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Objective: To determine whether influenza vaccination during hospitalization increases health care utilization, fever, and infection evaluations postdischarge., Patients and Methods: This retrospective cohort study conducted at Kaiser Permanente Southern California included patients aged 6 months or older hospitalized in a Kaiser Permanente Southern California facility with admission and discharge dates between September 1 and March 31 of the following calendar year, from 2011 to 2014. All influenza vaccinations administered during the period of August 1 to April 30 for influenza seasons 2011-2012, 2012-2013, and 2013-2014 were identified. We compared the risk of outcomes of interest between those who received influenza vaccination during their hospitalization vs those who were never vaccinated that season or were vaccinated at other times using propensity score analyses with inverse probability of treatment weighting. Outcomes of interest included rates of outpatient and emergency department visits, readmissions, fever, and clinical laboratory evaluations for infection (urine, blood, and wound culture; complete blood cell count) in the 7 days following discharge., Results: We included in the study 290,149 hospitalizations among 255,737 patients. In adjusted analyses, we found no increased risk of readmissions (relative risk [RR], 0.88; 95% CI, 0.83-0.95), outpatient visits (RR, 0.97; 95% CI, 0.95-0.99), fever (RR, 0.80; 95% CI, 0.68-0.93), and clinical evaluations for infection (RR, 0.95; 95% CI, 0.92-0.98) among those vaccinated during hospitalization compared with those who were never vaccinated or were vaccinated at other times., Conclusion: Our findings provide reassurance about the safety of influenza vaccination during hospitalization. Every contact with a health care professional, including during a hospitalization, is an opportunity to vaccinate., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and validate a risk prediction model that would help individualize treatment and improve the shared decision-making process between clinicians and patients., Patients and Methods: We developed a risk prediction tool for mortality during the first year of dialysis based on pre-end-stage renal disease characteristics in a cohort of 35,878 US veterans with incident end-stage renal disease who transitioned to dialysis treatment between October 1, 2007, and March 31, 2014 and then externally validated this tool among 4284 patients in the Kaiser Permanente Southern California (KPSC) health care system who transitioned to dialysis treatment between January 1, 2007, and September 30, 2015., Results: To ensure model goodness of fit, 2 separate models were selected for patients whose last estimated glomerular filtration rate (eGFR) before dialysis initiation was less than 15 mL/min per 1.73 m 2 or 15 mL/min per 1.73 m 2 or higher. Model discrimination in the internal validation cohort of veterans resulted in C statistics of 0.71 (95% CI, 0.70-0.72) and 0.66 (95% CI, 0.65-0.67) among patients with eGFR lower than 15 mL/min per 1.73 m 2 and 15 mL/min per 1.73 m 2 or higher, respectively. In the KPSC external validation cohort, the developed risk score exhibited C statistics of 0.77 (95% CI, 0.74-0.79) in men and 0.74 (95% CI, 0.71-0.76) in women with eGFR lower than 15 mL/min per 1.73 m 2 and 0.71 (95% CI, 0.67-0.74) in men and 0.67 (95% CI, 0.62-0.72) in women with eGFR of 15 mL/min per 1.73 m 2 or higher., Conclusion: A new risk prediction tool for mortality during the first year after transition to dialysis (available at www.DialysisScore.com) was developed in the large national Veterans Affairs cohort and validated with good performance in the racially, ethnically, and gender diverse KPSC cohort. This risk prediction tool will help identify high-risk populations and guide management strategies at the transition to dialysis., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To compare renal function decline, incident end-stage renal disease (ESRD), and mortality among patients with 5 common glomerular diseases in a large diverse population., Patients and Methods: A retrospective cohort study (between January 1, 2000, and December 31, 2011) of patients with glomerulonephropathy using the electronic health record of an integrated health system was performed. Estimated glomerular filtration rate (eGFR) change, incident ESRD, and mortality were compared among patients with biopsy-proven focal segmental glomerulosclerosis (FSGS), membranous glomerulonephritis (MN), minimal change disease (MCD), immunoglobulin A nephropathy (IgAN), and lupus nephritis (LN). Competing risk models were used to estimate hazard ratios for different glomerulonephropathies for incident ESRD, with mortality as a competing outcome after adjusting for potential confounders., Results: Of the 2350 patients with glomerulonephropathy (208 patients [9%] younger than 18 years) with a mean follow-up of 4.5±3.6 years, 497 (21%) progressed to ESRD and 195 (8%) died before ESRD. The median eGFR decline was 1.0 mL/min per 1.73 m 2 per year but varied across different glomerulonephropathies (P<.001). The highest ESRD incidence (per 100 person-years) was observed in FSGS 8.72 (95% CI, 3.93-16.72) followed by IgAN (4.54; 95% CI, 1.37-11.02), LN (2.38; 95% CI, 0.37-7.82), MN (2.15; 95% CI, 0.29-7.46), and MCD (1.67; 95% CI, 0.15-6.69). Compared with MCD, hazard ratios (95% CIs) for incident ESRD were 3.43 (2.32-5.08) and 2.35 (1.46-3.81), 1.28 (0.79-2.07), and 1.02 (0.62-1.68) for FSGS, IgAN, LN, and MN, respectively. No significant association between glomerulonephropathy types and mortality was detected (P=.24)., Conclusion: Our findings from a real-world clinical environment revealed significant differences in eGFR decline and ESRD risk among patients with 5 glomerulonephropathies. These variations in presentation and outcomes warrant different management strategies and expectations., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the risk of prostate cancer mortality among men treated with 5- alpha reductase inhibitors (5-ARIs) with those treated with alpha-adrenergic blockers (ABs) in community practice settings., Patients and Methods: A retrospective matched cohort (N=174,895) and nested case-control study (N=18,311) were conducted in 4 regions of an integrated health care system. Men 50 years and older who initiated pharmaceutical treatment for benign prostatic hyperplasia between January 1, 1992, and December 31, 2007, and had at least 3 consecutive prescriptions were followed through December 31, 2010. Adjusted subdistribution hazard ratios, accounting for competing risks of death, and matched odds ratios were used to estimate prostate cancer mortality associated with 5-ARI use (with or without concomitant ABs) as compared with AB use., Results: In the cohort study, 1,053 men died of prostate cancer (mean follow-up, 3 years), 15% among 5-ARI users (N= 25,388) and 85% among AB users (N=149,507) (unadjusted mortality rate ratio, 0.80). After accounting for competing risks, it was found that 5-ARI use was not associated with prostate cancer mortality when compared with AB use (adjusted subdistribution hazard ratio, 0.85; 95% CI, 0.72-1.01). Similar results were observed in the case-control study (adjusted matched odds ratio, 0.95; 95% CI, 0.78-1.17)., Conclusion: Among men being pharmaceutically treated for benign prostatic hyperplasia, 5-ARI use was not associated with an increased risk of prostate cancer-specific mortality when compared with AB use. The increased prevalence of high-grade lesions at the time of diagnosis noted in our study and the chemoprevention trials may not result in increased prostate cancer mortality., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the risks associated with zoster vaccine when administered to patients taking immunosuppressant medications., Patients and Methods: Patients enrolled in 1 of 7 managed care organizations affiliated with the Vaccine Safety Datalink between January 1, 2006, and December 31, 2009, were eligible. The exposure of interest was zoster vaccination in patients with current or remote immunosuppressant drug use. The primary outcomes were disseminated varicella zoster virus (VZV) and herpes zoster in the 42 days after vaccination. Automated data were collected on immunosuppressant drugs and baseline medical conditions. A logistic regression model using inverse probability treatment weights was used to estimate the odds of developing VZV or herpes zoster., Results: A total of 14,554 individuals had an immunosuppressant medication dispensed around the time of vaccination, including 4826 with current use and 9728 with remote use. Most patients were taking low-dose corticosteroids. No cases of disseminated VZV were found in the current or remote users. The risk of herpes zoster was elevated in the 42 days after vaccination in current vs remote users (adjusted odds ratio, 2.99; 95% CI, 1.58-5.70)., Conclusion: We found that patients taking immunosuppressant medications at the time of vaccination had a modest increased risk of herpes zoster in the 42 days after vaccination. The development of herpes zoster within 42 days after vaccination suggests that this is more likely due to reactivation of latent zoster virus than dissemination of the vaccine-derived varicella virus. These findings support the current zoster vaccination guidelines., (Copyright © 2015 Mayo Foundation for Medical Education and Research. All rights reserved.)

