Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

PURPOSE

The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices.

METHODS

We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines.

RESULTS

We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001).

CONCLUSIONS

Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.

Risk Factors for Herpes Zoster Among Adults

Background. The causes of varicella-zoster virus reactivation and herpes zoster (HZ) are largely unknown. We assessed potential risk factors for HZ, the data for which cannot be obtained from the medical sector.

Methods. We conducted a matched case-control study. We established active surveillance in Olmsted County, Minnesota to identify HZ occurring among persons age ≥50 years during 2010–2011. Cases were confirmed by medical record review. Herpes zoster-free controls were age- and sex-matched to cases. Risk factor data were obtained by telephone interview.

Results. We enrolled 389 HZ case patients and 511 matched controls; the median age was 65 and 66 years, respectively. Herpes zoster was associated with family history of HZ (adjusted odds ratio [aOR] = 1.65); association was highest with first-degree or multiple relatives (aOR = 1.87 and 3.08, respectively). Herpes zoster was also associated with prior HZ episodes (aOR = 1.82), sleep disturbance (aOR = 2.52), depression (aOR = 3.81), and recent weight loss (aOR = 1.95). Stress was a risk factor for HZ (aOR = 2.80), whereas a dose-response relationship was not noted. All associations indicated were statistically significant (P < .05). Herpes zoster was not associated with trauma, smoking, tonsillectomy, diet, or reported exposure to pesticides or herbicides (P > .1).

Conclusions. We identified several important risk factors for HZ; however, the key attributable causes of HZ remain unknown.

Primary Care Physicians', Nurse Practitioners' and Physician Assistants' Knowledge, Attitudes and Beliefs Regarding COPD: 2007 To 2014

To assess current primary care physicians', nurse practitioners' (NP) and physicians assistants' (PA) knowledge, attitudes and beliefs regarding chronic obstructive pulmonary disease (COPD) and changes from a similar 2007 assessment, we surveyed attendees of 3 regional continuing medical education programs and compared the 2013/2014 responses with responses to a similar survey completed in 2007. Survey data included information on personal demographics, agreement with perceived barriers to COPD diagnosis, awareness, and use of COPD guidelines, and beliefs regarding the value of available COPD therapies. In 2013/2014, 426 primary care clinicians (278 medical doctors [MDs] and doctors of osteopathic medicine [DO] and 148 NPs/PAs) provided useable responses (overall response rate 61%). Overall these physicians were older and more experienced than the NPs/PAs but with few other differences in responses except significantly greater physician reported use of spirometry for COPD diagnosis. About half of the clinicians reported having in-office spirometers but less than two thirds reported using them for all COPD diagnoses. All respondents reported multiple barriers to COPD diagnosis but with fewer than in 2007 reporting lack of knowledge or awareness of COPD guidelines as a major barrier. The most striking difference between 2007 and 2013/2014 responses was the marked increase in beliefs by all clinicians in the ability of COPD treatments to reduce symptoms and numbers of exacerbations. These data affirm that primary care clinicians continue to report multiple barriers to COPD diagnosis including lack of easy access to spirometry and frequent failure to include spirometry in diagnostic confirmation. However, since 2007, the clinicians report a remarkable decline in therapeutic nihilism, which may enhance their interest in learning more about diagnosing and managing COPD.

Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings: A Practice-Based Network Assessment

OBJECTIVE

To assess primary care adherence to 2007 US asthma guidelines.

PATIENTS AND METHODS

Patients with persistent asthma aged 5 to 65 years from 22 primary care participating practices provided the data for this analysis of baseline information from the pragmatic randomized clinical trial the Asthma Tools Study. Using a combination of abstracted medical record data and patient-reported demographic information, we assessed the medical record documentation for elements of the 2007 US asthma guidelines. Elements assessed included documentation of (1) assessment of control, (2) factors that affect control (medication adherence evaluation, inhaler technique education, and evaluation for triggers), (3) self-management support (action plan), and (4) asthma medications prescribed (short-acting β-agonists and daily maintenance therapy). The baseline data was collected from March 16, 2009, to May 1, 2014.

RESULTS

In 1176 patients (285 children, 211 tweens, and 680 adults) from 16 family medicine and 6 pediatric practices across the United States, documented guideline adherence was highest for prescription of medications (88.0% for short-acting β-agonists and 70.4% for maintenance medications) and lowest for an asthma action plan (3.1%). Documentation of control (15.0%) and factors that affect control (inhaler technique education, 7.6%; medication adherence assessment, 32.5%; and allergy evaluation, 32.5%) was not common and even less common for adults compared with children. A total of 22.2% of the enrolled patients had no asthma-related visit in the year before enrollment. Adherence to the nonmedication elements were higher in practices located in cities of more than 250,000 people and cities that used electronic medical records. Older patient age was negatively associated with guideline adherence.

CONCLUSION AND RELEVANCE

Adherence to asthma guidelines is poor in primary care practices, leaving many opportunities for improvement.

Herpes zoster vaccine effectiveness and manifestations of herpes zoster and associated pain by vaccination status

Options for managing herpes zoster (HZ)-related pain and complications have limited effectiveness, making HZ prevention through vaccination an important strategy. Limited data are available on HZ vaccine effectiveness against confirmed HZ and manifestations of HZ among vaccinated persons. We conducted a matched case-control study to assess HZ vaccine effectiveness for prevention of HZ and other HZ-related outcomes and a cohort study of persons with HZ to compare HZ-related outcomes by vaccination status. Cases were identified through active surveillance among persons age ≥ 60 years with HZ onset and health-care encounters during 2010-2011 in Southeastern Minnesota. Controls were age- and sex-matched to cases. Data were collected by medical record review and from participants via interviews and daily pain diaries. 266 HZ case-patients and 362 matched controls were enrolled in the vaccine effectiveness studies and 303 case-patients in the cohort study of HZ characteristics by vaccination status. Vaccination was associated with 54% (95% CI:32%-69%) reduction in HZ incidence, 58% (95% CI:31%-75%) reduction in HZ prodromal symptoms, and 70% (95% CI:33%-87%) reduction in medically-attended prodrome. HZ vaccine was statistically significant effective at preventing postherpetic neuralgia (PHN) measured at 30 d after rash onset, 61% (95% CI: 22%-80%). Among persons who developed HZ, no differences were found by vaccination status in severity or duration of HZ pain after rash onset. In this population-based study, HZ vaccination was associated with >50% reduction in HZ, HZ prodrome, and medically-attended prodrome.

Risk of Stroke and Myocardial Infarction After Herpes Zoster in Older Adults in a US Community Population

OBJECTIVE

To assess the risk of stroke and myocardial infarction (MI) after herpes zoster in a US community population of older adults.

PATIENTS AND METHODS

We performed a community cohort study (January 1, 1986, to October 1, 2011) comparing the risk of stroke and MI in 4862 adult residents of Olmsted County, Minnesota, 50 years and older with and without herpes zoster and 19,433 sex- and age-matched individuals with no history of herpes zoster. Odds ratios are presented for MI and stroke at 3, 6, 12, and 36 months after index herpes zoster plus hazard ratios for long-term risk (up to 28.6 years).

RESULTS

Individuals with herpes zoster had more risk or confounding factors for MI and stroke, suggesting that they had worse health status overall. When controlling for the multiple risk factors, those with herpes zoster were at increased risk for stroke at 3 months after herpes zoster compared with those without a history of herpes zoster (odds ratio, 1.53; 95% CI, 1.10-2.33; P=.04). The association between herpes zoster and MI at 3 months was not robust across analytic methods. Herpes zoster was not associated with an increased risk of stroke or MI at any point beyond 3 months.

CONCLUSIONS

Herpes zoster was associated with only a short-term increased risk of stroke, which may be preventable with the prevention of herpes zoster.

