Residents Of Rochester Research Articles

OUTCOMES OF COVID-19 INFECTION: COMMUNITY-BASED RETEROSPECTIVE COHORT STUDY

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: COVID-19 infection is associated with a broad-range of clinical presentations from asymptomatic infection to severe pneumonia with multi-system features. Similarly, short- and long-term outcomes vary widely. Although multiple studies have addressed outcomes of patients hospitalized with COVID-19 infection, Community-based studies are sparse and are needed to provide a broader perspective of the lasting impact of this disease, especially lung damage. METHODS: This is a retrospective, Community-based, cohort study of residents of Rochester, Minnesota, who were enrolled in the Mayo Clinic COVID-19 database. Subjects were included if they were diagnosed with COVID-19 infection from March 01, 2020 to May 31, 2020. The clinical presentation, laboratory results, pulmonary function results, and chest imaging findings at the time of presentation and events in the following months until December 31, 2020 were assessed by review of medical records and imaging studies. RESULTS: We identified 570 community patients with COVID-19 infection;median age 38.5 years (range 18-98 years) - 526 patients did not require hospitalization while 44 (7.5%) patients (median age 51.8 years, range 20 - 81) had hypoxemia warranting admission (moderate to severe disease based on WHO clinical progression scale)[i]. At the time of hospitalization, all has undergone chest radiography, and 42 patients (95%) had chest CT with all demonstrating peripheral patchy ground glass opacities (GGOs) bilaterally.Thirteen patients (29.5%) returned for chest radiograph (median interval, 5.9 months);4 of them (13%) had residual parenchymal opacities, of whom nearly all (94%) were 45 years or older. Twenty-five patients had follow-up CT scans three months after initial diagnosis;8 patients (32%) had complete resolution of the CT infiltrates. Seventeen patients (9 females and 8 males) had residual parenchymal opacities with the most common being peripheral and bibasilar GGOs;5 patients had residual reticulonodular scarring and traction bronchiectasis on imaging. 6 patients (13.6%) underwent pulmonary function testing at follow-up visit (median interval 4.6 months), of whom 2 manifested abnormal findings consisting of mild restriction. Overall, 50% of the patients had evidence of residual lung disease (imaging and/or pulmonary function) three months after presentation. Ten patients (59%) with residual disease on chest CT had been hospitalized (six requiring ICU level of care) and manifested significantly elevated inflammatory markers (ferritin, interleukin-6 and C-reactive protein);9 out of these 10 patients with residual disease did not receive steroids at the time of hospitalization. Seven patients (41%) with residual lung infiltrates on CT scan was not hospitalized and didn’t have evidence of severe inflammatory disease. CONCLUSIONS: In our study, we assessed the initial severity and outcomes of subjects diagnosed with COVID-19 in our community and found 3% to manifest persistent lung abnormalities following the acute infection. The residual radiological findings consisted mainly of GGOs affecting the peripheral zones of the lung;however, in a minority of the patients, fibrotic changes were present. Almost two thirds of the patients with persistently abnormal imaging had been hospitalized for at least two days and had high serologic inflammatory markers (C-reactive protein, Ferritin and interleukin-6). This might indicate that the resultant fibrosis is mainly driven by post-inflammatory processes rather than the direct effect of the virus. conversely a considerable number of patients developed interstitial infiltrates without evidence of acute inflammatory reaction which may suggest another non-inflammatory etiology of these findings. Furthermore, most of our patients who manifested lung fibrosis on follow-up CT had not received steroids. Although the long-term course and significance of these residual radiologic findings are not established, prior data of Middle East Respiratory Syndrome and Se ere Acute Respiratory Syndrome suggest that most of these lesions resolve over time among those who survived hospitalization. CLINICAL IMPLICATIONS: The results of this community-based study will provide a broader perspective of the lasting impact of COVID-19 on the lungs. DISCLOSURES: No relevant relationships by Faysal Al-ghoula, source=Web Response Research - industry initiated (clinical relationship with AstraZeneca Pharmaceuticals, LP Please note: 2020 Added 04/27/2021 by Philippe Bauer, source=Web Response, value=Grant/Research Support Research - industry initiated (clinical relationship with Corvus Pharmaceuticals, Inc Please note: 2021 Added 04/27/2021 by Philippe Bauer, source=Web Response, value=Grant/Research Support No relevant relationships by Eva Carmona, source=Web Response No relevant relationships by Tobias Peikert, source=Web Response No relevant relationships by Jay Ryu, source=Web Response

Utility of EEG Activation Procedures in Epilepsy: A Population-Based Study.

