2011 into a longitudinal study. Information on resuscitation preferences (Full Code or do-not-resuscitate [DNR]) was obtained from medical records through April 1, 2013. Of 608 patients enrolled, 237 died during follow-up. At enrollment, most patients (73.4%) were Full Code, whereas at death, most (78.5%) were DNR. The independent predictors of DNR status at enrollment were advanced age, chronic obstructive pulmonary disease, previous malignancy, and decreased mobility. Patients who were DNR were at increased risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.48-2.73; P<0.001), but this risk did not persist after adjusting for age, comorbidity, and self-perceived general health (hazard ratio, 0.97; 95% confidence interval, 0.74-1.30; P=0.83). Of 481 patients who were Full Code during follow-up, 22 (4.6%) received cardiopulmonary resuscitation for an in-hospital cardiac arrest. Eight patients survived to hospital discharge; only 2 (9.1% of those receiving cardiopulmonary resuscitation) made a complete recovery and returned home. The median time from a final decision to be DNR until death was only 37 (7,70) days. The resuscitation preferences of patients with heart failure seem to be driven by the decline in clinical status that often accompanies advanced age and multimorbidity. Furthermore, these data suggest that electing DNR status does not independently affect a patient's risk of death.

Familial risk of epilepsy: a population-based study

Almost all previous studies of familial risk of epilepsy have had potentially serious methodological limitations. Our goal was to address these limitations and provide more rigorous estimates of familial risk in a population-based study. We used the unique resources of the Rochester Epidemiology Project to identify all 660 Rochester, Minnesota residents born in 1920 or later with incidence of epilepsy from 1935-94 (probands) and their 2439 first-degree relatives who resided in Olmsted County. We assessed incidence of epilepsy in relatives by comprehensive review of the relatives' medical records, and estimated age-specific cumulative incidence and standardized incidence ratios for epilepsy in relatives compared with the general population, according to proband and relative characteristics. Among relatives of all probands, cumulative incidence of epilepsy to age 40 was 4.7%, and risk was increased 3.3-fold (95% confidence interval 2.75-5.99) compared with population incidence. Risk was increased to the greatest extent in relatives of probands with idiopathic generalized epilepsies (standardized incidence ratio 6.0) and epilepsies associated with intellectual or motor disability presumed present from birth, which we denoted 'prenatal/developmental cause' (standardized incidence ratio 4.3). Among relatives of probands with epilepsy without identified cause (including epilepsies classified as 'idiopathic' or 'unknown cause'), risk was significantly increased for epilepsy of prenatal/developmental cause (standardized incidence ratio 4.1). Similarly, among relatives of probands with prenatal/developmental cause, risk was significantly increased for epilepsies without identified cause (standardized incidence ratio 3.8). In relatives of probands with generalized epilepsy, standardized incidence ratios were 8.3 (95% confidence interval 2.93-15.31) for generalized epilepsy and 2.5 (95% confidence interval 0.92-4.00) for focal epilepsy. In relatives of probands with focal epilepsy, standardized incidence ratios were 1.0 (95% confidence interval 0.00-2.19) for generalized epilepsy and 2.6 (95% confidence interval 1.19-4.26) for focal epilepsy. Epilepsy incidence was greater in offspring of female probands than in offspring of male probands, and this maternal effect was restricted to offspring of probands with focal epilepsy. The results suggest that risks for epilepsies of unknown and prenatal/developmental cause may be influenced by shared genetic mechanisms. They also suggest that some of the genetic influences on generalized and focal epilepsies are distinct. However, the similar increase in risk for focal epilepsy among relatives of probands with either generalized (2.5-fold) or focal epilepsy (2.6-fold) may reflect some coexisting shared genetic influences.

Impact of Asthma on the Severity of Serious Pneumococcal Disease.