Asthma as a risk factor for zoster in adults: A population-based case-control study

BACKGROUND

We recently reported an increased risk of herpes zoster (shingles or zoster) in children with asthma, but little is known about whether the same is true for adults with asthma.

OBJECTIVE

We determined whether asthma is associated with an increased risk of zoster in adults.

METHODS

This study was designed as a population-based case-control study. Zoster cases during the study period were identified among adults (aged ≥50 years) who resided in Olmsted County, Minnesota. We compared the frequency of asthma between zoster cases and birthday- and sex-matched control subjects (1:2 matching) without a history of zoster. Asthma status was ascertained based on predetermined criteria. A conditional logistic regression model was used to assess the association of asthma with risk of zoster.

RESULTS

A total of 371 zoster cases and their 742 matched control subjects were enrolled. Of the 371 cases, 246 (66%) were female, 348 (94%) were white, and the mean ± SD age was 66.8 ± 10.7 years. Twenty-three percent (n = 87) of zoster cases had a history of asthma compared with 15% (n = 114) of control subjects. Controlling for pertinent covariates and confounders, there was a significant association between a history of asthma and risk of zoster (adjusted odds ratio, 1.70; 95% CI, 1.20-2.42; P = .003). The population attributable risk percentage for asthma was about 10%.

CONCLUSIONS

Asthma is an unrecognized risk factor for zoster in adults. Consideration should be given to immunizing adults with asthma aged more than 50 years as a target group.

Obesity, low levels of physical activity and smoking present opportunities for primary care asthma interventions: an analysis of baseline data from The Asthma Tools Study

BACKGROUND

Asthma prevalence, severity and outcomes are associated with various patient characteristics and lifestyle choices.

AIMS

To identify potentially modifiable factors associated with poor asthma outcomes among US primary care patients.

METHODS

Using baseline data from the Asthma Tools Study, we calculated cross-sectional frequencies of activity levels, smoking, secondhand smoke exposure and the presence of obesity, as well as rates of out-of-control asthma and asthma exacerbations. Frequencies were stratified by sex, and into three age groups: 5-11 years, 12-18 years and 19 years and older. Logistic regression was used to identify factors associated with each of the asthma outcomes.

RESULTS

In the 901 individuals enrolled in this asthma study, tobacco smoke exposure, obesity, low activity levels, poverty, inadequately controlled asthma and high asthma-related health-care utilisation were common. Across all age groups, obesity was associated with poorer asthma outcomes: either poor asthma control (odds ratio (OR)=2.3, 95% confidence interval (CI) 1.1-4.7 in 5- to 11-year-olds and OR=1.5, 95% CI 1.1-2.2 in adults) or asthma exacerbations (OR 2.9, 95% CI 1.6-5.1 in 12- to 18-year-olds and OR 1.7, 95% CI 1.1-2.5 in adults). Among adults, smoking was associated with both measures of poorer asthma outcomes; inadequate asthma control (OR=2.3, 95% CI 1.5-3.5), and asthma exacerbations (OR 1.7, 95% CI 1.1-2.6), and low physical activity were associated with poor asthma control (OR=1.5, 95% CI 1.1-2.2).

CONCLUSIONS

Obesity, low levels of physical activity and smoking are common, and they are associated with poor asthma outcomes in a sample of primary care patients, suggesting important targets for intervention.

Repeated depression screening during the first postpartum year

PURPOSE

Postpartum depression (PPD) screening at 4 to 12 weeks' postpartum can improve outcomes for women when linked to in-practice management programs. The benefit of repeated PPD screening during the first year postpartum remains unclear.

METHODS

We report a substudy of a large pragmatic trial of early PPD screening and practice management, the Translating Research into Practice for Postpartum Depression (TRIPPD) study. Outcome analyses were based on demographic information and Patient Health Questionnaire (PHQ-9) screening scores from questionnaires mailed to all enrolled women at baseline (4 to 12 weeks' postpartum) and again at 6 and at 12 months' postpartum. The main outcomes of this substudy were the 6- and 12-month rates of PHQ-9 scores that were 10 or greater for women whose baseline PHQ-9 scores were less than 10. Women whose scores were 10 or greater would be considered at high risk of PPD and appropriate for further evaluation.

RESULTS

At 6 months, 134 (10.9%) of the 1,235 women who did not have PHQ-9 scores greater than 10 at baseline had elevated scores appropriate for further evaluation. At 12 months, 59 (6.1%) of the 969 women who did not have PHQ-9 scores greater than 10 at baseline or at 6 months had elevated scores. Together the 6- and 12-month repeated screenings identified 193 women at high risk of depression. This finding represents 13.5% of the 1,432 women whose screening results were negative for PPD at baseline.

CONCLUSIONS

Repeated PPD screening at 6 and 12 months' postpartum increases the percentage of women identified as being at high risk of PPD. Further work will be required to understand the impact of this repeated screening on patient outcomes.

Herpes zoster eye complications: rates and trends

PURPOSE

To provide population-based data on the risk, types, and outcomes of eye involvement in herpes zoster (HZ).

METHODS

A cohort study based on review of the medical records of patients in whom HZ was diagnosed between January 1, 1980, and December 31, 2007, was performed. Herpes zoster was confirmed by the presence of the typical rash and symptoms or by laboratory testing, and eye involvement was confirmed by ophthalmologists' evaluation. Information was collected on all eye diagnoses and on HZ eye-related visits, treatments, procedures, and outcomes.

RESULTS

Of the 2035 individuals with HZ in any dermatome, 184 (9.0%) had eye involvement. The mean age of the 184 was 62.6 years, and 5 cases occurred in patients younger than 21. Overall, 6.5% (12) were immunosuppressed at the time of the eye complications. The rate of increase in HZ eye involvement was 23% by decade from 1980 to 2007. Common eye complications were keratitis (n=144, 76.2%), uveitis/iritis (n=88, 46.6%), and conjunctivitis (n=67, 35.4%). Recurrent keratitis and recurrent iritis/uveitis occurred in 6.9% (13) and 7.4% (14), respectively. Outcomes included 6 patients (3.3%) with new vision decrements to 20/200 or worse. Two individuals had successful corneal transplants. Another 6 individuals (3.3%) had lid ptosis that affected vision, including 1 elderly woman with permanent unilateral tarsorrhaphy. Severe HZ eye pain was reported to be directly responsible for 1 unsuccessful suicide attempt. Acute retinal necrosis did not develop in any individual. A mean of 10.8 eye visits per patient with HZ and eye involvement was reported to continue for a mean of 308 days.

CONCLUSION

Eye complications are common and result in considerable health care use and permanent vision decrement in about 6.6% (6) of individuals with HZ eye involvement. Most health care use and long-term adverse outcomes occurred in patients in whom prevention of HZ with the zoster vaccine would be possible.

10-year trends in the diagnosis and treatment of hepatitis C and concomitant mental health disorders: 1995 to 2005

OBJECTIVE

To evaluate trends in the rate and timing of treatment for hepatitis C in those with and without mental health comorbidities.

METHOD

Data from the population-based Olmsted County Hepatitis C Registry in Minnesota were linked to patients' medical records to identify the dates and duration of any hepatitis C-specific therapy as well as all diagnoses of mental health comorbid conditions prior to initiation of therapy. The most common mental health conditions, major depressive disorder, alcohol dependence, and intravenous drug use, were assessed separately. The registry includes all Olmsted County residents with a physician diagnosis of hepatitis C or non-A/non-B hepatitis (ICD-9 criteria) from January 1, 1990, through December 31, 2005.

RESULTS

The age-adjusted prevalence of diagnosed hepatitis C increased markedly between 1995 and 2000 (15.5/10,000 persons to 27.0/10,000 persons) but changed little between 2000 and 2005 (27.0 to 27.9/10,000 persons). The number of people with comorbid hepatitis C and depressive disorder (including minor depression) increased significantly between 1995 and 2005 from 18% to over 35% of all people with diagnosed hepatitis C. Treatment rates more than doubled between 1995 and 2005, while the time from diagnosis to treatment decreased during that same period. By 2005, major depressive disorders were associated with a high rate of reasonably prompt treatment. There were no gender differences in treatment rates or time to treatment when other comorbidities and age were included in the analyses.