No previous population-based study has addressed the contribution of activation procedures to the yield of epileptiform abnormalities on serial EEGs. We assessed yield of activation-related epileptiform abnormalities and predictors of finding an activation-related abnormality with multiple EEGs in a population-based study of newly diagnosed epilepsy. We used the resources of the Rochester Epidemiology Project to identify 449 residents of Rochester, Minnesota with a diagnosis of newly diagnosed epilepsy at age 1 year or older, between 1960 and 1994, who had at least one EEG. Information on all activation procedures (i.e., sleep, hyperventilation, and photic activation) and seizure/epilepsy characteristics was obtained by comprehensive review of medical records. At the first EEG, the yield of epileptiform abnormalities was greatest for individuals 1 to 19 years of age at diagnosis, for each activation procedure. The yield in patients aged 1 to 19 versus ≥20 years was 21.6% versus 10.3% for sleep, 6.5% versus 3.3% for photic stimulation, and 10.3% versus 5% for hyperventilation. Among young people (aged 1-19 years), sleep was associated with an increased likelihood of finding an activation-related abnormality on any EEG. The likelihood of finding an activation-related abnormality on any EEG was decreased for postnatal symptomatic and for unknown etiology. Among activation procedures, sleep showed the highest yield of epileptiform abnormalities. There was a low yield for photic stimulation and hyperventilation. Within each activation procedure, younger age at diagnosis had the greatest yield. Sleep is the most effective activation procedure, especially in younger patients, and should be performed when possible.

Yield of epileptiform electroencephalogram abnormalities in incident unprovoked seizures: a population-based study.

The yield of epileptiform abnormalities in serial electroencephalography (EEG) studies has not been addressed in a population-based setting for subjects with incident epilepsy or a single unprovoked seizure, raising the possibility of methodologic limitations such as selection bias. Our aim was to address these limitations by assessing the yield and predictors of epileptiform abnormalities for the first and subsequent EEG recording in a study of incident epilepsy or single unprovoked seizure in Rochester, Minnesota. We used the resources of the Rochester Epidemiology Project to identify all 619 residents of Rochester, Minnesota, born in 1920 or later with a diagnosis of incident epilepsy (n = 478) or single unprovoked seizure (n = 141) between 1960 and 1994, who had at least one EEG study. Information on all EEG studies and their results was obtained by comprehensive review of medical records. Among subjects with epilepsy, the cumulative yield of epileptiform abnormalities was 53% after the first EEG study and 72% after the third. Among subjects with a single unprovoked seizure, the cumulative yield was 39% after the first EEG study and 68% after the third. Young age at diagnosis and idiopathic etiology were risk factors for finding epileptiform abnormalities across all EEG recordings. Although the cumulative yield of epileptiform abnormalities increases over successive EEG recordings, there is a decrease in the increment for each additional EEG study after the first EEG study. This is most evident in incident epilepsy and in younger subjects. Clinically it may be worthwhile to consider that the probability of finding an epileptiform abnormality after the third nonepileptiform EEG recording is low.

Gender Differences in Presenting Signs and Symptoms of Acute Ischemic Stroke: A Population-Based Study

There are few population-based data regarding gender differences in signs and symptoms of acute ischemic stroke, and previously reported data have been inconsistent and conflicting. The goal of this study was to address the gender differences of the presenting signs and symptoms of acute ischemic stroke in a population-based study. All patients with first ischemic stroke occurring between 1985 and 1989 were identified; subjects were residents of Rochester, Minnesota. Signs and symptoms were collected via review of comprehensive medical records. Differences were identified using the Pearson χ(2) test. A total of 449 cases of first ischemic stroke were identified; 268 (60%) were women. Symptoms at ischemic stroke presentation differed between men and women. Women more commonly presented with generalized weakness (P = 0.005) and mental status change (P = 0.0001). Men more commonly presented with paresthesia (P = 0.003), ataxia (P = 0.006), and double vision (P = 0.005). Signs at ischemic stroke presentation differed between men and women. Men more commonly presented with nystagmus (P = 0.002) on examination. Significant trends were that women more commonly presented with fatigue (P = 0.02), disorientation (P = 0.04), and fever (P = 0.02), whereas men more commonly presented with sensory abnormalities (P = 0.02). There were gender differences in signs and symptoms at presentation of ischemic stroke in these study patients. In addition to selected focal symptoms, women more commonly presented with diffuse symptoms of generalized weakness, fatigue, disorientation, and mental status change.