Objective: To describe incidence rates (IRs) of polymerase chain reaction (PCR)-diagnosed Clostridium difficile infection (CDI) in a large high-risk cohort., Patients and Methods: Members of Kaiser Permanente Southern California 1 year or older who were admitted to any of 14 Kaiser Permanente hospitals from January 1, 2011, through December 31, 2012, were included in the study. The CDI cases were identified by PCR in the inpatient and outpatient settings. The CDI IRs per 10,000 inpatient-days are estimated by year, surveillance category, age, sex, race/ethnicity, and Charlson comorbidity index. Recurrence rates are presented by age, sex, and race/ethnicity. Death and colectomy in the 30 days after CDI diagnosis, white blood cell count, and serum creatinine level are assessed., Results: Among 268,655 patients, 4286 (1.6%) had CDI. Among these patients, 671 (15.7%) had recurrent infections. The IR was highest among community-onset, health care facility-associated infections (11.1 per 10,000 inpatient-days). The CDI IRs differed by age, sex, and race/ethnicity. Overall, 528 patients (12.3%) died within 30 days of a positive CDI test result. The CDI IRs increased 34% with implementation of PCR testing., Conclusion: Increasingly, PCR is being used because of its higher diagnostic sensitivity. Reassessing the epidemic using PCR updates our understanding of CDI risk. Our capacity to identify patients presenting in the outpatient setting after discharge provides a more accurate picture of health care-associated CDI rates, particularly because the community appears to assume an increasing role in CDI onset and possibly transmission. The CDI burden differs by race, comorbidity, sex, and previous health care use. The detected increase in CDI incidence after transitioning to PCR diagnosis was modest compared with previous studies., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the prevalence of and characterize resistant hypertension in a large representative population with successful hypertension management and reliable health information., Patient and Methods: We performed a cross-sectional study using clinical encounter, laboratory, and administrative information from the Kaiser Permanente Southern California health system between January 1, 2006, and December 31, 2007. From individuals older than 17 years with hypertension, resistant hypertension was identified and prevalence was determined. Multivariable logistic regression was used to calculate odds ratios (ORs), with adjustments for demographic characteristics, clinical variables, and medication use., Results: Of 470,386 hypertensive individuals, 60,327 (12.8%) were identified as having resistant disease, representing 15.3% of those taking medications. Overall, 37,061 patients (7.9%) had uncontrolled hypertension while taking 3 or more medicines. The ORs (95% CIs) for resistant hypertension were greater for black race (1.68 [1.62-1.75]), older age (1.11 [1.10-1.11] for every 5-year increase), male sex (1.06 [1.03-1.10]), and obesity (1.46 [1.42-1.51]). Medication adherence rates were higher in those with resistant hypertension (93% vs 89.8%; P<.001). Chronic kidney disease (OR, 1.84; 95% CI, 1.78-1.90), diabetes mellitus (OR, 1.58; 95% CI, 1.53-1.63), and cardiovascular disease (OR, 1.34; 95% CI, 1.30-1.39) were also associated with higher risk of resistant hypertension., Conclusion: In a more standardized hypertension treatment environment, we observed a rate of resistant hypertension comparable with that of previous studies using more fragmented data sources. Past observations have been limited due to nonrepresentative populations, reliability of the data, heterogeneity of the treatment environments, and less than ideal control rates. This cohort, which was established using an electronic medical record-based approach, has the potential to provide a better understanding of resistant hypertension and outcomes., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To identify patients who could safely avoid unnecessary radiation and instrumentation after the detection of microscopic hematuria., Patients and Methods: We conducted a prospective cohort study of patients who were referred to urologists and underwent a full evaluation for asymptomatic microscopic hematuria during a 2-year period in an integrated care organization in 3 regions along the West Coast of the United States. A test cohort and validation cohort of patients with hematuria evaluations between January 9, 2009, and August 15, 2011, were identified. Patients were followed passively through their electronic health records for a diagnosis of urothelial or renal cancer. The degree of microscopic hematuria, history of gross hematuria, smoking history, age, race, imaging findings, and cystoscopy findings were evaluated as risk factors for malignant tumors., Results: The test cohort consisted of 2630 patients, of whom 55 (2.1%) had a neoplasm detected and 50 (1.9%) had a pathologically confirmed urinary tract cancer. Age of 50 years or older and a recent diagnosis of gross hematuria were the strongest predictors of cancer. Male sex was also predictive of cancer, whereas smoking history and 25 or more red blood cells per high-power field on a recent urinalysis were not statistically significant. A Hematuria Risk Index developed from these factors had an area under the receiver operating characteristic curve of 0.809. In the validation cohort of 1784 patients, the Hematuria Risk Index performed comparably (area under the curve = 0.829). Overall, 32% of the population was identified as low risk and 0.2% had a cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer found., Conclusion: These results suggest that a considerable proportion of patients could avoid extensive evaluations with the use of the Hematuria Risk Index., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the distribution of longitudinal changes in serum prostate-specific antigen (PSA) levels from a population-based sample of men., Patients and Methods: In this prospective cohort study, a random sample of Olmsted County, Minnesota, men aged 40 to 79 years in 1990 were followed up biennially from January 1, 1990, through August 29, 2007. Serum PSA levels were determined at each examination, and men were censored for follow-up with a diagnosis of prostate cancer or treatment for benign prostatic hyperplasia. The empirical distributions of annual percent change and annual absolute change in serum PSA level were calculated and tabulated, including the median and 75th and 95th percentiles., Results: For men with PSA measurements 2 years apart, the median annual percent change in serum PSA level was 4.83% and the 95th percentile was about 49.76%. The variability in estimated annual change decreased with increasing time between assessments, with a 95th percentile of 21.82% after 8 or more years between assessments. Although the median absolute change per year increased with increasing age, the median percent change per year was fairly consistent across age groups., Conclusion: These data demonstrate that, with shorter intervals between assessments, greater variability should be expected. These distributions should prove helpful to patients and clinicians in interpreting changes in serum PSA levels observed in typical clinical practices., (Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the rate and correlates of completion of the quadrivalent human papillomavirus vaccine (HPV4) 3-dose regimen because nonadherence to the regimen may adversely affect vaccine efficacy., Participants and Methods: Female members of Kaiser Permanente Southern California who were 9 to 26 years old, received the first dose of HPV4 between October 2006 and March 2007, and maintained health plan membership 12 months afterward were identified and followed up for regimen completion. We examined the following: (1) demographics/socioeconomic status, (2) primary care physician characteristics, (3) historical health service utilization, (4) women's health-related conditions, and (5) selected immune-related conditions for their association with completion in 2 age groups: 9 to 17 years and 18 to 26 years. Multivariable log-binomial regression was used to directly estimate relative risk (RR)., Results: Of the 34,193 females who initiated HPV4, the completion rate was 41.9% in the 9- to 17-year-old group and 47.1% in the 18- to 26-year-old group. Black race (RR, 0.70; 95% confidence interval [CI], 0.64-0.77) and lower neighborhood education level were associated with lower regimen completion. However, those in the 9- to 17-year-old group who were covered by the state-subsidized program Medi-Cal were more likely to complete the regimen (RR, 1.14; 95% CI, 1.07-1.22). Historical hospitalizations and emergency department visits (RR, 0.92; 95% CI, 0.87-0.96; and RR, 0.96; 95% CI, 0.94-0.98 per visit, respectively) and having a pediatrician were also predictors of noncompletion. A history of sexually transmitted diseases, abnormal Papanicolaou test results, and immune-related conditions (eg, asthma/infections) were not associated with regimen completion., Conclusion: These findings suggest that factors such as race or socioeconomic status should be considered when human papillomavirus vaccination programs are being designed and evaluated.

