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We recently expanded the viral genomic surveillance program in Minnesota, USA, to include human respiratory syncytial virus. We performed whole-genome sequencing of 575 specimens collected at Minnesota healthcare facilities during July 2023-February 2024. Subgroups A and B differed in their genomic landscapes, and we identified 23 clusters of genetically identical genomes.

Aims and Methods: In the United States, blacklegged Ixodes spp. ticks are the primary vector of Lyme disease. Minnesota is among the states with the highest reported incidence of Lyme disease, having an average of 1857 cases reported annually during 2011-2019. In contrast to the Northeast and mid-Atlantic United States where exposure to ticks predominately occurs around the home, the circumstances regarding risk for exposure to blacklegged ticks in Minnesota are not well understood, and risk is thought to be highest in rural areas where people often participate in recreational activities (e.g. hiking, visiting cabins). We analysed enhanced surveillance data collected by the Minnesota Department of Health during 2011-2019 to describe epidemiologic and tick exposure characteristics among people with reported Lyme disease., Results: We found that younger age, male gender, residence in a county with lower Lyme disease risk, residence in the Minneapolis-St. Paul metropolitan area, and an illness onset date later in the year were independently associated with higher odds of reporting tick exposures away from the home. We also describe the range of activities associated with tick exposure away from the home, including both recreational and occupational activities., Conclusions: These findings refine our understanding of Lyme disease risk in Minnesota and highlight the need for heterogeneous public health prevention messaging, including an increased focus on peridomestic prevention measures among older individuals living in high-risk rural areas and recreational and occupational prevention measures among younger individuals living in the Minneapolis-St. Paul metropolitan area., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

The COVID-19 pandemic has claimed over one million lives in the United States and has drastically changed how patients interact with the healthcare system. Emergency medical services (EMS) are essential for emergency response, disaster preparedness, and responding to everyday emergencies. We therefore examined differences in EMS utilization and call severity in 2020 compared to trends from 2015-2019 in a large, multi-state advanced life support EMS agency serving the U.S. Upper Midwest. Specifically, we analyzed all emergency calls made to Mayo Clinic Ambulance, the sole advanced life support EMS provider serving a large area in Minnesota and Wisconsin, and compared the number of emergency calls made in 2020 to the number of calls expected based on trends from 2015-2019. We similarly compared caller demographics, call severity, and proportions of calls made for overdose/intoxication, behavioral health, and motor vehicle accidents. Subgroup analyses were performed for rural vs. urban areas. We identified 262,232 emergent EMS calls during 2015-2019 and 53,909 calls in 2020, corresponding to a decrease of 28.7% in call volume during 2020. Caller demographics shifted slightly towards older patients (mean age 59.7 [SD, 23.0] vs. 59.1 [SD, 23.7] years; p<0.001) and to rural areas (20.4% vs. 20.0%; p = 0.007). Call severity increased, with 95.3% of calls requiring transport (vs. 93.8%; p<0.001) and 1.9% resulting in death (vs. 1.6%; p<0.001). The proportion of calls for overdose/intoxication increased from 4.8% to 5.5% (p<0.001), while the proportion of calls for motor vehicle collisions decreased from 3.9% to 3.0% (p<0.001). All changes were more pronounced in urban areas. These findings underscore the extent to which the COVID-19 pandemic impacted healthcare utilization, particularly in urban areas, and suggest that patients may have delayed calling EMS with potential implications on disease severity and risk of death., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Shalom et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Cancer screening trials have required large sample sizes and long time-horizons to demonstrate cancer mortality reductions, the primary goal of cancer screening. We examine assumptions and potential power gains from exploiting information from testing control-arm specimens, which we call the "intended effect" (IE) analysis that we explain in detail herein. The IE analysis is particularly suited to tests that can be conducted on stored specimens in the control arm, such as stored blood for multicancer detection (MCD) tests., Methods: We simulated hypothetical MCD screening trials to compare power and sample size for the standard vs IE analysis. Under two assumptions that we detail herein, we projected the IE analysis for 3 existing screening trials (National Lung Screening Trial [NLST], Minnesota Colon Cancer Control Study [MINN-FOBT-A], and Prostate, Lung, Colorectal, Ovarian Cancer Screening Trial-colorectal component [PLCO-CRC])., Results: Compared with the standard analysis for the 3 existing trials, the IE design could have reduced cancer-specific mortality P values 6-fold (NLST), 33-fold (MINN-FOBT-A), or 260 000-fold (PLCO-CRC) or, alternately, reduced sample size (90% power) by 25% (NLST), 47% (MINN-FOBT-A), or 63% (PLCO-CRC). For potential MCD trial designs requiring 100 000 subjects per arm to achieve 90% power for multicancer mortality for the standard analysis, the IE analysis achieves 90% power for only 37 500-50 000 per arm, depending on assumptions concerning control-arm test-positives., Conclusions: Testing stored specimens in the control arm of screening trials to conduct the IE analysis could substantially increase power to reduce sample size or accelerate trials and could provide particularly strong power gains for MCD tests., (Published by Oxford University Press 2024.)