July '64 (review)

Reviewed by: July '64 Patrick D. Jones July '64 (2006). Directed by Carvin Elson. Distributed by California Newsreel. www.newsreel.org 53 minutes. Director Carvin Elson's documentary, July '64, explores three nights of racial violence in Rochester, New York, during the summer of 1964, an episode that resulted in the first National Guard intervention in a Northern city during the civil rights era. The film underscores the yawning gap between white [End Page 151] perception and black experience in post-war urban America and the explosive results of that chasm during the sixties. For most white residents of Rochester, the period following WWII represented a golden age of economic expansion, rising wages, home ownership, and cultural revival. Home to industrial giants like Kodak, Bausch & Lomb and Xerox, as well as historic figures like Frederick Douglass and Susan B. Anthony, Rochester prided itself as a progressive city with a reputation for equal opportunity. Yet, this success also contributed to what some viewed as a smug and complacent attitude among affluent residents and civic leaders. White Rochesterians displayed a general apprehensiveness toward outsiders and a stubborn unwillingness to recognize the growing racial inequality in their community and, thus, the need for change. African American experience in Rochester stood in sharp contrast to the prosperity enjoyed by most whites, but was sadly typical of black circumstances across urban America at the time. Between 1950 and 1960, the black population rose roughly three hundred percent from 8,400 to more than 30,000 as African Americans fled the Jim Crow South in search of greater respect, increased job opportunities, better housing and quality education for their children. Upon arrival, though, black migrants faced cramped, segregated housing in dilapidated, rat-infested structures, widespread employment discrimination, and substandard urban public schools. In the film, residents call the conditions "inhuman," "shameful," "uncivilized" and "drastically wrong." The resulting poverty led inevitably to a growing "quiet rage" and rising tensions with local police who used strong-arm tactics and German shepherds to maintain order in black neighborhoods. African Americans referred to the situation as a "police state" while the mayor of the city suggested that black residents were over-reacting. Either way, by the mid-1960s, most African American citizens agreed that Rochester's two predominately black wards were a "keg of dynamite and all it needed was a match." The explosion took place on July 25th as police tried to subdue an intoxicated black reveler at a neighborhood block party. Some claimed the crowd reacted to excessive force by the officers, while others said the culprit's friends interfered with police. Rumors that a police dog bit a young girl and that an officer slapped a pregnant woman only added fuel to the fire. One resident suggested that identifying a trigger was "like finding the raindrop that caused the storm or the snowflake that caused the blizzard." Whatever the immediate catalyst, the long-simmering tensions of urban racial inequality finally boiled over, resulting in three days of unrest. Young black residents [End Page 152] clashed with hundreds of policemen armed with batons and fire-hoses in scenes that many will find eerily reminiscent of racial conflict in Birmingham the previous year. Dozens of storefronts were smashed and businesses looted before National Guardsmen finally restored order. Constance Mitchell, a ward supervisor prominently featured throughout the film, called the disturbance "a crude awakening" for the city. While the eruption brought new attention to the struggles of Rochester's black community, the documentary also makes clear that large-scale demographic and economic trends have ensured the continuation of urban racial inequality up to the present day. Aesthetically, July '64 takes a traditional documentary approach to its subject. Based primarily on archival footage, colorful (and, in retrospect, somewhat humorous) promotional films and interviews with local people, including the mayor, city council members, journalists and residents, the film also relies heavily on Dr. James Turner and journalist Jack Germond to situate local events within a broader historical context. The singular voice of Roscoe Lee Brown provides the narration. The film does include some rough cuts, but overall, it is well constructed. Historically, July '64 provides an important look at racial violence in...

Increased risk of serious pneumococcal disease in patients with atopic conditions other than asthma

We reported an increased risk of serious pneumococcal disease (SPD) among patients with asthma. It is not known whether this is true for patients with other atopic conditions. To determine the relationship between atopic conditions other than asthma and SPD. The study subjects were residents of Rochester, Minn, who developed SPD between 1964 and 1983 and their 2 sex-matched and age-matched controls. We used a population-based computer-linked medical diagnosis system to identify all individuals with potential SPD. All records were reviewed by using explicit predetermined criteria for SPD. All individuals with atopic conditions were identified by the physician diagnoses including atopic dermatitis or eczema, allergic rhinitis, and hay fever documented in medical records. The associations between these atopic conditions and SPD were assessed by using conditional logistic regression. A total of 3941 records were reviewed, and we identified 174 SPD cases. Of these 174 cases, 50.6% were male, and 94.3% were Caucasian. Twenty-six (14.9%) of the SPD cases and 29 (8.3%) of the controls had atopy. Atopic conditions other than asthma were associated with an increased risk of SPD (odds ratio, 2.13; 95% CI, 1.04-4.35; P = .04) after adjusting for smoking status, previous high-risk conditions for SPD, educational status, and ethnicity. Like asthma, other atopic conditions, particularly atopic dermatitis, are associated with an increased risk of SPD. There may be a common immunogenetic mechanism underlying increased risk of SPD among individuals with either asthma or other atopic conditions. Our study findings need to be studied further.