Objective: To assess the association between erectile dysfunction (ED) and the long-term risk of coronary artery disease (CAD) and the role of age as a modifier of this association., Participants and Methods: From January 1, 1996, to December 31, 2005, we biennially screened a random sample of 1402 community-dwelling men with regular sexual partners and without known CAD for the presence of ED. Incidence densities of CAD were calculated after age stratification and adjusted for potential confounders by time-dependent Cox proportional hazards models., Results: The prevalence of ED was 2% for men aged 40 to 49 years, 6% for men aged 50 to 59 years, 17% for men aged 60 to 69 years, and 39% for men aged 70 years or older. The CAD incidence densities per 1000 person-years for men without ED in each age group were 0.94 (40-49 years), 5.09 (50-59 years), 10.72 (60-69 years), and 23.30 (> or =70 years). For men with ED, the incidence densities of CAD for each age group were 48.52 (40-49 years), 27.15 (50-59 years), 23.97 (60-69 years), and 29.63 (> or =70 years)., Conclusion: ED and CAD may be differing manifestations of a common underlying vascular pathology. When ED occurs in a younger man, it is associated with a marked increase in the risk of future cardiac events, whereas in older men, ED appears to be of little prognostic importance. Young men with ED may be ideal candidates for cardiovascular risk factor screening and medical intervention.

Objective: To measure the association between cardiac structure and function abnormalities and isolated metabolic syndrome (metabolic syndrome excluding established hypertension or diabetes mellitus)., Participants and Methods: We collected data prospectively on a population-based random sample of 2042 Olmsted County, Minnesota, residents aged 45 years or older who underwent echocardiography between January 1, 1997, and September 30, 2000. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Panel III criteria., Results: The prevalence of isolated metabolic syndrome was 21.7% (214/984) in men and 16.7% (177/1058) in women. Left ventricular (LV) mass index was greater (91.7 vs 87.9 g/m2; P=.04) and LV diastolic dysfunction more prevalent (28.2% [50/177] vs 14.9% [81/544]; P<.001) in women with isolated metabolic syndrome than in women without metabolic syndrome; no difference was found in men. When patients with hypertension or diabetes mellitus were included in the cohort, there was a stepwise increase in LV mass index and LV diastolic dysfunction from no metabolic syndrome to isolated metabolic syndrome to metabolic syndrome in women and men., Conclusion: Isolated metabolic syndrome, which is associated with increased LV mass index and LV diastolic dysfunction in women, identifies women with evidence of early ventricular dysfunction.