CONCLUSIONS

From 1995 to 2005, rates of treatment for hepatitis C among people with and without comorbid mental health problems increased. Rates of increase were higher among those with depression and hepatitis C than among those with hepatitis C and drug abuse or other mental health diagnoses. Even with this progress in treating those with multiple diagnoses, over 75% of people with hepatitis C remain untreated.

Herpes zoster recurrences more frequent than previously reported

OBJECTIVE

To present population-based estimates of herpes zoster (HZ) recurrence rates among adults.

PATIENTS AND METHODS

To identify recurrent cases of HZ, we reviewed the medical records (through December 31, 2007) of all Olmsted County, Minnesota, residents aged 22 years or older who had an incident case of HZ between January 1, 1996, and December 31, 2001. Kaplan-Meier curves and Cox regression models were used to describe recurrences by age, immune status, and presence of prolonged pain at the time of the incident HZ episode.

RESULTS

Of the 1669 persons with a medically documented episode of HZ, 95 had 105 recurrences (8 persons with >1 recurrence) by December 31, 2007, an average follow-up of 7.3 years. The Kaplan-Meier estimate of the recurrence rate at 8 years was 6.2%. With a maximum follow-up of 12 years, the time between HZ episodes in the same person varied from 96 days to 10 years. Recurrences were significantly more likely in persons with zoster-associated pain of 30 days or longer at the initial episode (hazard ratio, 2.80; 95% confidence interval, 1.84-4.27; P<.001) and in immunocompromised individuals (hazard ratio, 2.35; 95% confidence interval, 1.35-4.08; P=.006). Women and anyone aged 50 years or older at the index episode also had a greater likelihood of recurrence.

CONCLUSION

Rates of HZ recurrence appear to be comparable to rates of first HZ occurrence in immunocompetent individuals, suggesting that recurrence is sufficiently common to warrant investigation of vaccine prevention in this group.

Health care utilization and cost burden of herpes zoster in a community population

OBJECTIVE

To conduct a population-based study to assess health care utilization (HCU) and costs associated with herpes zoster (HZ) and its complications, including postherpetic neuralgia (PHN) and nonpain complications, in adults aged 22 years and older.

PATIENTS AND METHODS

Medical record data on HCU were abstracted for all confirmed new cases of HZ from January 1, 1996, through December 31, 2001, among residents of Olmsted County, Minnesota. Herpes zoster-related costs were estimated by applying the Medicare Payment Fee Schedule to health care encounters and mean wholesale prices to medications. All costs were adjusted to 2006 US dollars using the medical care component of the Consumer Price Index.

RESULTS

The HCU and cost of the 1669 incident HZ cases varied, depending on the complications involved. From 3 weeks before to 1 year after initial diagnosis, there were a mean of 1.8 outpatient visits and 3.1 prescribed medications at a cost of $720 for cases without PHN or nonpain complications compared with 7.5 outpatient visits and 14.7 prescribed medications at a cost of $3998 when complications, PHN, or nonpain complications were present.

CONCLUSION

The annual medical care cost of treating incident HZ cases in the United States, extrapolated from the results of this study in Olmsted County, is estimated at $1.1 billion. Most of the costs are for the care of immunocompetent adults with HZ, especially among those 50 years and older.

Health care utilization and cost burden of herpes zoster in a community population

OBJECTIVE

To conduct a population-based study to assess health care utilization (HCU) and costs associated with herpes zoster (HZ) and its complications, including postherpetic neuralgia (PHN) and nonpain complications, in adults aged 22 years and older.

PATIENTS AND METHODS

Medical record data on HCU were abstracted for all confirmed new cases of HZ from January 1, 1996, through December 31, 2001, among residents of Olmsted County, Minnesota. Herpes zoster-related costs were estimated by applying the Medicare Payment Fee Schedule to health care encounters and mean wholesale prices to medications. All costs were adjusted to 2006 US dollars using the medical care component of the Consumer Price Index.

RESULTS

The HCU and cost of the 1669 incident HZ cases varied, depending on the complications involved. From 3 weeks before to 1 year after initial diagnosis, there were a mean of 1.8 outpatient visits and 3.1 prescribed medications at a cost of $720 for cases without PHN or nonpain complications compared with 7.5 outpatient visits and 14.7 prescribed medications at a cost of $3998 when complications, PHN, or nonpain complications were present.

CONCLUSION

The annual medical care cost of treating incident HZ cases in the United States, extrapolated from the results of this study in Olmsted County, is estimated at $1.1 billion. Most of the costs are for the care of immunocompetent adults with HZ, especially among those 50 years and older.

Long-term trends in carpal tunnel syndrome

OBJECTIVE

To assess temporal trends in carpal tunnel syndrome (CTS) incidence, surgical treatment, and work-related lost time.

METHODS

Incident CTS and first-time carpal tunnel release among Olmsted County, Minnesota, residents were identified using the medical records linkage system of the Rochester Epidemiology Project; 80% of a sample were confirmed by medical record review. Work-related CTS was identified from the Minnesota Department of Labor and Industry.

RESULTS

Altogether, 10,069 Olmsted County residents were initially diagnosed with CTS in 1981-2005. Overall incidence (adjusted to the 2000 US population) was 491 and 258 per 100,000 person-years for women vs men (p < 0.0001) and 376 per 100,000 for both sexes combined. Adjusted annual rates increased from 258 per 100,000 in 1981-1985 to 424 in 2000-2005 (p < 0.0001). The average annual incidence of carpal tunnel release surgery was 109 per 100,000, while that for work-related CTS was 11 per 100,000. An increase in young, working-age individuals seeking medical attention for symptoms of less severe CTS in the early to mid-1980s was followed in the 1990s by an increasing incidence in elderly people.

CONCLUSIONS

The incidence of medically diagnosed carpal tunnel syndrome (CTS) accelerated in the 1980s. The cause of the increase is unclear, but it corresponds to an epidemic of CTS cases resulting in lost work days that began in the mid-1980s and lasted through the mid-1990s. The elderly present with more severe disease and are more likely to have carpal tunnel surgery, which may have significant health policy implications given the aging population.

The prevalence of neuropathic pain: clinical evaluation compared with screening tools in a community population

BACKGROUND

Neuropathic pain is reported to be common based on studies from specialty centers and survey studies. However, few prevalence estimates have been completed in a community population using clinical evaluation.

OBJECTIVE

To develop an estimate of the prevalence of neuropathic pain in community-dwelling adults.

METHODS

Data from a mailed survey (N = 3,575 community respondents), telephone interview (N = 907), and a clinical examination (N = 205) were linked to estimate the population prevalence of neuropathic pain. Using the clinical examination as the "gold" standard, estimates from several screening tools were developed and adjusted to the Olmsted County, MN adult population.

RESULTS

The estimated community prevalence of neuropathic pain from the clinical examination (gold standard) was 9.8%. Most other estimates were lower, including a 3.0% population prevalence using the Berger criteria and 8.8% using the Leeds Assessment of Neuropathic Symptoms and Signs. Only the prevalence rate based on self-report of nerve pain was higher (12.4%). Overlap among the groups each tool identified as having "neuropathic predominant pain" was only modest and the groups had significantly different rates of depressive symptoms, anxiety, limited functional ability, and use of complementary and alternative medicine.

CONCLUSIONS

The estimated rates and personal characteristics of community residents with "neuropathic pain" vary widely depending on the tools used to identify neuropathic pain. None of the screening tools compared well with clinical evaluation. The differences in the groups identified by alternative screening methods become of major importance when reporting neuropathic pain epidemiology, studying therapies for neuropathic pain, or attempting to translate neuropathic pain research into clinical practice.