Not All First Seizures Are Created Equally

Is a First Acute Symptomatic Seizure Epilepsy? Mortality and Risk for Recurrent Seizure. Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Epilepsia 2009;50(5):1102–1108. PURPOSE: To compare mortality and subsequent unprovoked seizure risk in a population-based study of acute symptomatic seizure and first unprovoked seizure due to static brain lesions. METHODS: We ascertained all first episodes of acute symptomatic seizure and unprovoked seizure due to central nervous system (CNS) infection, stroke, and traumatic brain injury (TBI). Subjects were residents of Rochester, Minnesota, identified through the Rochester Epidemiology Project's records-linkage system between January 1, 1955 and December 31, 1984. Information was collected on age, gender, seizure type, etiology, status epilepticus (SE), 30-day and 10-year mortality, and subsequent episodes of unprovoked seizure. RESULTS: Two hundred sixty-two individuals experienced a first acute symptomatic seizure and 148 individuals experienced a first unprovoked seizure, all due to static brain lesions. Individuals with a first acute symptomatic seizure were 8.9 times more likely to die within 30 days compared to those with a first unprovoked seizure [95% confidence intervals (CI) = 3.5–22.5] after adjustment for age, gender, and SE. Among 30-day survivors, the risk of 10-year mortality did not differ. Over the 10-year period, individuals with a first acute symptomatic seizure were 80% less likely to experience a subsequent unprovoked seizure compared with individuals with a first unprovoked seizure [adjusted rate ratio (RR) = 0.2, 95% CI = 0.2–0.4]. DISCUSSION: The prognosis of first acute symptomatic seizures differs from that of first unprovoked seizure when the etiology is stroke, TBI, and CNS infection. Acute symptomatic seizures have a higher early mortality and a lower risk for subsequent unprovoked seizure. These differences argue against the inclusion of acute symptomatic seizures as epilepsy.

Validation and Refinement of the ABCD2 Score

Transient ischemic attacks are a frequent diagnosis in the emergency department setting, yet expert opinion as to the proper follow-up and need for hospitalization differs widely. Recently, an effort has been made to risk-stratify patients presenting with transient ischemic attacks through scoring systems such as the ABCD and ABCD2 scales. The aim of our study was to independently validate these scores using a population-based cohort. Using the data from the Rochester Stroke and Transient Ischemic Attack Registry and resources of the Rochester Epidemiology Project, medical records of all residents of Rochester, Minn, with a diagnosis of incident transient ischemic attack from 1985 through 1994 were examined (N=284). Patients were scored on the ABCD and ABCD2 scales and new scores were created by adding hyperglycemia and a history of hypertension. The end points of stroke and death were collected previously and were verified through the Rochester Epidemiology Project data. Although our study did find that scores >4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (< or =4) on the ABCD2 scale. Including history of hypertension and hyperglycemia on presentation increased the sensitivity of the score to identify patients who had a stroke within 7 days. Reliance on the ABCD and ABCD2 scores misses some patients who will have a stroke within 7 days of a transient ischemic attack. Adding hyperglycemia and a history of hypertension to the predictive model could be useful, but the value of these additions need to be evaluated further.

Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure

To compare mortality and subsequent unprovoked seizure risk in a population-based study of acute symptomatic seizure and first unprovoked seizure due to static brain lesions. We ascertained all first episodes of acute symptomatic seizure and unprovoked seizure due to central nervous system (CNS) infection, stroke, and traumatic brain injury (TBI). Subjects were residents of Rochester, Minnesota, identified through the Rochester Epidemiology Project's records-linkage system between 1/1/55 and 12/31/84. Information was collected on age, gender, seizure type, etiology, status epilepticus (SE), 30-day and 10-year mortality, and subsequent episodes of unprovoked seizure. Two hundred sixty-two individuals experienced a first acute symptomatic seizure and 148 individuals experienced a first unprovoked seizure, all due to static brain lesions. Individuals with a first acute symptomatic seizure were 8.9 times more likely to die within 30 days compared to those with a first unprovoked seizure [95% confidence intervals (CI) = 3.5-22.5] after adjustment for age, gender, and SE. Among 30-day survivors, the risk of 10-year mortality did not differ. Over the 10-year period, individuals with a first acute symptomatic seizure were 80% less likely to experience a subsequent unprovoked seizure compared with individuals with a first unprovoked seizure [adjusted rate ratio (RR) = 0.2, 95% CI = 0.2-0.4]. The prognosis of first acute symptomatic seizures differs from that of first unprovoked seizure when the etiology is stroke, TBI, and CNS infection. Acute symptomatic seizures have a higher early mortality and a lower risk for subsequent unprovoked seizure. These differences argue against the inclusion of acute symptomatic seizures as epilepsy.