Objective: To evaluate the association of neighborhood-level income and individual-level education with post-myocardial infarction (MI) mortality in community patients., Participants and Methods: From November 1, 2002, through May 31, 2006, 705 (mean+/-SD age, 69+/-15 years; 44% women) residents of Olmsted County, MN, who experienced an MI meeting standardized criteria were prospectively enrolled and followed up. The neighborhood's median household income was estimated by census tract data; education was self-reported. Demographic and clinical variables were obtained from the medical records., Results: Living in a less affluent neighborhood and having a low educational level were both associated with older age and more comorbidity. During follow-up (median, 13 months), 155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile) and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were independently associated with mortality risk. Adjustment for demographics and various post-MI prognostic indicators attenuated these estimates, yet excess risk persisted for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous variable, each $10,000 increase in annual income was associated with a 10% reduction in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99)., Conclusion: In this geographically defined cohort of patients with MI, low individual education and poor neighborhood income were associated with a worse clinical presentation. Poor neighborhood income was a powerful predictor of mortality even after controlling for a variety of potential confounding factors. These data confirm the socioeconomic disparities in health after MI.

Objective: To compare the characteristics and survival of participants and nonparticipants in a community-based study of myocardial infarction (MI)., Participants and Methods: Residents of Olmsted County, MN, who presented with elevated cardiac troponin T levels from September 1, 2002, through December 31, 2005, were prospectively enrolled and classified with standardized criteria for MI. With specific Institutional Review Board approval, the medical records of patients with MI who did not provide consent but who had given general research authorization were reviewed, as was done for their consenting peers., Results: During the study period, 2277 individuals with elevated cardiac troponin T levels were approached, of whom 1863 (82 percent) consented to participate. Among the 414 nonparticipants, 375 (91 percent) had general research authorization. Of the 558 with general research authorization who met the criteria for incident (ie, first-ever) MI, 67 (12 percent) refused to participate. These participants tended to be older (mean plus or minus SD age, 71 plus or minus 14 vs 67 plus or minus 15 years; P equals .04), were more likely to be of races other than white (9 percent vs 2 percent; P equals .01), and had more comorbidities, including peripheral vascular disease (P equals .02), chronic pulmonary disease (P equals .06), heart failure (P equals .07), and impaired creatinine clearance (P equals .02). No significant differences were detected in cardiovascular risk factors or MI characteristics. During a median follow-up of 517 days, nonparticipants experienced increased mortality rates compared with participants (hazard ratio, 1.97; 95 percent confidence interval, 1.21 to 3.20), which was largely attributable to their older age and excess comorbidities (adjusted hazard ratio, 1.43; 95 percent confidence interval, 0.86 to 2.35)., Conclusion: In this community-based study of MI, nonparticipants experienced worse survival rates than participants largely because of differences in demographic and clinical characteristics. These differences should be kept in mind when interpreting study results, particularly if participation is low.

Objective: To compare estimated glomerular filtration rate (GFR) in the general population on the basis of equations derived from different subsets of the general population., Participants and Methods: Adults (ages &#95;45 years) were randomly selected from 1997 to 2000 from the Olmsted County, Minnesota, population and had their serum creatinine levels measured. The GFR was estimated using previously reported equations derived from a sample of patients with chronic kidney disease (CKD), a sample of healthy persons, and the combined samples. Serum creatinine was measured with the same assay used to derive these equations., Results: Of 4203 subjects, 2042 (47% participation rate) were enrolled and studied. Serum samples from 1982 subjects were used to measure creatinine levels. The prevalence of a reduced estimated GFR (<60 mL/min per 1.73 m2) was 12% (95% confidence interval [CI], 10%-13%) based on an equation derived with all CKD patients, and this finding was similar to prior reports. However, the prevalence of a reduced estimated GFR was 5.7% (95% CI, 4.8%-6.8%) based on an equation derived with both CKD patients and healthy persons and 0.2% (95% CI, 0.1%-0.5%) based on an equation derived with all healthy persons. Women had a higher risk of reduced estimated GFR according to an equation derived with all CKD patients, but men had a higher risk with an equation derived with both CKD patients and healthy persons.

Objective: To define the population-based 3-year period prevalence of repeated group A beta-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.

Objective: To examine the use of tests that measure ejection fraction (EF) and the use of coronary angiography among patients with an initial diagnosis of heart failure (HF)., Patients and Methods: All potential cases of incident HF in Olmsted County, Minnesota, between 1979 and 1999 were identifled. In a random sample of cases validated with the Framingham criteria, we examined the frequency of tests that measure EF (echocardiography, radionuclide ventriculography, and left ventricular angiography) and coronary angiography within 90 days after diagnosis., Results: A total of 655 patients with incident HF were included in the analysis. The use of tests that measure EF and coronary angiography increased early in the study period but stabilized thereafter. In the most recent years (1995-1999), EF was measured in 65% of the patients and coronary angiography performed in 12%. After adjustment for year of diagnosis, body mass index, hypertension, diabetes mellitus, smoking, hyperlipidemia, comorbidity, prior myocardial infarction, and prior angina, men were more likely than women to have EF measured (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.01-2.16) and coronary angiography (OR, 2.61; 95% CI, 1.43-4.76). Increasing age was associated with less use of tests (OR, 0.83; 95% CI, 0.76-0.91; for EF measurement; OR, 0.72; 95% CI, 0.63-0.82; for coronary angiography for every 5-year increase in age)., Conclusion: Among patients with HF, tests that measure EF are used substantially less than recommended, and coronary angiograms are used infrequently. Use was particularly low in women and elderly patients. Given the potential benefits of such tests, including more appropriate therapy and more objective monitoring of ventricular function, outcomes in persons with HF may be improved with more consistent use.

Objectives: To quantify potential biases that may occur when placebo arms of clinical trials are used to characterize the natural history of disease and to compare incidence rates of benign prostatic hyperplasia (BPH) outcomes in community-dwelling men with outcomes in the placebo arm of a clinical trial of BPH., Subjects and Methods: White men aged 50 years or older at baseline were selected randomly from the Olmsted County, Minnesota, community in 1990 and were monitored biennially through 1996 for urologic outcomes. Symptom progression, acute urinary retention, and minimally Invasive or surgical treatment of BPH were assessed from a validated questionnaire and a review of community medical records. Findings from the Olmsted County Study (N=1193) and a selected subcohort (n=238) were compared with those from the placebo arm of the Medical Therapy of Prostatic Symptoms trial (N=737)., Results: During more than 5088 person-years of follow-up (mean, 4.9 years) In the Olmsted County Study, Incidence rates per 1000 person-years were 8.5 (95% confidence Interval [CI], 6.4-11.2) for acute urinary retention, 97.1 (95% CI, 88.7-106.0) for symptom progression, 6.6 (95% CI, 4.8-9.0) for surgery or minimally invasive treatment, and 105.1 (95% CI, 96.4-114.4) for any outcomes for all men. For those meeting trial Inclusion criteria (selected subcohort, n=238), Incidence rates were 18.3, 86.5, 16.8, and 109.4, respectively. By comparison, Incidence rates per 1000 person-years for the placebo arm of the Medical Therapy of Prostatic Symptoms clinical trial for BPH (mean follow-up, 4.5 years) were 6 for acute urinary retention, 36 for symptom progression, and 45 for any outcome, but the estimate of 13 for surgery or minimally invasive treatment was higher than for men in the Olmsted County Study., Conclusions: Compared with community-dwelling men, men in the placebo arm of this clinical trial of BPH treatments had a substantially lower risk of BPH-related outcomes. Extrapolation of findings from the placebo arm of clinical trials to describe the natural history of disease in community-dwelling men should be done with caution and appropriate recognition of limitations.