Knowledge and attitudes of family physicians coming to COPD continuing medical education

PURPOSE

COPD remains under-recognized and under-treated. Much of early COPD care is given by primary care physicians but only when COPD is recognized. This survey explores the attitudes, beliefs, and knowledge related to COPD recognition, diagnosis, and treatment from family physicians and nurse practitioners (NPs) and physician assistants (PAs) working in primary care.

METHODS

We completed a survey of family physicians, and NPs/PAs attending one of three CME programs on five common chronic conditions including COPD.

RESULTS

Return rate was 62% (n = 284) including 178 physicians and 100 NPs/PAs. Fewer than half of the respondents reported knowledge of or use of COPD guidelines. The barriers to recognition and diagnosis of COPD they reported included the multiple morbidities of most COPD patients, failure of patients to report COPD symptoms, as well as lack of knowledge and inadequate training in COPD diagnosis and management. Three quarters (74%) of respondents reported use of spirometry to diagnose COPD but only 32% said they included reversibility assessment. COPD was incorrectly assessed as a disease primarily of men (78% ofrespondents) that appeared after age 60 (61%). Few respondents reported that they believed COPD treatment was useful or very useful for improving symptoms (15%) or decreasing exacerbations (3%) or that pulmonary rehabilitation was helpful (3%), but 13% reported they thought COPD treatment could extend longevity.

CONCLUSIONS

Primary care physicians and NPs/PAs working in primary care continue to report lack of awareness and use of COPD guidelines, as well as correct information related to COPD epidemiology or potential benefits of available treatments including pulmonary rehabilitation. It is unlikely that diagnosis and management of COPD will improve in primary care until these knowledge gaps and discrepancies with published efficacy of therapy issues are addressed.

A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction

OBJECTIVE

To establish accurate, up-to-date, baseline epidemiological data for herpes zoster (HZ) before the introduction of the recently licensed HZ vaccine.

METHODS

Using data from January 1, 1996, to October 15, 2005, we conducted a population-based study of adult residents (Greater than or equal to 22 years) of Olmsted County, MN, to determine (by medical record review) the incidence of HZ and the rate of HZ-related complications. Incidence rates were determined by age and sex and adjusted to the US population.

RESULTS

A total of 1669 adult residents with a confirmed diagnosis of HZ were identified between January 1, 1996, and December 31, 2001. Most (92%) of these patients were immunocompetent and 60% were women. When adjusted to the US adult population, the incidence of HZ was 3.6 per 1000 person-years (95% confidence interval, 3.4-3.7), with a temporal increase from 3.2 to 4.1 per 1000 person-years from 1996 to 2001. The incidence of HZ and the rate of HZ-associated complications increased with age, with 68% of cases occurring in those aged 50 years and older. Postherpetic neuralgia occurred in 18% of adult patients with HZ and in 33% of those aged 79 years and older. Overall, 10% of all patients with HZ experienced 1 or more nonpain complications.

CONCLUSIONS

Our population-based data suggest that HZ primarily affects immunocompetent adults older than 50 years; 1 in 4 experiences some type of HZ-related complication.

Validation of the S-LANSS in the community setting

The Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), an assessment tool to determine if pain is predominantly neuropathic, has not been validated in a community setting. Previously identified residents of Olmsted County, Minnesota, with chronic pain were recruited using a stratified randomization process to increase the frequency of neuropathic pain in the study sample. Subjects completed the S-LANSS in mailed and telephone formats, and underwent clinical assessment to determine if a component of their pain was neuropathic. Sensitivity and specificity of the S-LANSS as compared to the clinical assessment were determined. Two hundred and five subjects participated in the study. Eighty-three subjects (40%) had a positive S-LANSS score in the mailed, as did 59 of 173 (34%) in the telephone format, with little inter-subject difference in scores (p=0.57). Clinical assessment identified a component of neuropathic pain in 37% of the sample (75/205). Compared to clinical assessment, sensitivity and specificity in the mailed S-LANSS were 57% (95% CI, 46-69%) and 69% (95% CI, 61-77%), respectively, and in the telephone S-LANSS were 52% (95% CI, 39-64%) and 78% (95% CI, 68-85%), respectively. The sensitivity and specificity of the S-LANSS in both formats were lower than the initial S-LANSS validation study. Differences in survey format and subject population could account for these differences, suggesting that the S-LANSS is best suited as a screening tool and its use to determine the prevalence of neuropathic pain in population studies should be viewed cautiously.

The gender specific frequency of risk factor and CHD diagnoses prior to incident MI: a community study

BACKGROUND

CHD is a chronic disease often present years prior to incident AMI. Earlier recognition of CHD may be associated with higher levels of recognition and treatment of CHD risk factors that may delay incident AMI. To assess timing of CHD and CHD risk factor diagnoses prior to incident AMI.

METHODS

This is a 10-year population based medical record review study that included all medical care providers in Olmsted County, Minnesota for all women and a sample of men residing in Olmsted County, MN with confirmed incident AMI between 1995 and 2000.

RESULTS

All medical care for the 10 years prior to incident AMI was reviewed for 150 women and 148 men (38% sample) in Olmsted County, MN. On average, women were older than men at the time of incident AMI (74.7 versus 65.9 years, p < 0.0001). 30.4% of the men and 52.0% of the women received diagnoses of CHD prior to incident AMI (p = 0.0002). Unrecognized and untreated CHD risk factors were present in both men (45% of men 5 years prior to AMI) and women (22% of women 5 years prior to first AMI), more common in men and those without a diagnosis of CHD prior to incident AMI (p < 0.0001).

CONCLUSION

A CHD diagnosis prior to incident AMI is associated with higher rates of recognition and treatment of CHD risk factors suggesting that diagnosing CHD prior to AMI enhances opportunities to lower the risk of future CHD events.

Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context

OBJECTIVE

To assess the frequency and types of visits related to modifications in the intensity of asthma medications.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of adults (aged 18-40 years) and children (aged 6-17 years) living in Olmsted County, Minnesota, to evaluate changes in asthma medications by dose and drug class and site and type of visit (routine vs unscheduled) at the time of changes. All records from all visits were reviewed for each patient to identify asthma-related visits at all sites of care from January 1, 2002, through December 31, 2003.

RESULTS

The study consisted of 397 adults and children. In 255 patients, 597 asthma medication changes occurred. Step-up changes usually occurred because of an exacerbation or loss of control of asthma and adhered to the medication hierarchy in the national asthma guidelines. Twenty step-up changes involved skipping inhaled corticosteroid (ICS) monotherapy and moving directly to combined ICSs plus a long-acting beta-agonist (LABA). Lack of documentation of asthma symptom frequency or interference with activities made it impossible to determine whether these 'skips' were appropriate. Only 78 physician-directed step-down changes were documented, usually to a lower dose of combined ICSs and LABAs or a move from combined ICSs and LABAs to anti-inflammatory monotherapy. Patients initiated additional step-down changes between encounters. Step-down changes occurred at routine or follow-up asthma visits, but the limited number of such visits provided few opportunities for step-down care.

CONCLUSION

The continuing episodic-style treatment of asthma aimed at exacerbation management facilitates step-up changes in asthma therapy. The dearth of asthma evaluation visits limited opportunities to step down use of asthma medications and to provide long-term asthma management.

The risk of hydrosalpinx formation and adnexectomy following tubal ligation and subsequent hysterectomy: a historical cohort study

OBJECTIVE

The objective of the study was to further investigate a previous finding that tubal sterilization followed by hysterectomy was associated with hydrosalpinx formation.

STUDY DESIGN

The Rochester Epidemiology Project (Rochester, MN) was used to identify three cohorts: women who had undergone tubal sterilization and subsequent hysterectomy, women who had undergone tubal sterilization alone, and women who had undergone hysterectomy alone. Four hundred seventy-three charts were reviewed and 337 met inclusion criteria. Patient histories were analyzed prospectively, looking for subsequent adnexal surgery.