Increased risk of serious pneumococcal disease in patients with asthma

Individuals with asthma have been reported to be at increased risk of invasive pneumococcal disease (IPD). These findings need to be confirmed in a different population-based study setting. We assessed whether serious pneumococcal disease (SPD), defined as an IPD, pneumococcal pneumonia, or both, was associated with asthma status. This is a retrospective case-control study using criteria-based methods for ascertaining SPD, as well as asthma. Subjects were residents of Rochester, Minnesota, who had SPD between 1964 and 1983 (the primarily pre-pneumococcal vaccine era) and their age- and sex-matched control subjects using 1:2 matching. Potential cases and control subjects were identified by using the Rochester Epidemiology project database and confirmed by medical record reviews. All cases and control subjects were merged with the database comprising the entire pool of Rochester residents with and without asthma between 1964 and 1983. A total of 3941 records of potential patients with SPD were reviewed, and we identified 174 cases of SPD (51% male subjects and 94% white subjects). SPD was associated with a history of asthma among all ages (odds ratio, 2.4; 95% CI, 0.9-6.6; P = .09) and among adults (odds ratio, 6.7; 95% CI, 1.6-27.3; P = .01), controlling for high-risk conditions for IPD and smoking exposure. The population-attributable risk percentage was 17% in the adult population. Adults with asthma might be at increased risk of SPD.

The widening mortality gap between rheumatoid arthritis patients and the general population

Overall mortality rates in the general US population have declined substantially over the last 4-5 decades, but it is unclear whether patients with rheumatoid arthritis (RA) have experienced the same improvements in survival. The purpose of this study was to determine the mortality trends among RA patients compared with those in the general population. A population-based incidence cohort of RA patients was assembled, comprising all residents of Rochester, Minnesota ages > or = 18 years in whom RA was first diagnosed (according to the American College of Rheumatology [formerly, the American Rheumatism Association] 1987 criteria) between 1955 and 1995 and all residents of Olmsted County, Minnesota in whom RA was first diagnosed between 1995 and 2000. The patients were followed up longitudinally through their complete (inpatient and outpatient) medical records until death or January 1, 2007. Expected mortality was estimated from the National Center for Health Statistics life tables on the white population in Minnesota, using person-year methods. Poisson regression was used to model the observed mortality rates, adjusting for age, sex, and disease duration. A cohort of 822 RA patients (72% women, mean age at RA incidence 58 years) was followed up for a median of 11.7 years, during which 445 of the RA patients died. Between 1965 and 2005, the mortality rates across the calendar years for female and male RA patients were relatively constant at 2.4 and 2.5 per 100 person-years, respectively. In contrast, the expected mortality rate in the Minnesota white population decreased substantially over the same time period in both sexes. Mortality in the female general population declined from 1.0 per 100 person-years in 1965 to 0.2 per 100 person-years in 2000. Mortality in the male general population decreased from 1.2 per 100 person-years in 1965 to 0.3 per 100 person-years in 2000. Therefore, the difference between the observed and expected mortality rates increased in more recent years, resulting in a widening of the mortality gap. Our findings show that RA patients have not experienced improvements in survival over the past 4 decades, despite dramatic improvements in the overall rates of mortality in the general US population. Further research into the causes of the widening gap in mortality between RA patients and the general population, and the influence of current therapeutic strategies on mortality, is needed in order to develop strategies to reduce the excess mortality observed in RA patients.

Recurrence of Afebrile Status Epilepticus

Risk factors for recurrence of afebrile status epilepticus (SE), in residents of Rochester, MN, were determined by researchers at Columbia University, New York; Harvard School of Public Health, Boston, MA; and Mayo Clinic, Rochester, MN.

Medical Presentation of Constipation From Childhood to Early Adulthood: A Population-Based Cohort Study

Constipation is a common disorder in children and adults, but the role of gender and early life risk factors remains undefined. The aims of the study were as follows: (1) to estimate the incidence of medical presentation for constipation in a population-based birth cohort, and (2) to examine factors associated with constipation presentation from childhood to adulthood. A birth cohort of all children born between 1976 and 1982 to mothers who were residents of Rochester, Minnesota, and who remained in the community until age 5 was used for this study. Medical visits for constipation were identified by diagnoses codes and chart review. Subjects were followed up based on their diagnoses accumulated while younger than 21 years old, and 80% of subjects remained in the area until 18 years of age. Of 5299 birth cohort members without constipation presentation before age 5, the overall age- and sex-adjusted incidence was 3.9 per 1000 person-years. A higher incidence for constipation in females occurred beginning at 13 years to early adulthood (rate ratio, 2.6 for 13-16 y and 4.2 for 17 to <21 y). Children with a diagnosis for constipation at younger than 5 years of age had a significantly higher incidence for subsequent medical visits for constipation through adolescence and early adulthood compared with the incidence rate of children without an early medical presentation (rate ratio, 4.5 for 5-8 y, 2.5 for 9-12 y, and 3.9 for 17-20 y). Early medical presentation and female sex influence incident and repeat medical visits for constipation from childhood to early adulthood.