Objective: To determine how well patient-reported cardiovascular disease (CVD) and CVD risk factor information agrees with medical record information., Methods: Information from Patient/Family History (PFH) questionnaires completed between 1996 and 1999 by residents of Olmsted County, Minnesota, aged 20 years and older was compared with information available through the Mayo Clinic medical diagnostic index. Positive and negative agreement values were calculated by comparing agreement between the 2 data sources. Also, with the Mayo Medical Index serving as the criterion standard, sensitivity, specificity, and positive and negative predictive values of questionnaire information were calculated overall and by subgroups of sex, age, and years of education., Results: Questionnaire responses were retrieved for 26,162 patients. Positive agreement values ranged from 31% for report of a medical problem or surgery related to arteries to the head, arms, or legs or the aorta to 78% for high blood pressure. Negative agreement values ranged from 90% for high cholesterol to 98% for medical problem or surgery related to arteries to the head, arms, or legs or the aorta. Sensitivity of questionnaire information ranged from 37% to 73%, whereas positive predictive values ranged from 27% to 86%. Positive agreement, sensitivity, and positive predictive values tended to increase with increasing age of the patient. Specificity and negative predictive values were 87% or greater, and negative agreement, specificity, and negative predictive values decreased with increasing age., Conclusion: Positive patient reports of CVD conditions and risk factors are relatively inaccurate. However, negative self-reports of these conditions are unlikely to be noted in the medical record. Further development of the PFH questionnaire is necessary to ensure accurate patient reporting of CVD data.

Objectives: To Identify risk factors for attention-deficit/hyperactivity disorder (ADHD) and to determine whether these factors differ between boys and girls., Subjects and Methods: We conducted a case-control study of all children born between January 1, 1976, and December 31, 1982, in Olmsted County, Minnesota (N=5701), and examined birth certificates for risk factors for ADHD. Using school and medical records, we identified 305 children with ADHD. All children not identified with ADHD served as controls (N=5326). Risk factors that were assessed included demographic characteristics of both children and parents, as well as pregnancy, labor, and delivery characteristics, including the effect of a multiple birth and presence of pregnancy and delivery complications., Results: Pregnancy and labor characteristics, low birth weight, and presence of a twin birth were not associated with ADHD. Male sex (odds ratio [OR], 3.05; 95% confidence interval [CI], 2.34-3.98) was associated with an increased risk for ADHD, whereas high maternal and paternal education levels (high maternal education: OR, 0.57; 95% CI, 0.42-0.78; high paternal education: OR, 0.58; 95% CI, 0.49-0.78) were associated with a decreased risk for ADHD. In addition, low maternal and paternal education levels increased the risk for ADHD in boys more than in girls., Conclusion: Male sex and low parental education levels are significant risk factors for ADHD. In addition, boys born to parents with low maternal and paternal education levels appear to be at an increased risk for ADHD compared with girls born to parents with low education levels.

Objectives: To examine secular trends in the use of evidence-based therapies in a geographically defined cohort of patients with myocardial infarction (MI) and to test the hypotheses that baseline use is increasing and that disparities in use are diminishing,, Patients and Methods: All consecutively hospitalized patients who were dismissed from Olmsted County, Minnesota, hospitals between 1979 and 1998 with a diagnosis of MI were identified using standardized criteria (biomarkers, cardiac pain, and electrocardiography). The entire community medical record, available via the Rochester Epidemiology Project, was reviewed to ascertain baseline characteristics including comorbidity, presence of ST-segment elevation on electrocardiography, and treatment. Logistic regression models were used to examine the association of treatment with age and sex, independent of other baseline characteristics., Results: Between 1979 and 1998, 2317 incident MIs (patient mean +/- SD age, 67+/-14 years; 43% women; 57% aged > or = 65 years) occurred in Olmsted County. The use of all evidence-based therapies increased over time, primarily reflecting the introduction of these medications at the time of Index MI. Between 1989 and 1998, age was not independently associated with use of aspirin or ACE inhibitors. Disparities in use persisted for reperfusion therapy and beta-blockers. Reperfusion therapy or revascularization was used less frequently in older persons, particularly in elderly women (P<.001). Use of beta-blockers decreased 16% among persons aged 65 years or older, independent of measurable differences in baseline characteristics and MI severity (hazard ratio, 0.84; 95% confidence interval, 0.74-0.93)., Conclusions: The use of all evidence-based therapies for MI increased markedly over time; however, residual gaps in use were noted. Reperfusion therapy or revascularization is used less frequently in women and elderly persons, and beta-blockers are used less frequently in elderly persons. These differences are not explained by measurable differences in baseline characteristics. Women and elderly persons represent an increasing proportion of patients with MIs in the community; therefore, these findings define therapeutic opportunities.

Objectives: To evaluate the cross-sectional association between lower urinary tract symptoms (LUTS) severity and sexual function in a population-based sample of men and the extent to which this association might be explained by age., Subjects and Methods: Subjects in The Olmsted County Study of Urinary Symptoms and Health Status Among Men (55% participation rate) included 2115 white men aged 40 to 79 years; subjects were recruited on January 1, 1990, from a random sample identified through the Rochester Epidemiology Project. At baseline in 1990 and biennially thereafter, these men completed a self-administered questionnaire that assessed LUTS severity with questions similar to those of the American Urological Association Symptom Index. At the 6-year follow-up, 11 previously validated questions about male sexual function from the Brief Sexual Function Inventory were added., Results: Overall, each of the sexual function domains (sexual drive, erectile function, ejaculatory function, problem assessment, and overall sexual satisfaction) was inversely associated with the severity of LUTS, with Spearman correlation coefficients ranging from -0.21 to -0.31 (all P<.001). In age-adjusted analyses, the ejaculatory function and problem assessment domains were most strongly associated with overall LUTS severity, whereas the association with sexual drive was substantially diminished. Little difference was noted in the magnitude of association between sexual function and either obstructive or irritative symptoms., Conclusions: The cross-sectional data suggest that sexual function is inversely associated with LUTS severity and that this association is only partially attributable to the confounding effects of age.