We recently reported an increased risk of serious pneumococcal disease (SPD) in asthmatics. Little is known about the impact of asthma status on the severity of SPD. We compared the severity of serious pneumococcal disease (SPD) between patients with asthma and those without asthma. The study subjects were Rochester, Minnesota residents who developed SPD between 1964 and 1983. SPD and asthma status were ascertained by using explicit predetermined criteria Severity of SPD was assessed using intensive care unit (ICU) admission rate and total days of ICU stay and hospitalization associated with treatment for SPD. We found that there were no significant differences in severity outcomes between asthmatics (n=11) and non-asthmatics (n=163). Asthma status may increase the risk of SPD but not influence its severity. However, given a small sample size of our study, a larger study needs to be considered to clarify the relationship between asthma and severity of SPD.

Brief Report: Accelerated Aging Influences Cardiovascular Disease Risk in Rheumatoid Arthritis

To determine whether the impact of aging on cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA) differs from that in the general population (as estimated by the Framingham Risk Score [FRS]). A population-based inception cohort of Olmsted County, Minnesota residents ages≥30 years who fulfilled the American College of Rheumatology 1987 criteria for RA in 1988-2008 was assembled and followed up until death, migration, or July 1, 2012. Data on CVD events were collected by medical records review. The 10-year FRS for CVD was calculated. Cox models adjusted for FRS were used to examine the influence of age on CVD risk. The study included 563 patients with RA without prior CVD (mean age 55 years, 72% women, and 69% seropositive [i.e., rheumatoid factor and/or anti-citrullinated protein antibody positive]). During a mean followup of 8.2 years, 98 patients developed CVD (74 seropositive and 24 seronegative), but the FRS predicted only 59.7 events (35.4 seropositive and 24.3 seronegative). The gap between observed and predicted CVD risk increased exponentially across age, and the effect of age on CVD risk in seropositive RA was nearly double its effect in the general population, with additional log(age) coefficients of 2.91 for women (P=0.002) and 2.06 for men (P=0.027). Our findings indicate that age exerts an exponentially increasing effect on CVD risk in seropositive RA, but no increased effect among seronegative patients. The causes of accelerated aging in patients with seropositive RA deserve further investigation.

Measuring frailty in heart failure: A community perspective

Frailty, an important prognostic indicator in heart failure (HF), may be defined as a biological phenotype or an accumulation of deficits. Each method has strengths and limitations, but their utility has never been evaluated in the same community HF cohort. Southeastern Minnesota residents with HF were recruited from 2007 to 2011. Frailty according to the biological phenotype was defined as 3 or more of: weak grip strength, physical exhaustion, slowness, low activity and unintentional weight loss >10 lb in 1 year. Intermediate frailty was defined as 1 to 2. The deficit index was defined as the proportion of deficits present out of 32 deficits. Among 223 patients (mean age 71 ± 14, 61% male), 21% were frail and 48% intermediate frail according to the biological phenotype. The deficit index ranged from 0.02-0.75, with a mean (SD) of 0.25 (0.13). Over a mean follow-up of 2.4 years, 63 patients died. After adjustment for age, sex and ejection fraction, patients categorized as frail by the biological phenotype had a 2-fold increased risk of death compared to those with no frailty, whereas a 0.1 unit increase in the deficit index was associated with a 44% increased risk of death. Both measures predicted death equally (C-statistics: 0.687 for biological phenotype and 0.700 for deficit index). The deficit index and the biological phenotype equally predict mortality. As the biological phenotype is not routinely assessed clinically, the deficit index, which can be ascertained from medical records, is a feasible alternative to ascertain frailty.