Recurrence of afebrile status epilepticus in a population-based study in Rochester, Minnesota

To determine the risk of recurrence of status epilepticus (SE) in a population-based sample and to identify risk factors for recurrence. We ascertained all first episodes of afebrile SE in residents of Rochester, MN, through the Rochester Epidemiology Project's records-linkage system between January 1, 1965, and December 31, 1984. Information was collected on age, gender, duration, seizure type, etiology, therapeutic response to initial antiepileptic drug medication, and subsequent episodes of SE. Among the 183 episodes of first afebrile SE, the risk of recurrent SE was 31.7% over a 10-year follow-up period. The risk of recurrence was about 25% for those with acute symptomatic SE, remote symptomatic SE, and idiopathic cryptogenic SE. Recurrence was 100% for those with progressive symptomatic SE. Female gender (rate ratio [RR] = 2.3, 95% CI = 1.1 to 5.0) and progressive symptomatic etiology (RR = 2.4, 95% CI = 0.6 to 8.9) increased the risk for recurrent SE. Both partial SE (RR = 0.5, 95% CI = 0.2 to 1.1) and good therapeutic response to the initial antiepileptic drug therapy (RR = 0.3, 95% CI = 0.1 to 0.7) were associated with a decreased risk of recurrent SE. Status epilepticus (SE) recurs in about one-third of individuals with a first episode of SE. Except for SE occurring in the setting a progressive brain disorder, the risk of recurrence is about 25%, regardless of the underlying etiology. Female gender and lack of response to the first antiepileptic drug medication after the initial episode of SE identify those individuals at greatest risk for recurrence.

Glucocorticoids and cardiovascular events in rheumatoid arthritis: A population‐based cohort study

To determine the relationship between glucocorticoid exposure and cardiovascular (CV) events in patients with rheumatoid arthritis (RA). A total of 603 adult residents of Rochester, Minnesota with incident RA between 1955 and 1995 were followed up through their medical records for a median of 13 years (total of 9,066 person-years). Glucocorticoid exposure was defined 3 ways: tertiles of cumulative exposure; recent use (< or =3 months) versus past use (>3 months); and average daily dosage (< or =7.5 mg/day or >7.5 mg/day). CV events, including myocardial infarction, heart failure, and death from CV causes, were defined according to validated criteria. Cox regression models were adjusted for demographic features, CV risk factors, and RA characteristics. Rheumatoid factor (RF)-negative patients with exposure to glucocorticoids were not at increased risk of CV events, irrespective of the glucocorticoid dosage or timing of use, as compared with the reference group of RF-negative patients who had never been exposed to glucocorticoids. In contrast, RF-positive patients were at increased risk of CV events, particularly with higher cumulative exposure, higher average daily dosage, and recent use of glucocorticoids. RF-positive patients with high cumulative exposure to glucocorticoids had a 3-fold increased risk of CV events (hazard ratio 3.06 [95% confidence interval 1.81-5.18]), whereas RF-negative patients with high cumulative exposure were not at increased risk (hazard ratio 0.85 [95% confidence interval 0.39-1.87]). RF-positive but not RF-negative patients were at increased risk of CV events following exposure to glucocorticoids. These findings suggest that glucocorticoids interact with RF status to modulate the occurrence of CV events in patients with RA. The mechanisms underlying this interaction are unknown and should be the subject of further research.

Population-Based Prevalence of Repeated Group A β-Hemolytic Streptococcal Pharyngitis Episodes

OBJECTIVE To define the population-based 3-year period prevalence of repeated group A β-hemolytic streptococcal (GABHS) pharyngitis episodes in children between 4 and 15 years of age. PATIENTS AND METHODS Residents of Rochester, Minn (age, 4-15 years), who had 3 or more GABHS pharyngitis episodes in 1 year, at least 1 month apart, between January 1, 1996, and December 31, 1998, were identified using the resources of the Rochester Epidemiology Project (N=536). Pharyngitis episodes (evidence of a sore throat with or without presence of fever) followed by either a positive rapid streptococcus test result or a positive plate culture test result were considered positive GABHS episodes. Age- and sex-specific prevalence rates were calculated, assuming that all residents 4 to 15 years of age in Rochester during 1996 to 1998 were at risk. RESULTS A total of 208 children met our definition for repeated GABHS episodes between 1996 and 1998 and were included in this study. Approximately 1% of children between the ages of 4 and 15 years experienced repeated GABHS pharyngitis episodes between 1996 and 1998. This estimate increased to approximately 2% among children 4 to 6 years of age and decreased to 0.1% among children 13 to 15 years old. CONCLUSION A relatively small proportion (1%) of children between 4 and 15 years of age experienced repeated GABHS episodes in a 3-year period; however, this proportion represents a substantial number of children who are affected at the population level. Given the increased costs associated with treating repeated GABHS episodes, further studies are necessary to determine how best to reduce episodes and treatment costs in this age group. To define the population-based 3-year period prevalence of repeated group A β-hemolytic streptococcal (GABHS) pharyngitis episodes in children between 4 and 15 years of age. Residents of Rochester, Minn (age, 4-15 years), who had 3 or more GABHS pharyngitis episodes in 1 year, at least 1 month apart, between January 1, 1996, and December 31, 1998, were identified using the resources of the Rochester Epidemiology Project (N=536). Pharyngitis episodes (evidence of a sore throat with or without presence of fever) followed by either a positive rapid streptococcus test result or a positive plate culture test result were considered positive GABHS episodes. Age- and sex-specific prevalence rates were calculated, assuming that all residents 4 to 15 years of age in Rochester during 1996 to 1998 were at risk. A total of 208 children met our definition for repeated GABHS episodes between 1996 and 1998 and were included in this study. Approximately 1% of children between the ages of 4 and 15 years experienced repeated GABHS pharyngitis episodes between 1996 and 1998. This estimate increased to approximately 2% among children 4 to 6 years of age and decreased to 0.1% among children 13 to 15 years old. A relatively small proportion (1%) of children between 4 and 15 years of age experienced repeated GABHS episodes in a 3-year period; however, this proportion represents a substantial number of children who are affected at the population level. Given the increased costs associated with treating repeated GABHS episodes, further studies are necessary to determine how best to reduce episodes and treatment costs in this age group.