RESULTS

There was no increased risk of hydrosalpinx formation in patients who had undergone tubal sterilization and hysterectomy, compared with tubal sterilization alone. The proportion of subjects undergoing later adnexectomy for any reason was significantly higher in the hysterectomy groups, compared with the sterilization only group (relative risk 3.5, 95% confidence interval 1.3-9.4).

CONCLUSION

This prospective study does not support the previously reported case-control data suggesting that tubal sterilization followed by hysterectomy resulted in an increased risk of hydrosalpinx formation, compared with tubal sterilization alone.

Silent pain sufferers

OBJECTIVE

To evaluate the proportion and characteristics of patients with chronic pain who do not seek treatment and assess whether these patients have unmet pain care needs.

PATIENTS AND METHODS

We performed a cross-sectional survey of residents of Olmsted County, Minnesota, from March through June 2004, with additional visit and diagnosis data from the Rochester Epidemiology Project database. Study participants were a random, population-based sample of eligible adult (>30 years) residents of Olmsted County with at least 1 visit to a local health care facility in the past 3 years.

RESULTS

Of the 5897 eligible participants, 3575 people (60.6%) responded. Of the respondents who reported pain of more than 3 months' duration, 497 (22.4%) of the 2211 patients stated that they had not informed their physician about their pain. Of these silent sufferers, 70.6% (351/497) reported having moderate or severe pain, 49.2% (243/497) reported having frequent pain (>8 days per month), and 40.6% (202/497) met both criteria. Silent sufferers also reported that pain interfered with their general activity and sleep to a level only slightly less than the chronic pain sufferers who reported discussing their pain with a physician. Silent sufferers made an average of 5.2 ambulatory physician visits per year, which was less than those who sought physician help for their pain (8.6 ambulatory visits per year; P < .001). Men and younger participants were more likely to be silent about their pain (P < .001).

CONCLUSION

More than 1 in 5 people with chronic pain did not seek physician care for their pain. This group is unknown to physicians and therefore represents an unreported patient group with an unmet need for pain care.

Identification of Women's Coronary Heart Disease and Risk Factors Prior to First Myocardial Infarction

PURPOSE

To understand when women's coronary heart disease (CHD) and CHD risk factors are recognized prior to first myocardial infarction (MI).

METHODS

Medical record review of the 10 years prior to incident MI among women with a confirmed incident MI between January 1, 1996, and December 31, 2001, to determine the timing of CHD diagnosis as well as assessment and treatment for risk factors.

RESULTS

One hundred fifty women had incident MIs during the study period. They made 8732 ambulatory visits and had 457 hospitalizations during the period of review (mean 9.1 years, range 6.2-10 years). Average age at incident MI was 74.7 years (SD 12.6, range 38.9-99.8 years). A CHD diagnosis prior to first MI was present in 52% (n = 78) of the women but was less common in those <70 years (p = 0.001). All but 3 women had one or more modifiable risk factors identified prior to their first MI. Treatment of recognized risk factors varied from 81% (antihypertension medications) to only 28% (drug therapy for abnormal lipid levels). Having a diagnosis of CHD was associated with an increased likelihood of having identified risk factors and receiving drug treatment for identified risk factors.

CONCLUSIONS

Women with undiagnosed CHD (48%) and those with unrecognized or untreated risk factors for CHD, especially younger women, represent missed opportunities for prevention of cardiac events.

Ovarian cancer: the neglected diagnosis

OBJECTIVE

To investigate presenting signs and symptoms of ovarian cancer and stage of tumor in a community cohort of women with the diagnosis of ovarian cancer.

PATIENTS AND METHODS

We reviewed retrospectively the medical records of all women who sought primary and specialty care in Olmsted County, Minnesota, between January 1, 1985, and December 31, 1997, to evaluate presenting symptoms, time from first symptom to diagnosis of ovarian cancer, and stage of tumor at diagnosis.

RESULTS

Of 107 women with a diagnosis of ovarian cancer, the most commonly documented presenting symptom was crampy abdominal pain. Urinary symptoms and abdominal pain were the most commonly documented presenting symptom in patients with stage I and II ovarian cancers, whereas abdominal pain and increased abdominal girth were the most commonly documented symptoms in patients with stage III and IV cancer. Approximately 15% of tumors (n = 15) were found during routine evaluations or during a procedure for another problem. Less than 25% of presenting symptoms (n = 24 women) related directly to the pelvis or were more traditional gynecologic symptoms. Delays in women seeking medical care, health care system issues, competing medical conditions, physicians' failure to follow up, and women not returning for follow-up were associated with longer time to diagnosis.

CONCLUSION

Both stage I and II cancer are associated with symptoms, but few symptoms are directly related to the reproductive pelvic organs or unique to ovarian cancer. A longer interval from first sign or symptom to diagnosis of ovarian cancer is associated with both patient and health care system factors.

Incidence of a clinical diagnosis of the irritable bowel syndrome in a United States population

BACKGROUND

The incidence of irritable bowel syndrome is uncertain. We aimed to determine the incidence of clinically diagnosed irritable bowel syndrome in the community.

METHODS

Using the Rochester Epidemiology Project, all diagnoses of irritable bowel syndrome made among adult residents of Olmsted County, Minnesota, over a 3-year period were identified. The complete medical records of a random sample of the potential subjects were reviewed for the 10 years prior to the irritable bowel syndrome diagnosis and any patient who had received a previous diagnosis of irritable bowel syndrome was excluded (prevalent cases).

RESULTS

The diagnostic index listed 1245 possible irritable bowel syndrome patients; 416 patient charts were reviewed and, of these, 149 were physician diagnosed incident cases of irritable bowel syndrome. The age- and sex-adjusted incidence rate was 196 per 100,000 person-years and increased with age (P = 0.006). The age-adjusted annual incidence per 100,000 in women was higher than in men: 238 vs. 141 (ratio 3:2; P = 0.005). The overall symptom frequency at the time of diagnosis was abdominal pain (73%), diarrhoea (41%) and constipation (16%).

CONCLUSIONS

The incidence of a clinical diagnosis of irritable bowel syndrome in adults was estimated to be two per 1000 per year, increased with age and was higher in women than men. As many people with irritable bowel syndrome do not seek care, the true incidence of irritable bowel syndrome is likely to be higher.

Temporal and gender-related trends in brain metastases from lung and breast cancer

Increased duration of cancer survival may allow a longer window for detection of metastases, including brain metastases. Using the entire population of Olmsted County, Minnesota, we looked at trends in the rate of brain metastases in people diagnosed with primary lung or breast cancers between January 1, 1988, and December 31, 2001. Yearly rates of brain metastases detection following the primary tumors were calculated from a combination of medical record and SEER database information. Trends in rates and gender differences were assessed. There was no discernible increase in the rates of brain metastases secondary to lung or breast cancer during the period of observation. However, women were twice as likely as men to have brain metastases detected following a primary lung cancer. This difference was constant over the time period. This twofold difference in brain metastases detected in women versus men with lung cancer deserves further evaluation and confirmation.

Test-retest reproducibility of heart rate recovery after treadmill exercise

BACKGROUND

Slowed heart rate recovery (HRR) of less than 12 beats per minute in the first minute after an exercise stress test has been suggested as a useful addition to the criteria currently used to assess exercise stress test results. Although HRR has been tested in large populations, the short-term test-retest stability (reproducibility) of abnormal HRR for an individual has not been assessed.

METHODS

The study was a retrospective comparison of medical record information using a community-practice-based sample of 90 patients undergoing 2 exercise stress tests separated by 18 weeks or less. Concordance of abnormal HRR results on the first and second stress tests were assessed for individual patients using definitions of abnormal HRR from the medical literature.