Background: Differences in the MS course between White and Black populations is well accepted. The existence of a large Somali immigrant population in Minnesota facilitates a study of MS characteristics in this immigrant native African population. The objective of this study was to compare Somali American (SA), African American (AA), and White American (WA) persons with MS (pwMS) regarding clinical features and disease modifying therapy (DMT) use., Methods: This single center (Mayo Clinic) geographically-restricted retrospective cohort study (residing within 250 miles of Rochester, MN, USA) included participants seen before May 2023. Age at immigration to the USA; age at MS onset; DMT use/type; MS phase/phenotype; age at progressive MS (PMS) onset; and proportion with severe MS (expanded disability status scale-EDSS ≥6) were examined., Results: 18 SApwMS, 92 AApwMS, and 94 WApwMS were included. Of the 15 SApwMS not born in USA, 3/15 immigrated pre-puberty, 3/15 peri‑puberty, 8/15 post-puberty, and 1/15 at an unknown date. SApwMS were younger at MS onset (median years, interquartile range (IQR)=25, 22-33 vs. AApwMS: 31, 25-38; p = 0.049 vs. WApwMS: 35, 27-41; p = 0.022). DMT use frequencies were 13/19 SApwMS, 69/92 AApwMS, 80/94 WApwMS (p > 0.05). SApwMS were treated with DMT earlier than AApwMS (HR 2.16, p = 0.012) and WApwMS (HR 1.86, p = 0.041). SApwMS were less commonly treated with natalizumab (SApwMS 0 %, AApwMS 13 %, WApwMS 25 %; p = 0.035) and anti-CD20 therapies (SApwMS 23 %, AApwMS 23 %, WApwMS 48 %; p = 0.005). PMS occurred in 3/19 SApwMS, 28/92 AApwMS and 29/94 WApwMS (p > 0.05). Age of PMS onset in SApwMS (47 years, 34-57) was similar to WApwMS (47 years, 31-71; p > 0.05) but older than AApwMS (41 years, 18-7; p = 0.008)., Conclusions: SApwMS that recently immigrated to the USA have similar disease course to WApwMS, and better than AApwMS from the same geographical region., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: To quantify infant mortality rates (IMR) using expanded racial categories, and to examine associations between infant formula exposure, housing instability and postneonatal mortality among Minnesota WIC Participants., Methods: Births in Minnesota from 2014 through 2019 (n = 404,102) and associated infant death records (n = 2034) were used to calculate neonatal and postneonatal rates using expanded racial categories. Those births that participated in the WIC program (n = 170,011) and their linked death records (n = 853) were analyzed using logistic regression to examine associations between formula exposure, housing instability, and postneonatal death., Results: Postneonatal IMR was more than twice as prevalent among Black (African American) as East African immigrant infants (IMR = 3.9 vs 1.5). After adjustment for confounding (term status and nativity of mother (U.S. vs foreign born), infants exposed to formula by 28 days were four times as likely to die in the postneonatal period as those without formula exposure (aOR = 4.0; 95% CI 3.2-4.9). WIC participants who experienced housing instability at birth were 1.7 times as likely to lose an infant in the postneonatal period (28 to 364 days of age) as those in stable housing (aOR = 1.7; 95% CI 1.2, 2.4)., Conclusions for Practice: Disaggregating Black mortality rates revealed inequities in infant mortality among Black families of varied backgrounds. Formula exposure and housing instability are modifiable risk factors associated with postneonatal mortality. Appropriate interventions to reduce barriers to breastfeeding and provide housing stability for vulnerable families could reduce disparities in postneonatal mortality., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Previous research has identified food insecurity as a risk factor for obesity but those studies employed cross-sectional designs and were largely focused on adults and young children. In addition, there is a paucity of studies examining the association between food insecurity and changes in children's overall diet quality. This study aimed to assess whether food insecurity is associated with subsequent changes in diet quality and BMI z-scores over 2 years among 7- to 12-year-old children. Methods: We used 2011-2019 secondary data ( n  = 404) from three randomized controlled trials in Minnesota. Food insecurity was identified using the U.S. Household Food Security Survey Module at baseline (Time 0). Diet quality was determined using the Healthy Eating Index (HEI)-2015 from 24-hour recalls, and BMI z-scores were calculated using measured height and weight. These two outcomes were measured at Time 0, Time 1 (10-12 months from Time 0), and Time 2 (15-24 months from Time 0). Results: Compared with children from food-secure households, those from food-insecure households experienced a 0.13 greater increase in BMI z-scores from Time 0 to Time 2 [95% confidence interval (CI): 0.04 to 0.21] and a 4.5 point increase in HEI-2015 from Time 0 to Time 1 (95% CI: 0.99 to 8.01). Conclusion: Household food insecurity may widen weight disparities among elementary school-aged children. Further studies are needed to identify the role of diet quality in weight changes among children with food insecurity. Clinical Trial Registration Number: NCT01538615, NCT02029976, NCT02973815.