A Comparative Analysis of Short- and Long-Term Outcomes After Ventricular Fibrillation Out-of-Hospital Cardiac Arrest in Patients With Ischemic and Nonischemic Heart Disease

Although ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) occurs primarily in the setting of severe ischemic heart disease (IHD), a significant proportion of events occurs in patients who do not have severe IHD. The relative effect of IHD on survival after VF OHCA is unknown. All residents of Rochester, Minnesota, who presented with a VF OHCA from November 1990 to December 2004, treated by emergency medical services, were included in the study. During the study, emergency medical services treated 208 patients (64.1 +/- 13.6 years of age) for VF OHCA, with an average call-to-shock time of 6.3 +/- 1.8 minutes. Of these patients, 156 had IHD and 39 had non-IHD. In 13, the underlying heart disease was unknown. Eighty-seven patients (41.8%) survived to hospital discharge with neurologic recovery (66 with IDH [42%] vs 21 with non-IHD [54%], p = 0.211)]. Five-year survival was 79 +/- 6% for patients with IHD versus 100% for those with non-IHD (p = 0.047). After adjustment for other patient characteristics, IHD was not predictive of 5-year survival (hazard ratio [HR] 2.2, 95% confidence interval [CI] 0.7 to 9.8, p = 0.177). Variables associated with poor outcomes included age >65 years (HR 4.9, 95% CI 2.0 to 13.4, p = 0.0003), ejection fraction <0.35% (HR 3.0, 95% CI 1.3 to 7.3, p = 0.012), and hypertension (HR 4.9, 95% CI 1.4 to 16.3, p = 0.001). In patients with IHD, use of an implantable cardioverter-defibrillator (HR 0.32, 95% CI 0.16 to 0.88, p = 0.024) and statin therapy (HR 0.68, 95% CI 0.17 to 0.73, p = 0.001) were associated with decreased mortality. In conclusion, compared with patients with non-IHD, those with IHD had similar short- and long-term survival rates. Long-term survival in patients with IHD was primarily influenced by other co-morbid conditions. Nonetheless, in patients with IHD, use of an implantable cardioverter-defibrillator and statin therapy were associated with higher long-term survival rates.

Clinically Confirmed Type 2 Diabetes Mellitus and Colorectal Cancer Risk: A Population-Based, Retrospective Cohort Study

Patients with type 2 diabetes mellitus (DM) may be at increased colorectal cancer (CRC) risk. However, existing data are inconsistent. We investigated CRC risks, overall and by anatomic subsite, within a population-based inception cohort of clinically confirmed type 2 DM subjects. All residents of Rochester, Minnesota who first met standardized criteria for type 2 DM from 1970 to 1994 (997 men and 978 women) were identified and followed forward in time until emigration, death, or December 31, 1999. Incident CRC cases were identified by review of inpatient and outpatient medical records. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were estimated to compare CRC incidence within the type 2 DM inception cohort with previously published rates for the Rochester general population. Over 19,158 person-years of follow-up, 51 incident CRC cases were identified within the type 2 DM cohort, while only 36.8 cases were expected (SIR = 1.39, 95% CI 1.03-1.82). Among men, type 2 DM was associated with increased overall (SIR = 1.67, 95% CI 1.16-2.33) and proximal (SIR = 1.96, 95% CI 1.16-3.10) CRC risks; distal CRC risk was also increased, but the point estimate was not statistically significant (SIR = 1.43, 95% CI 0.82-2.32). Among women, type 2 DM was not a risk factor for overall, proximal, or distal CRC (SIR = 1.03, 95% CI 0.60-1.66; SIR = 1.17, 95% CI 0.58-2.09; and SIR = 0.74, 95% CI 0.24-1.72, respectively). Within the type 2 DM cohort, current and former cigarette smokers were at higher CRC risk (SIR = 1.77, 95% CI 1.24-2.47) than never smokers (SIR = 0.99, 95% CI 0.57-1.61) and the interaction between type 2 DM and cigarette smoking status was statistically significant (p= 0.05). In this population-based, retrospective cohort study, clinically confirmed type 2 DM was associated with increased CRC risk, predominantly among men. Cigarette smoking appeared to positively modify DM-associated CRC risk, which to our knowledge has not been previously reported. These data suggest that further investigation of potential interactions between endogenous and exogenous factors involved in colorectal carcinogenesis may help to clarify the magnitude and extent of CRC risk experienced by persons with type 2 DM.