Depression, Healthcare Utilization, and Death in Heart Failure

Background— The increasing prevalence of heart failure (HF) and high associated costs have spurred investigation of factors leading to adverse outcomes in patients with HF. Studies to date report inconsistent evidence on the link between depression and outcomes with only limited data on emergency department and outpatient visits. Methods and Results— Olmsted, Dodge, and Fillmore county, Minnesota residents with HF were prospectively recruited between October 2007 and December 2010 and completed a 1-time 9-item Patient Health Questionnaire for depression categorized as: none to minimal (Patient Health Questionnaire score, 0–4), mild (5–9), or moderate to severe (≥10). Andersen-Gill models were used to determine whether depression predicted hospitalizations and emergency department visits, whereas negative binomial regression models explored the association of depression with outpatient visits. Cox proportional hazards regression characterized the relationship between depression and all-cause mortality. Among 402 patients with HF (mean age, 73±13 years; 58% men), 15% had moderate to severe depression, 26% mild, and 59% none to minimal depression. During a mean follow-up of 1.6 years, 781 hospitalizations, 1000 emergency department visits, 15 515 outpatient visits, and 74 deaths occurred. After adjustment, moderate to severe depression was associated with nearly a 2-fold increased risk of hospitalization (hazard ratio, 1.79; 95% confidence interval, 1.30–2.47) and emergency department visits (hazard ratio, 1.83; 95% confidence interval, 1.34–2.50), a modest increase in outpatient visits (rate ratio, 1.20; 95% confidence interval, 1.00–1.45), and a 4-fold increase in all-cause mortality (hazard ratio, 4.06; 95% confidence interval, 2.35–7.01). Conclusions— In this prospective cohort study, depression independently predicted an increase in the use of healthcare resources and mortality. Greater recognition and management of depression in HF may optimize clinical outcomes and resource utilization.

Association of diabetes with amnestic and nonamnestic mild cognitive impairment

BackgroundType 2 diabetes may increase the risk of amnestic mild cognitive impairment (aMCI) through Alzheimer's disease (AD)-related and vascular pathology and may also increase the risk of nonamnestic MCI (naMCI) through vascular disease mechanisms. We examined the association of type 2 diabetes with mild cognitive impairment (MCI) and MCI subtype (aMCI and naMCI) overall and by sex. MethodsParticipants were Olmsted County, Minnesota residents (70 years and older) enrolled in a prospective, population-based study. At baseline and every 15 months thereafter, participants were evaluated using the Clinical Dementia Rating scale, a neurological evaluation, and neuropsychological testing for a diagnosis of normal cognition, MCI, and dementia by a consensus panel. Type 2 diabetes was ascertained from the medical records of participants at baseline. ResultsOver a median 4.0 years of follow-up, 348 of 1450 subjects developed MCI. Type 2 diabetes was associated (hazard ratio [95% confidence interval]) with MCI (1.39 [1.08–1.79]), aMCI (1.58 [1.17–2.15]; multiple domain: 1.58 [1.01–2.47]; single domain: 1.49 [1.09–2.05]), and the hazard ratio for naMCI was elevated (1.37 [0.84–2.24]). Diabetes was strongly associated with multiple-domain aMCI in men (2.42 [1.31–4.48]) and an elevated risk of multiple domain naMCI in men (2.11 [0.70–6.33]), and with single domain naMCI in women (2.32 [1.04–5.20]). ConclusionsDiabetes was associated with an increased risk of MCI in elderly persons. The association of diabetes with MCI may vary with subtype, number of domains, and sex. Prevention and control of diabetes may reduce the risk of MCI and Alzheimer's disease.

Powassan Virus Encephalitis, Minnesota, USA

To the Editor: Birge and Sonnesyn report the first death of a Minnesota resident caused by Powassan virus (POWV) (1). However, they provide an inaccurate description of several critical diagnostic and surveillance issues concerning POWV. The 17 POWV infections detected in Minnesota residents from 2008 through 2011 (6 cases were identified through 2010, not 8 as reported by Birge and Sonnesyn) (Minnesota Department of Health [MDH], unpub. data) were found through enhanced surveillance. Health alerts to Minnesota medical providers described POWV as a possible etiologic agent for viral meningitis and encephalitis. Providers consulted with MDH on suspected cases and submitted serum and cerebrospinal fluid specimens to MDH. MDH conducted serologic testing for endemic arboviruses (including POWV) and reverse transcription PCR (RT-PCR) for flaviviruses and POWV. MDH would not have detected any POWV infections without enhanced surveillance. Limited field studies also identified POWV-infected ticks in 4 Minnesota counties (not 2 as reported [1]) (MDH, unpub. data). Commercial laboratories do not provide testing for POWV, and only a few state health department laboratories and the Centers for Disease Control and Prevention offer testing. Serologic testing (enzyme immunoassay with plaque-reduction neutralization testing confirmation) is preferred (2) because POWV RT-PCRs are not validated, and the short viremic periods of flaviviruses limit their usefulness (3). Few POWV infections are identified by lineage (prototype vs. deer tick virus); Minnesota’s first case in 2008 was identified as a deer tick virus infection, but the lineage was unknown for the other 16 cases. However, many case-patients had likely exposure to Ixodes scapularis ticks (blacklegged ticks), the tick species associated with deer tick virus transmission, and viruses from all POWV-positive tick pools were confirmed as deer tick virus by sequencing. The distribution of the 2 lineages in North America is poorly understood, and most cases likely go undetected without specific POWV surveillance efforts.