Objective: Rheumatoid arthritis (RA) has been associated with an elevated dementia risk. This study aimed to examine how different diagnostic dementia definitions perform in patients with RA compared to individuals without RA., Methods: The study population included 2050 individuals (1025 with RA) from a retrospective, population-based cohort in southern Minnesota and compared the performance of 3 code-based dementia diagnostic algorithms with medical record review diagnosis of dementia. For the overall comparison, each patient's complete medical history was used, with no time frames. Sensitivity analyses were performed using 1-, 2-, and 5-year windows around the date that dementia was identified in the medical record (reference standard)., Results: Algorithms performed very similarly in persons with and without RA. The algorithms generally had high specificity, negative predictive values, and accuracy, regardless of the time window studied (> 88%). Sensitivity and positive predictive values varied depending on the algorithm and the time window. Sensitivity values ranged 56.5-95.9%, and positive predictive values ranged 55.2-83.1%. Performance measures declined with more restrictive time windows., Conclusion: Routinely collected electronic health record (EHR) data were used to define code-based dementia diagnostic algorithms with good performance (vs diagnosis by medical record review). These results can inform future studies that use retrospective databases, especially in the same or a similar EHR infrastructure, to identify dementia in individuals with RA., (Copyright © 2024 by the Journal of Rheumatology.)