Objective: To examine sex differences in evaluation and outcome after stress testing for coronary artery disease (CAD) in a geographically defined cohort., Subjects and Methods: Subjects were residents of Olmsted County, Minnesota, who underwent an initial stress test between January 1, 1987, and December 31, 1990. End points included referral for coronary angiography, death, and cardiac events, defined as cardiac death, nonfatal myocardial infarction, or congestive heart failure., Results: A total of 2276 men and 1270 women under went stress tests. Women were older and had more risk factors and comorbidities (P < .05). Among persons without documented CAD (86% of the cohort), the median probability of CAD was 11% (interquartile range, 5%-25%) for men and 8% (interquartile range, 2%-31%) for women (P < .001). Within 6 months after stress testing, 9% of men and 7% of women underwent coronary angiography. Among persons without documented CAD, there was no sex difference in referral for angiography when the stress test result was negative. When the test result was positive, men were more likely to be referred for angiography (adjusted odds ratio [OR] for male sex, 2.02; 95% confidence interval [CI], 1.21-3.38; P = .008). After adjusting for the predicted probability of CAD, this association was no longer detected (adjusted OR for male sex, 0.67; 95% CI, 0.26-1.73; P = .41). Among persons with documented CAD, no sex difference was noted. After a mean +/- SD follow-up of 7.6 +/- 2.7 years and among persons without documented CAD, male sex was associated with a higher adjusted risk of death (relative risk for male sex, 1.40; 95% CI, 1.05-1.86; P = .02) and cardiac events (relative risk for male sex, 1.67; 95% CI, 1.24-2.26; P < .001). Among persons with documented CAD, no sex difference in outcome was noted., Conclusion: These population-based data indicate that, when the diagnosis of CAD was not established, there was a greater use of angiography among men with positive stress test results, which could be attributed to the increased probability of CAD in men. In the absence of documented CAD, men fared worse than women, with an increase in the risk of death and cardiac events. Among persons with documented CAD, no sex difference in use of angiography and outcome was noted.

Objective: To examine the effect of differing age-at-immunization policies on measles antibody levels in US children immunized at the age of 15 months compared with Canadian children immunized at the age of 12 months., Subjects and Methods: Healthy, volunteer US and Canadian children aged 6 to 11 years who had been immunized with a single dose of the measles vaccine were enrolled from 1991 to 1993. Measles antibody was measured with a whole-virus, measles-specific IgG enzyme-linked immunoassay. Age, race, sex, country of residence, general health status, age at time of measles immunization, and time from immunization to sampling were recorded., Results: Of the 1052 children enrolled in the study, US children (n=719) had a significantly higher measles seroprevalence (87%) compared with Canadian children (n=333) (76%; P<.001). After adjustment for time from immunization and age at immunization, the differences in seropositive rates were no longer significant (odds ratio [OR], 1.53; 95% confidence interval, 0.87-2.69; P=.15). We found a significant dose-response relationship between age at the time of immunization and the odds of being seropositive after immunization, with ORs varying from 1 with immunization at 13 months or younger to 2.30 with immunization at 16 months of age (P=.01)., Conclusions: The current US policy of immunizing with the first dose of measles at the age of 12 months may be less effective than a policy of immunizing at 12 to 15 months of age. These findings may be highly significant as we move toward an era in which measles exposure may be rare and policies are developed to eradicate measles.

Objective: To investigate the association between daily use of nonsteroidal anti-inflammatory drugs (NSAIDs) and prostate cancer., Patients and Methods: Subjects were 50- to 79-year-old white men randomly selected in January 1990 from the Olmsted County, Minnesota, community (n=1362) from among participants in a longitudinal study of lower urinary tract symptoms. At the beginning of the study, all medications that were used daily, including prescription and nonprescription NSAIDs, were ascertained by trained interviewers. Men who developed a histologically proved diagnosis of prostate cancer during a median of 66 months (maximum, 6 years) of follow-up were identified from a complete review of the community medical record., Results: Twenty-three (4%) of 569 NSAID users and 68 (9%) of 793 nonusers developed prostate cancer during follow-up (P=.001). The relative odds of prostate cancer were 0.45 (95% confidence interval [CI], 0.28-0.73) in NSAID users compared with nonusers. This inverse association with NSAID use increased with increasing age at study onset. Thus, the relative odds of prostate cancer among NSAID users were 0.9 (95% CI, 0.4-2.2) in men aged 50 to 59 years, 0.4 (95% CI, 0.2-0.8) in men aged 60 to 69 years, and 0.2 (95% CI, 0.1-0.5) in men aged 70 to 79 years compared with similarly aged men who did not use NSAIDs., Conclusion: The study findings suggest that daily use of NSAIDs may be associated with a lower incidence of prostate cancer in men aged 60 years or older. The stronger effect among older men suggests that NSAIDs may prevent the progression of prostate cancer from latent to clinical disease.

Objectives: To compare measles, mumps, and rubella antibody levels in Somali immigrant, Hispanic migrant, and US children in Rochester, Minn, and to determine whether parental vaccination reports predict seropositivity., Subjects and Methods: From 1995 to 1997, we conducted a cross-sectional analysis using measles, mumps, and rubella antibody levels obtained from a sample of Somali, Hispanic, and Rochester children. Volunteers provided blood samples, vaccination histories, and demographic information. We assessed differences in measles, mumps, and rubella antibody levels among the 3 groups of children and calculated positive and negative predictive values to determine whether parental report of vaccination predicted seropositivity., Results: Study participants included 79 Hispanic migrant, 69 Somali immigrant, and 730 Rochester children. Somali children reported vaccination at significantly older ages compared with Hispanic or Rochester children (P<.001). Most children were seropositive for all 3 antibodies. Parental reports of vaccination had high positive predictive values (71%-100%) but low negative predictive values (0%-50%)., Conclusion: Somali and Hispanic children were as likely as Rochester children to be seropositive for measles, mumps, and rubella antibodies despite poor documentation of vaccination. Somali children, however, tended to receive vaccinations at significantly older ages than Hispanic and Rochester children.