RESULTS

Individual patient's HRR was markedly variable from the first to second stress test. In this sample, no definition of abnormal HRR provided more than 55% concordance between results from the first and second stress tests.

CONCLUSION

These preliminary data suggest that HRR appears to have limited short-term test-retest stability or reproducibility and therefore might not be a reliable addition to current results of exercise stress tests.

Effect of multiple freeze-thaw cycles on detection of measles, mumps, and rubella virus antibodies

We investigated the effect of multiple freeze-thaw cycles on mumps, measles, and rubella virus serum antibody levels with whole-virus immunoglobulin G enzyme-linked immunoassays. Fresh serum samples from nine healthy adult volunteers were divided into six sets of five aliquots each. Samples were taken through a total of 10 freeze-thaw cycles and stored at 4 degrees C until assayed. Each assay measurement was done in replicates of five, and the mean value was reported. After completing 10 freeze-thaw cycles, we found no clinically or statistically significant effect on measured antibody levels and found no discernible detrimental effect on the ability to measure these antibodies by enzyme-linked immunoassays.

Development and maintenance of a community-based hepatitis C registry

OBJECTIVE

To develop a model for community-population- or health system-based registries of all patients with diagnosed hepatitis C, to facilitate clinical care and epidemiologic studies.

STUDY DESIGN

Geographically defined, population-based cohort study.

METHODS

Registry subjects were identified using January 1, 1990, to December 31, 1999, data from the Rochester Epidemiology Project (REP), which lists all diagnoses for Olmsted County residents recorded by clinicians during visits to Olmsted County medical providers. We supplemented diagnostic data with information from laboratory databases that record all hepatitis C testing in Olmsted County. All diagnoses based on the REP and laboratory databases were confirmed by medical record review. Proposed data elements to be included in a hepatitis C registry were identified and defined, and data collection methodology was tested.

RESULTS

A total of 355 subjects (62% male) were identified in the total community population of 130,000. Both the diagnostic summary database (n = 309, 87%) and the laboratory database (n = 46, 133%) were important in the identification of subjects for the registry. Nine additional subjects with diagnostic or laboratory evidence of hepatitis C refused the legislatively mandated (Minnesota statute) medical records research authorization and could not be included in the registry. Most desired data elements were available in the medical records.

CONCLUSIONS

Both medical visit diagnostic summaries (administrative or billing data) and laboratory databases are required to identify subjects with physician-based diagnoses of hepatitis C. Few patients refused the authorization required for inclusion in a research registry.

Do published guidelines for evaluation of irritable bowel syndrome reflect practice?

BACKGROUND

The only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis.

METHODS

This is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis.

RESULTS

Of the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort.

CONCLUSIONS

Primary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes.

School attendance and school performance: a population-based study of children with asthma

OBJECTIVE

To analyze school attendance and school achievement as outcomes of the care of children with asthma.

METHODS

A previously identified Rochester, Minnesota, cohort of children with asthma and age- and sex-matched children without asthma were studied. School attendance, standardized achievement test scores, grade point average, grade promotion, and class rank of graduating students for children with asthma and control subjects were obtained from the Rochester Public School system.

RESULTS

Children with asthma (n = 92) and age- and sex-matched non-asthmatic control subjects with 640 school-years of observation were studied. Children with asthma had 2.21 (95% CI, 1.41 to 3.01) more days absent than children without asthma. There was no significant difference in standardized achievement test scores (reading percentile difference 1.22% [95% CI, -3.68 to 6.12], mathematics percentile difference 2.36% [95% CI, -2.89 to 7.60], language percentile difference 2.96% [95% CI, -4.03 to 7.15]). There was no significant difference in grade point average, grade promotion, or class rank of graduating students.

CONCLUSION

In this community, although children with asthma had 2 excess days of absenteeism, the school performance of children with asthma was similar to that of children without asthma.

Diagnosis and care of irritable bowel syndrome in a community-based population

OBJECTIVE

To identify the healthcare utilization and evaluation in a community-based population with an incident diagnosis of irritable bowel syndrome (IBS).

STUDY DESIGN

Retrospective cohort.

PATIENTS

A randomly selected cohort of 149 Olmsted County, MN, adults with an incident diagnosis of IBS between June 1, 1992, and December 31, 1994.

METHODS

Retrospective medical record review of each medical encounter for the 10 years before and the 3 years after the incident IBS diagnosis. Specific attention was given to healthcare visits, tests, and treatment associated with documented gastrointestinal (GI) tract symptoms and diagnosis of IBS.

RESULTS

Of 149 patients, 98 (66%) were women, and the mean patient age was 46.6 years. Patients averaged 4.7 healthcare visits annually, including 0.5 related to GI tract symptoms. Two thirds of patients had GI tract symptom-related visits at least 2 years before IBS diagnosis. Only 5% of IBS diagnoses were made by a gastroenterologist. Colon examinations (colonoscopy or barium enema) were performed on 47% of patients and were more common in those aged > or = 55 years (58% vs 36%; P = .02). One third of patients had no GI tract testing proximal to the IBS diagnosis. Following the IBS diagnosis, only about half the patients made any IBS or GI tract symptom-related visits per year.

CONCLUSION

The path to diagnosis of IBS is through the primary care physician and includes minimal testing and limited follow-up care.

Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines

The growing abundance of highly immunogenic vaccines has arrived with a burden of pain, distress, and common adverse reactions that in turn may interfere with parental compliance and aggravate anti-vaccine sentiment. In a study of 150 children in each of 2 age-groups, we found that approximately 20% of the subjects suffered serious distress or worse. During the procedural phase, approximately 90% of the 15-to-18 month old children and 45% of the 4-to-6 year old children showed serious distress or worse. To address non-adherence with pediatric vaccine schedules, we must consider all of the possible issues that might prevent a parent from taking a child to a health care provider for vaccination. In that same study we identified useful predictors for both preparatory and procedural distress - predictors that might be used in identifying children who might benefit from preventive interventions. Vaccine providers might consider a variety of interventions. Attitude, empathy, instruction, and practice have all been shown to have a salutatory effect upon pain and anxiety with medical procedures in general and specifically with vaccinations. Distraction has also been found to be an effective method for distress and pain prevention in children. More formal methods of clinical hypnosis which combine a deep state of relaxation with focused imagery and suggestion have also been found to be effective in helping children and adolescents prepare for, cope with, and tolerate the pain and anxiety associated with medical procedures. So-called 'sugar nipples' delivering small amounts of sucrose orally at the time of a painful procedure in an infant has been not been shown to decrease vaccination pain and studies on refrigerant topical anesthetics are mixed. Studies have found a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) effective in providing adequate local anesthesia in children, but it suffers from problems in practical application. Studies with various injection techniques have not identified ready solutions, and although jet injection appears to provoke less anxiety and cause less immediate pain, studies also indicate a somewhat greater incidence of delayed local reactogenicity including soreness and edema. Other measures to prevent or rapidly treat other common adverse events have been shown effective and should be considered as well.

Fish oil supplementation in type 2 diabetes: a quantitative systematic review

OBJECTIVE

To determine the effects of fish oil supplementation on lipid levels and glycemic control in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A comprehensive search of Medline, Embase, Lilacs, the Cochrane Clinical Trials Registry bibliographies of relevant papers, and expert input updated through September 1998 was undertaken. All randomized placebo-controlled trials were included in which fish oil supplementation was the only intervention in subjects with type 2 diabetes. Three investigators performed data extraction and quality scoring independently with discrepancies resolved by consensus. Eighteen trials including 823 subjects followed for a mean of 12 weeks were included. Doses of fish oil used ranged from 3 to 18 g/day The outcomes studied were glycemic control and lipid levels.