Abstract WP336: Telestroke To Bring Tertiary Center Acute Stroke Practice To Rural Minnesota Residents; Percent Treated With Interventional Procedures, Timing, And Clinical Results.

The utility of telemedicine to increase the use of IV tPA for acute ischemic stroke (AIS) patients in the rural setting is well established. The availability of intraarterial (IA) reperfusion therapy is restricted to larger stroke centers in metropolitan areas so the process for evaluation and transfer within a stroke system of care will be critical to its rapid delivery to rural patients. In 2012, we conducted a review of the use of IA therapy in our stroke system; studying efficiency of the team approach, timing of treatment, and patient outcomes to evaluate the hypothesis that telemedicine can facilitate IA treatment for the AIS patient presenting in a rural setting. METHODS: All patients presenting to the spoke hospitals (SHs) and the hub hospitals (HH) with AIS and subsequently receiving IA therapy were reviewed for the months of March 2011 through February 2012. This review followed institution of a stroke code improvement process for SHs which included an aggressive 30 minute door-to-drug goal, addition of CTA imaging, and early mobilization of helicopter transport. FINDINGS: Of the HH patients receiving reperfusion therapy 26 of 68 patients (38%) received IA treatment and 62% received IV tPA treatment alone. In contrast, only 5 of 31 treated cases from SHs (16%) received IA treatment. In IA treated cases, mean door-to-case-start time from the SHs (143 min) was comparable to that of cases presenting directly to the HH (117 min) despite the helicopter travel required prior to case start for SHs. Reperfusion success (TICI2b/3) was similar whether the patients presented to HH or the SHs (69% and 60%) and discharge MRS≥3 was achieved in 46% and 40% respectively. CONCLUSION: With a telemedicine supported system, IA treatment options can be initiated in a time efficient fashion with similar outcomes whether the patient presents to a rural spoke hospital site or the hub hospital with IA capability. Differences in the rate of use of IA treatment may be related to EMS referral patterns of patients with severe stroke to a tertiary stroke center.

Outcomes of Patients With Microscopic Colitis Treated With Corticosteroids: A Population-Based Study

To evaluate the outcomes of corticosteroid-treated microscopic colitis (MC) in a population-based cohort, and to compare these outcomes in patients treated with prednisone or budesonide. A historical cohort study of Olmsted County, Minnesota residents diagnosed with collagenous or lymphocytic colitis (LC) between 1986 and 2010 was performed using the Rochester Epidemiology Project. Of 315 patients with MC, 80 (25.4%) were treated with corticosteroids. The median age at colitis diagnosis was 66.5 years (range: 16-95) and 78.7% were female. Forty patients (50%) had LC and 40 (50%) had collagenous colitis. Prednisone was used in 17 patients (21.2%) and budesonide in 63 (78.8%); 56 (75.6%) had complete response and 15 (20.3%) had partial response. Patients treated with budesonide had a higher rate of complete response than those treated with prednisone (82.5 vs. 52.9%; odds ratio, 4.18; 95% CI, 1.3-13.5). Six patients were lost to follow-up. The remaining 74 had a median follow-up of 4 years (range 0.2-14). Fifty patients out of the 71 who responded (70.4%) had a recurrence after corticosteroid discontinuation. Patients treated with budesonide were less likely to recur than those treated with prednisone (hazard ratio, 0.38; 95% CI, 0.18-0.85; P=0.02). After 397 person years of follow-up in the 73 patients with long-term data, 47 (64.4%) required maintenance with corticosteroids. Patients with MC often respond to corticosteroid therapy, but with a high relapse rate. Budesonide had a higher response rate and a lower risk of recurrence than prednisone.