Objective: To report the incidence of reading disability among school-aged children., Subjects and Methods: In this population-based, retrospective birth cohort study, subjects included all 5718 children born between 1976 and 1982 who remained in Rochester, Minn, after the age of 5 years. Based on records from all public and nonpublic schools, medical facilities, and private tutorial services and on results of all individually administered IQ and achievement tests, extensive medical, educational, and socioeconomic information were abstracted. Reading disability was established with use of research criteria based on 4 formulas (2 regression-based discrepancy, 1 non-regression-based discrepancy, and 1 low achievement)., Results: Cumulative incidence rates of reading disability varied from 5.3% to 11.8% depending on the formula used. Boys were 2 to 3 times more likely to be affected than girls, regardless of the identification methods applied., Conclusions: In this population-based birth cohort, reading disability was common among school-aged children and significantly more frequent among boys than girls, regardless of definition.

Objective: To evaluate the validity of death certificate diagnosis of out-of-hospital (OOH) coronary heart disease (CHD) and sudden cardiac death (SCD) in Olmsted County, Minnesota, between 1981 and 1994., Methods: In this review of the medical records, autopsy reports, and coroner's files, OOH deaths with heart disease as the underlying cause of death on the death certificate were classified into CHD (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 410-414) and non-CHD (other ICD-9-CM heart disease codes) deaths. A 10% random sample (n = 174) of these death certificates was reviewed by physicians, and published validation criteria were applied to classify these deaths into validated CHD or non-CHD categories. Sudden cardiac death was defined as validated CHD that occurred at an OOH location with less than 24 hours between symptom onset and death., Results: The death certificate definition of OOH CHD death (ICD-9-CM codes 410-414) had high sensitivity and positive predictive value of 91% and 96%, respectively. The specificity and the negative predictive value were slightly lower at 86% and 72%, respectively. The sensitivity of death certificate diagnosis of CHD for validated SCD was 89%, and the positive predictive value was 77%. Using a more restrictive definition of SCD, that is, less than 1 hour between the onset of symptoms and death, the positive predictive value of CHD codes for SCD was lower at 52%., Conclusions: In Olmsted County, the positive predictive values of death certificate diagnosis for OOH CHD and SCD are high. Relying on death certificate diagnoses results in about 5% underestimation of the true CHD rates, whereas their use as a surrogate for SCD yields a 16% overestimation of the true SCD rates.

Background: Although age-adjusted heart disease mortality has declined since the 1960s, this decline may not have applied equally to all subgroups., Objective: To examine recent trends in heart disease mortality, specifically in women and in the elderly., Methods: Age- and sex-specific heart disease mortality (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 390-398, 402, 404-429) in Olmsted County, Minnesota, between 1979 and 1994 were studied., Results: The total number of heart disease deaths was 3095; 1578 (51%) occurred in women and 1984 (64%) in persons aged 75 years or older. Most heart disease deaths (77%) were coronary disease deaths (ICD-9-CM codes 410-414). Age-adjusted heart disease mortality rates declined from 123 per 100,000 (95% confidence interval [CI], 102-144/100,000) in 1979 to 81 per 100,000 (95% CI, 67-95/100,000) in 1994. Poisson regression analyses indicated that the trends differed according to sex and age. For women, the relative risk (RR) of heart disease death in 1994 compared with 1979 was 0.69 vs 0.53 for men (P = .06). This equates to a decline in heart disease mortality of 2.5% per year in women or 32% over the period and 4.2% per year in men or 47% over the period. The decline was less pronounced as age increased (P < .001). For 60-year-old women, the RR for 1994 compared with 1979 was 0.59, whereas for 80-year-old women, the RR for 1994 compared with 1979 was 0.76. For men, the RR for 1994 compared with 1979 was 0.60 for 80-year-old men vs 0.46 for 60-year-old men., Conclusions: Between 1979 and 1994, in Olmsted County, the decline in heart disease mortality was of lesser magnitude in women and in the elderly, emphasizing the importance of age- and sex-specific trends to characterize time patterns in heart disease deaths to target preventive measures.

Objective: To analyze the influence of recent changes in Minnesota statutes that generally require prior authorization for use of medical records for research from patients who received medical care after Jan. 1, 1997., Material and Methods: In this Mayo Clinic Institutional Review Board-approved study, we obtained a stratified random sample of patients encountered at Mayo Clinic Rochester during the period 1994 through 1996 and estimated the proportion willing to provide the general authorization. On the basis of data from administrative files, we then compared demographic, diagnostic, and utilization characteristics for patients who provided authorization and those who did not., Results: Overall, 3.2% (95% confidence interval, 2.4 to 4.0%) of the study subjects declined authorization. If patients not responding to requests for authorization were also considered to have refused, the overall refusal rate would be 20.7% (95% confidence interval, 18.5 to 22.9%). Women were somewhat more likely to refuse authorization than were men (4.0% versus 2.4%; P = 0.067), and patients younger than 60 years were more likely to refuse than were older patients (5.4% versus 1.2%; P<0.001). Patients residing more than 120 miles from Rochester were much less likely to decline authorization than were local residents (2.1% versus 5.8%; P = 0.001). Patients with prior diagnoses that might be considered more sensitive such as mental disorders, infectious diseases, and reproductive problems also were more likely to refuse authorization., Conclusion: These data demonstrate that laws requiring written authorization for research use of the medical record could result in substantial biases in etiologic and outcome studies, the direction and magnitude of which may vary from topic to topic. Clinicians should be prepared to enter the discussion to help inform patients and legislators of the potential hazards of laws that restrict access to medical records for research purposes.