O0025 CONSTIPATION IN CHILDREN: INCIDENCE IN A POPULATION BASED BIRTH COHORT

Introduction: Constipation is a common complaint of childhood. However, little is known about the epidemiology of this disorder or if risk factors present at birth influence this presentation. Aims: 1. To estimate the incidence of constipation in a population based birth cohort from birth to 5 years. 2. To evaluate if biologic or socioeconomic risk factors determined at birth are associated with the presentation of constipation in children. Methods: A birth cohort of all children born between 1976 and 1982 to mothers who were residents of Rochester, MN, and who remained in the community until age 5 years (N=5718) was considered for this study. Subjects who had not denied research authorization were utilized (N=5506). Biologic (low birth weight, prematurity, multiple births, mother age <21 yo), and socioeconomic (single parent, maternal education, amount of prenatal care) risk factors were obtained from computerized state birth certificate records. Utilizing the combined medical index of the Rochester Epidemiology Project, diagnostic codes for constipation (including functional constipation, fecal retention, encopresis, but excluding Hirschsprung’s disease or identified organic gastrointestinal disorders) for the birth cohort members were identified. The medical records were reviewed to determine the date of presentation, number of medical visits, and the frequency and duration of symptoms. In addition, a group of age and gender matched controls (1:2) from the same birth cohort who did not have an identified diagnostic code were utilized for comparison of risk factors. Results: Of the 5506 birth cohort members, 158 had a medical visit for constipation before the age of 5. The sex-specific incidence for AP by age 5 years per 1000 person-years of observation was 5.4 (95% CI, 4.1–6.6) for girls, 6.3 for boys (95% CI, 5.0–7.6), and 5.8 (95% CI, 4.9–6.7) overall. The age-specific incidences were similar for girls and boys. There was no evidence to suggest that either biologic or socioeconomic risk factors influenced the presentation for constipation, although the factors are rare.Table 1: Age of Constipation DiagnosisConclusion: This is the first examination of constipation in children using a population based birth cohort.

Long-term fracture risk following adult-onset asthma: a population-based study.

There are few data on skeletal outcomes in the growing population of patients with adult-onset asthma. We conducted a population-based retrospective (historical) cohort study among 226 residents of Rochester, Minnesota, USA, who were 35 years of age or older when first diagnosed with asthma. Fractures were ascertained by review of comprehensive community medical records, and observed fractures were compared with expected numbers based on incidence rates in the local population (standardized incidence ratios, SIR). During 4,022 person-years of follow-up, 100 patients experienced 211 fractures, for an actuarially estimated cumulative incidence of 63% after 30 years compared with 59% expected ( p=0.004). Statistically significant increases were seen for moderate trauma fractures of the vertebrae (SIR, 2.9; 95% CI, 2.1 to 3.8) and ribs (SIR, 2.0; 95% CI, 1.2 to 3.2), as well as the proximal femur (SIR, 1.8; 95% CI, 1.02 to 2.8). As assessed by proportional hazards models, the only independent predictors of any subsequent moderate trauma fracture were age (hazard ratio [HR] per 10-year increase, 1.7; 95% CI, 1.5 to 2.1) and cumulative corticosteroid dose greater than the median of 1,775 mg (HR, 1.8; 95% CI, 1.1 to 3.0). In another multivariate analysis, the predictors of a moderate trauma vertebral fracture were older age (HR, 1.6; 95% CI, 1.3 to 2.1), concomitant chronic obstructive pulmonary disease (HR, 2.4; 95% CI, 1.2 to 4.9), cigarette smoking (HR, 2.3; 95% CI, 1.2 to 4.8), and cumulative corticosteroid dose greater than the median (HR, 2.6; 95% CI, 1.4 to 5.0). Other asthma therapies did not contribute significantly to these models. Thus, a 70% increase in overall fracture risk among unselected community patients with adult onset asthma was mainly confined to the subset who also had chronic obstructive pulmonary disease and was influenced by substantial corticosteroid use.