RESULTS

Meta-analysis of pooled data demonstrated a statistically significant effect of fish oil on lowering triglycerides (-0.56 mmol/l [95% CI -0.71 to -0.41]) and raising LDL cholesterol (0.21 mmol/l [0.02 to 0.41]). No statistically significant effect was observed for fasting glucose. HbA1c total cholesterol, or HDL cholesterol. The triglyceride-lowering effect and the elevation in LDL cholesterol were most marked in those trials that recruited hypertriglyceridemic subjects and used higher doses of fish oil. Heterogeneity was observed and explained by the recruitment of subjects with baseline hypertriglyceridemia in some studies.

CONCLUSIONS

Fish oil supplementation in type 2 diabetes lowers triglycerides, raises LDL cholesterol, and has no statistically significant effect on glycemic control. Trials with hard clinical end points are needed.

Long-term trends in the incidence of Paget's disease of bone

Existing data on the epidemiology of Paget's disease of bone are limited by the lack of directly determined secular trends in clinically diagnosed Paget's disease. In the current study, we examine trends in Paget's disease incidence in Olmsted County, MN, using data from the Rochester Epidemiology Project medical records linkage system. During the period 1950 through 1994, 236 Olmsted County, MN residents were diagnosed for the first time with Paget's disease of bone at a mean age of 69.6 years. Overall, there were 129 (54.7%) men and 107 women, and the age-adjusted incidence of Paget's disease was 12.7 per 100,000 person-years (95% CI 10.4-14.9) among the men compared with 7.0 per 100,000 person-years (95% CI 5.6-8.3) among Olmsted County women (male/female ratio of 1.8:1). The higher incidence in males compared with females and the increase in incidence with older age were statistically significant. The incidence of Paget's disease in Olmsted County seems to have increased over the first part of the study period and then declined. This may have resulted from ascertainment bias: the introduction of a 12-test automated serum chemistry panel in 1974 might have led to a sudden increase in the apparent incidence of Paget's disease followed by a compensatory decrease. In addition, there was a decrease in the proportion of patients who were symptomatic at diagnosis, from 36% in 1950-1959 to 27% in 1980-1994. This finding also suggests that routine measurement of alkaline phosphatase may have led to more diagnosis of asymptomatic individuals. The subsequent fall in the incidence of Paget's disease is consistent with previous reports, although this apparent decline could be artifactual to the extent that the reservoir of undiagnosed cases in the population was exhausted by earlier testing.

The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial

OBJECTIVE

To compare the canalith repositioning procedure (CRP) with a sham maneuver for the treatment of benign paroxysmal positional vertigo.

PATIENTS AND METHODS

We recruited 50 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination (Dix-Hallpike maneuver). Patients were randomized to either the CRP (n = 24) or a sham maneuver (n = 26). Measured outcomes included resolution of vertigo and positional nystagmus at follow-up examination.

RESULTS

The mean duration of follow-up was 10 days for both groups. Resolution of symptoms was reported by 12 (50%) of the 24 patients in the CRP group and by 5 (19%) of the 26 patients in the sham group (P = .02). The results of the Dix-Hallpike maneuver were negative for positional nystagmus in 16 (67%) of 24 patients in the CRP group and in 10 (38%) of 26 patients in the sham group (P = .046).

CONCLUSION

The CRP is effective treatment of benign paroxysmal positional vertigo, and this procedure can be performed by general internists on outpatients with this disorder.

Colorectal cancer screening: a community case-control study of proctosigmoidoscopy, barium enema radiography, and fecal occult blood test efficacy

OBJECTIVE

To examine the effectiveness of screening proctosigmoidoscopy, barium enema radiography, and the fecal occult blood test (FOBT) in decreasing colorectal cancer mortality in a community setting.

PATIENTS AND METHODS

In this population-based case-control study, cases comprised 218 Rochester, Minn, residents who died of colorectal cancer between 1970 and 1993. Controls were 435 age- and sex-matched residents who did not have a diagnosis of colorectal cancer. Screening proctosigmoidoscopy, barium enema radiography, and FOBT results were documented for the 10 years prior to and including the date of diagnosis of fatal colorectal cancer in cases and for the same period in matched controls. History of general medical examinations and hospitalizations was also recorded.

RESULTS

Within the 10 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening proctosigmoidoscopy were 23 (10.6%) of 218 cases vs 43 (9.9%) of 435 controls; at least 1 screening barium enema radiographic study was done in 12 (5.5%) of 218 vs 25 (5.7%) of 435. Within 3 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening FOBT were 27 (12.4%) of 218 vs 44 (10.1%) of 435. Adjusted odds ratios were 1.04 (95% confidence interval [CI], 0.21-5.13) for proctosigmoidoscopy (distal rectosigmoid cancers only), 0.67 (95% CI, 0.31-1.48) for barium enema radiography, and 0.83 (95% CI, 0.45-1.52) for FOBT over the above time periods.

CONCLUSION

In this case-control study within a community setting, a colorectal cancer-specific mortality benefit could not be demonstrated for screening by FOBT, proctosigmoidoscopy, or barium enema radiography. Screening frequency was low, which may have contributed to the lack of measurable effects.

Retrospective review of grafting techniques utilized in conjunction with endosseous implant placement

Bone resorptive patterns may prevent the ideal placement of endosseous implants. Numerous techniques have been described to create a more favorable surgical site for implant placement. This retrospective review was conducted to determine the frequency of need for implant site preparation in an outpatient clinical setting. In addition, different techniques of surgical site preparation were evaluated to determine their frequency of use and surgical outcome. A history review was conducted of all consecutively treated partially edentulous patients between January 1993 and December 1997. This review evaluated the number of implants placed, the age and gender of patient, the type of graft used, and the status of the implant. In all, 542 patients were seen in this time interval, with a total of 1,313 implants placed. Implant site preparation was needed in 4.4% of the patients, with the requirement for grafts occurring more frequently in the maxilla. Implant site preparation is a relatively infrequent requirement in the general population. Grafts are required more frequently in the maxilla than in the mandible. Complications following grafting were relatively infrequent and were not severe.

Immunogenicity of three Haemophilus influenzae type b protein conjugate vaccines in HIV seropositive adults and analysis of predictors of vaccine response

HIV-seropositive adults may be at increased risk of infection due to Haemophilus influenzae type b (Hib) as compared with HIV-seronegative adults. Protein conjugate vaccines have been demonstrated to induce protective levels of antibodies against Hib in immunocompetent infants and also in HIV-seropositive infants. In this study we determined the immunogenicity of three protein conjugate Hib vaccines (PRP-D, HbOC, HbNOMP) in 135 HIV-seropositive adults who received one dose of Hib vaccine. Anti-polyribosylribitol phosphate (PRP) antibodies were measured at 0, 1, 3 and 12 months postimmunization by the Farr method. We demonstrate that all three vaccines are highly immunogenic and result in protective (> 1.0 microg/ml) levels of antibody. Overall the anti-PRP antibody level was > 1.0 microg/ml in 26% of patients preimmunization, 91% at both 1 and 3 months, and 79% at 12 months postvaccination. Comparison of responses to the three vaccines over time demonstrated differences in the mean geometric anti-PRP antibody level at 1 month (p=0.03) and the 12 month time points (p=0.03) with lower geometric mean levels in the HbNOMP group, though baseline differences in groups limit the interpretation of these findings. In a univariate analysis of baseline characteristics which predicted poor vaccine response, low total IgG2 levels preimmunization predicted a poor antibody response at 1 month (p < 0.01) and at 12 months (p=0.05), while low CD4 T-cell count predicted poor response at 12 months (p < 0.01). We conclude that all three US licensed protein conjugate Hib vaccines are immunogenic in HIV-seropositive adults, and that baseline CD4 T-cell count and IgG2 levels predict the likelihood of antibody response to vaccine.