Objective: To assess the potential bias, due to migration from the community, in a birth cohort study of learning disability in Olmsted County, Minnesota., Material and Methods: The 1976 through 1982 birth cohort consisted of 8,548 children born to mothers who were residents of Rochester, Minnesota, at the time of delivery. The current status of all children was determined for the 1995 to 1996 school year with the resources of Independent School District #535, the Rochester Epidemiology Project, and the Rochester Reading Center. Information from birth certificates was compared between migrants and nonmigrants with use of standard statistical tests., Results: The cumulative probability of migration by age 5 years was 32.2% (95% confidence interval, 31.2 to 33.2%). When migrants were compared with nonmigrants, the distributions of Apgar scores, father's age, gestational age at birth, and number of children in the family were virtually identical. In contrast, migrants were more likely to be nonwhite (6% versus 2%), be born to a single parent (11% versus 7%), and have a congenital defect noted at birth (1.5% versus 0.7%). When considered simultaneously in a logistic regression model, the parents of migrants were more highly educated, migrant mothers were younger and had fewer prenatal visits, and migrant children were more likely to be black., Conclusion: This report demonstrates the extreme effort that must be made to assemble a birth cohort in our mobile society. Furthermore, the results suggest that only slight differences exist between migrants and nonmigrants; these are unlikely to compromise the future results of the ongoing learning disability study.

Objective: To determine which factors are associated with duration of use of a levonorgestrel implant (Norplant) for contraception in adolescents and young adults., Design: We retrospectively studied 144 young women (14 to 21 years of age) who chose a levonorgestrel contraceptive implant at Mayo Clinic Rochester between April 1990 and December 1993., Material and Methods: The following information was obtained at the time of insertion of the implant and from any follow-up visits: demographics, prior contraceptive experiences, frequency and management of complications, complications noted at removal of the implant, and subsequent contraceptive choice. The duration of use was examined., Results: Of the 144 young women who underwent insertion of a Norplant system, 75 telephoned or made a medical appointment because of implant-related side effects. During the follow-up period, 64 patients had the Norplant system removed. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83 % and for at least 24 months was 63 %. Duration of Norplant use was not found to differ with respect to age, prior contraceptive use, or timing of insertion, but it was significantly shorter among those with a prior pregnancy than in those who had never been pregnant., Conclusion: These findings suggest that a group of young women who are likely to continue use of a contraceptive implant (with or without treatment for side effects) are those who have never been pregnant.

Objective: To compare the initial clinical manifestations and sequelae of epiglottitis among children and adult residents of Olmsted County, Minnesota., Material and Methods: We conducted a population-based retrospective cohort study of all Olmsted County residents with the diagnosis of epiglottitis during the 15-year period from Jan. 1, 1976, through Dec. 31, 1990., Results: From 1976 through 1990, 41 residents (20 children and 21 adults) of Olmsted County were diagnosed with epiglottitis. (One case in an adult was first diagnosed at autopsy and was included only in the incidence rates and analysis of seasonal and secular trends.) Children had a mean annual incidence rate of 4.25 per 100,000, whereas the rate in adults was 2.18 per 100,000. The age- and sex-adjusted incidence of epiglottitis decreased during the study period from 4.94 per 100,000 during 1976 through 1980 to 2.08 per 100,000 during 1986 through 1990. No seasonal effect was detected in adults or children. At initial assessment, adults tended to have pharyngeal symptoms (sore throat and odynophagia), cervical adenopathy, and ear pain, whereas children most often had respiratory (stridor, dyspnea, and retractions) and laryngeal symptoms. Proportionately, more children than adults received artificial airway support and had associated pneumonia. One death occurred in an adult, in whom the diagnosis was made at autopsy., Conclusion: The incidence of epiglottitis has decreased significantly in recent years. Children and adults have considerably different initial manifestations of epiglottitis.

Objective: To apply uniform diagnostic criteria for sudden infant death syndrome (SIDS) for an extended period for comparison of incidence rates from 1945 to 1992 in Olmsted County, Minnesota, to investigate the influence of a person-time or live birth denominator on the estimate of incidence, to calculate the proportionate mortality rate for SIDS over time, and to evaluate the accuracy of death certificates for case ascertainment and the role of interobserver variation in case classification., Design: We retrospectively reviewed the autopsy results and complete medical records for all infant death from 1945 through 1992 for residents of Olmsted County, Minnesota., Material and Methods: Cases were identified from a computerized list of all Olmsted County deaths of infants occurring at ages 48 hours to 365 days. All resident cases were categorized as non-SIDS, possible SIDS, SIDS, or incomplete, on the basis of findings from autopsy and clinical history. Incidence rates were calculated for two different SIDS groups and with use of denominators of person-time and live births., Results: For the study period, 82 cases of SIDS were identified (97% white and 3% Asian). The mean age at death was 12.5 weeks; male infants constituted 59% of cases. No significant trend in seasonal distribution was noted; 73% of deaths occurred between midnight and noon. The incidence rate, defined as SIDS definite and possible deaths per 1,000 resident live births, increased from 0.55 in 1950 through 1953 to 1.28 in 1990 through 1992. The secular trend was best described by a linear model with constant positive slope. Similar trends were observed with other definitions of incidence. During the study period, SIDS as a percentage of total infant deaths dramatically increased, ranging from 2.5 in 1950 through 1953 to 17.9 in 1990 through 1992. The death certificate diagnosis correctly predicted 72% of SIDS cases before 1970 and 100% of cases after 1970., Conclusion: Since 1945, the incidence of SIDS apparently has increased, although diagnostic transfer from other causes of death probably contributes to the observed trend. The comparison of live births versus person-time as denominators showed no significant difference in incidence rates. Interobserver reliability is modest for SIDS cases diagnosed before 1970 and may contribute to the variability in reported SIDS incidence rates.

Although congestive heart failure is a fairly common clinical syndrome and the societal costs associated with its care are high, relatively little is known about the incidence or prevalence of the condition in the community. Using the resources of the Rochester Epidemiology Project, we identified all 46 persons 0 through 74 years of age who had a new diagnosis of congestive heart failure during 1981 and all 113 persons with a prevalent diagnosis on Jan. 1, 1982, in the city of Rochester, Minnesota. After confirming the diagnosis in the medical record by using criteria similar to those in the Framingham study, we found the annual incidence of congestive heart failure to be 110 per 100,000 after adjusting for age. Incidence rates were higher among male than among female study subjects (157 versus 71 per 100,000). In both male and female subjects, the incidence generally increased with advancing age, reaching 1,618 per 100,000 and 981 per 100,000, respectively. Prevalence rates on Jan. 1, 1982, demonstrated similar patterns. Overall, the prevalence of congestive heart failure was higher among male than among female subjects (327 versus 214 per 100,000) and increased exponentially with advancing age, reaching almost 3% in both sexes. Survival after a diagnosis of congestive heart failure was extremely poor, with only 80% alive at 3 months and 66% at 1 year. These data underscore the effect of congestive heart failure in the community and provide estimates of the number of persons who might benefit from early intervention.