Population-based incidence and survival figures in essential thrombocythemia and agnogenic myeloid metaplasia: an Olmsted County Study, 1976-1995

To provide basic information about occurrence and outcome of essential thrombocythemia (ET) and agnogenic myeloid metaplasia (AMM), we used the Rochester Epidemiology Project medical record linkage system for residents of Olmsted County, Minnesota. We identified all residents who were diagnosed with ET or AMM from 1976 to 1995. Community inpatient and outpatient medical records were reviewed to verify the diagnosis of ET or AMM, and patients were followed passively through their medical records to determine the outcome after diagnosis. We identified 39 cases of ET and 21 of AMM, with age- and sex-adjusted incidence rates of 2.53 and 1.46 cases/100,000 population annually, respectively. The respective median ages at diagnosis were 72 and 67 years. The female-to-male ratios were 1.8 and 1.6 for ET and AMM, respectively, and when adjusted for age, there was no difference in risk. The median follow-up period was 62.9 months for ET and 33.2 months for AMM. Five- and 10-year survivals were 74.4% and 61.3%, respectively, for ET and were significantly lower than expected for age-matched controls (P = 0.012). Prognosis was worse for AMM, with a median progression time of 7 months and a 3-year survival of 52.4%. This was significantly worse than for age-matched controls (P < 0.001). This study provides population-based incidence and comparative survival figures in ET and AMM.

Death from pulmonary thromboembolism in severe obesity: lack of association with established genetic and clinical risk factors

Several clinical and environmental conditions are causally related to sudden death from acute pulmonary thromboembolism (APT). Morbid obesity, despite its frequency and association with adverse health effects, is usually considered at most only an additive risk factor for APT. We reviewed protocols and histories from 7227 consecutive autopsies performed between 1985 and 1996 at the Mayo Clinic, including all deaths from APT where no clinical or environmental risk factor could be identified in the study. Body mass indices (BMI) were calculated and compared with those of age- and sex-matched controls who had died suddenly and naturally without evidence of APT. Resistance to activated protein C is the most common molecular clotting defect predisposing to APT, and it is caused by a point mutation in the factor V gene (R506Q). Genomic DNA was extracted from archival tissues of all cases and controls, and the R506Q status was determined by polymerase chain reaction amplification, restriction endonuclease digestion, and direct sequencing. APT was found as the immediate cause of death in 433 patients, with 36 (8%) having no previously established risk factors. Twenty-four of these persons (67%) were morbidly obese (BMI >30 kg/m2). compared with only five controls (14%, P<0.0001). Four patients in both groups, each with a BMI <30 kg/m2. had at least one allele positive for R506Q. Morbid obesity is an independent risk factor in cases of sudden death from APT after the exclusion of previously established clinical, environmental, and molecular risk factors.

Pleomorphic xanthoastrocytoma: what do we really know about it?

BACKGROUND

Pleomorphic xanthoastrocytomas (PXA) may recur and demonstrate aggressive clinical behavior with a mortality rate between 15% and 20%. To the authors' knowledge, no histopathologic features currently are known to reliably predict recurrence or tumor progression.

METHODS

The study was based on 71 cases with available information regarding clinical and therapeutic data and follow-up. Diagnostic features included cellular pleomorphism, giant and/or xanthic cells, eosinophilic granular bodies, desmoplasia, and leptomeningeal involvement. The mitotic index (MI), the presence of necrosis, and endothelial proliferation were recorded in all primary resection specimens.

RESULTS

The study included 35 females and 36 males, age 26+/-16 years (mean +/- standard deviation). Approximately 98% of tumors were supratentorial, with 49% in the temporal lobe. Seizures were the presenting symptoms in 71% of patients. Extent of tumor removal was macroscopic total resection in 68% of cases and subtotal resection (STR) in 32% of cases. Postoperative radiotherapy, alone or with chemotherapy, was administered in 29% and 12.5% of cases, respectively. The recurrence free survival rates (RFS) were 72% at 5 years and 61% at 10 years, whereas overall survivals rates (OS) were 81% at 5 years and 70% at 10 years. In univariate analysis, the extent of resection was the single factor associated most strongly with RFS (P=0.003), followed by MI (P=0.007) and atypical mitoses (P=0.04). Necrosis was not found to be significant. The extent of resection and MI were confirmed as independent predictors of RFS by multivariate analysis. MI (P=0.001), atypical mitoses (P=0.02), and necrosis (P=0.04) were associated with OS by univariate analysis. In multivariate analysis, only MI was an independent predictor of survival. Information regarding MIB-1 labeling index and the use of adjuvant therapy was too limited to explore their prognostic significance confidently.

CONCLUSIONS

The study confirms that PXA is an astrocytic tumor with a relatively favorable prognosis. MI and extent of resection appear to be the main predictors of RFS and OS. Given the slow growth of the tumor, more studied cases and longer periods of follow-up will be essential to confirm our findings regarding prognostic factors affecting this unusual tumor.

"Malignancy" in meningiomas: a clinicopathologic study of 116 patients, with grading implications

BACKGROUND

Due to the rarity of malignancy in meningiomas, prior studies have been limited to small series. Controversies regarding the definition of malignant meningioma have complicated matters further. Although histologic anaplasia and extracranial metastasis are established criteria, the former is difficult to define and the latter represents a clinical finding. Traditionally, brain invasion has also been accepted, although this has recently been debated. In a prior series, the authors were unable to prove that 23 meningiomas that had invaded the brain were more aggressive than atypical meningiomas.

METHODS

The authors expanded their analysis to include 116 patients diagnosed with "malignant meningioma" due to brain invasion, frank anaplasia (20 mitoses per 10 high-power fields or histology resembling carcinoma, sarcoma, or melanoma), and/or extracranial metastasis. Patients were followed until death or for a median of 3.7 years.

RESULTS

Survival time was highly variable, ranging from 10 days to 24 years. In multivariate analysis, histologic anaplasia (P=0.0035), subtotal resection (P=0.0038), 20 mitoses per 10 high-power fields (P=0.0071), and nuclear atypia (P=0.0068) were associated with poor survival. Of the 89 cases of meningioma that had invaded the brain, 23% were otherwise benign, 61% were otherwise atypical, and 17% were frankly anaplastic. Those without anaplasia behaved similarly to atypical meningiomas from the authors' prior study. In contrast, anaplastic meningiomas were usually fatal, associated with a median survival of 1.5 years.

CONCLUSIONS

Based on these findings, the authors suggest that brain invasion constitutes an additional criterion for the diagnosis of atypical meningioma (World Health Organization [WHO] Grade II), whereas frank anaplasia indicates high grade (WHO Grade III-IV) malignancy.

Population-based incidence and survival figures in essential thrombocythemia and agnogenic myeloid metaplasia: an Olmsted County Study, 1976-1995

To provide basic information about occurrence and outcome of essential thrombocythemia (ET) and agnogenic myeloid metaplasia (AMM), we used the Rochester Epidemiology Project medical record linkage system for residents of Olmsted County, Minnesota. We identified all residents who were diagnosed with ET or AMM from 1976 to 1995. Community inpatient and outpatient medical records were reviewed to verify the diagnosis of ET or AMM, and patients were followed passively through their medical records to determine the outcome after diagnosis. We identified 39 cases of ET and 21 of AMM, with age- and sex-adjusted incidence rates of 2.53 and 1.46 cases/100,000 population annually, respectively. The respective median ages at diagnosis were 72 and 67 years. The female-to-male ratios were 1.8 and 1.6 for ET and AMM, respectively, and when adjusted for age, there was no difference in risk. The median follow-up period was 62.9 months for ET and 33.2 months for AMM. Five- and 10-year survivals were 74.4% and 61.3%, respectively, for ET and were significantly lower than expected for age-matched controls (P = 0.012). Prognosis was worse for AMM, with a median progression time of 7 months and a 3-year survival of 52.4%. This was significantly worse than for age-matched controls (P < 0.001). This study provides population-based incidence and comparative survival figures in ET and AMM.