Objectives: Continuous, therapeutic anticoagulation is the standard of care for patients on extracorporeal membrane oxygenation (ECMO). The risks of hemorrhage exacerbated by anticoagulation must be weighed with the thrombotic risks associated with ECMO. We hypothesized increased thrombotic events in patients who had interrupted (vs. continuous) anticoagulation during venovenous ECMO., Design: This is a retrospective, observational study., Setting: Enrollment of individuals took place at three adult ECMO centers in Minnesota from 2013 to 2022., Patients: This study consists of 346 patients supported with venovenous ECMO., Interventions: Anticoagulation administration was collected from electronic health records, including frequency and duration of anticoagulation interruptions (IAs) and timing and type of thrombotic events, and data were analyzed using descriptive statistics., Measurements and Main Results: A total of 156 patients had IA during their ECMO run and 190 had continuous anticoagulation. Risk adjusted logistic regression demonstrated that individuals in the IA group were not statistically more likely to experience a thrombotic complication (odds ratio [OR], 0.69; 95% CI, 0.27-1.70) or require ECMO circuit change (OR, 1.36; 95% CI, 0.52-3.49). Subgroup analysis demonstrated greater frequency of overall thrombotic events with increasing frequency and duration of anticoagulation being interrupted (p = 0.001)., Conclusions: Our multicenter analysis found a similar frequency of thrombotic events in patients on ECMO when anticoagulation was interrupted vs. administered continuously. Further investigation into the impact of the frequency and duration of these interruptions is warranted., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Aims: We investigated the presence of SARS-CoV-2 in free-ranging wildlife populations in Northeastern Minnesota on the Grand Portage Indian Reservation and Isle Royale National Park., Methods and Results: One hundred twenty nasal samples were collected from white-tailed deer, moose, grey wolves and black bears monitored for conservation efforts during 2022-2023. Samples were tested for viral RNA by RT-qPCR using the CDC N1/N2 primer set. Our data indicate that no wildlife samples were positive for SARS-CoV-2 RNA., Conclusions: Continued surveillance is therefore crucial to better understand the changing landscape of zoonotic SARS-CoV-2 in the Upper Midwest., (© 2024 The Author(s). Zoonoses and Public Health published by Wiley‐VCH GmbH.)

Background: This study aims to determine the population-based incidence and characterize the features of nonarteritic anterior ischemic optic neuropathy (NAION) using the Rochester Epidemiology Project (REP)., Methods: All patients diagnosed with an optic neuropathy from January 1, 1990, to December 31, 2016, were retrospectively reviewed to identify incident cases of NAION using the REP database, which is a record-linkage system of medical records for all patient-physician encounters among Olmsted County, Minnesota residents. The overall incidence of NAION was estimated using the age-specific and sex-specific population figures for Olmsted County census data for 1990 through 2016. Visual outcomes and risk factors were evaluated. The systemic risk factors were compared with age-matched controls., Results: One hundred four patients were diagnosed with NAION during the 26-year study period. The overall age and sex adjusted incidence was 3.89 per 100,000 individuals (95% confidence interval [CI]: 3.14-4.65). The incidence was 7.73 (CI: 6.24-9.22) in patients aged 40 years or older and 10.19 (CI: 8.15-12.23) in patients aged 50 years or older. Median age at diagnosis was 65 years (range, 40-90 years), and 59 (56.7%) were male. The median logMAR visual acuity at presentation was 0.35 (Snellen equivalent of 20/40) with 14 patients (13.5%) having vision of counting fingers or worse. Among the 91 patients with final visual acuity outcome data available, the median visual acuity was 0.40 (Snellen equivalent of 20/50) with 12 patients (13.2%) having vision of counting fingers or worse. Twenty-four patients (26.4%) were noted to have final acuity at least 3 Snellen lines worse than at presentation, whereas 17 patients (18.7%) were noted to improve by at least 3 lines. The median mean deviation on automated visual field testing was -10.2 dB at presentation and -11.1 dB at follow-up. Twenty-two patients (21.2%) suffered NAION in the fellow eye; the median interval between involvement of the first and second eyes was 1.39 years. Systemic diseases present in the NAION cohort included hypertension (79.8%), diabetes mellitus (39.4%), obstructive sleep apnea (23.1%), and hyperlipidemia (74.0%), which were all statistically higher than age-matched controls., Conclusions: NAION is a relatively common optic neuropathy in elderly patients with vascular risk factors. Our data indicate that the incidence of NAION has remained relatively stable in the population of Olmsted County over the past 4 decades., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by North American Neuro-Ophthalmology Society.)

Importance: This is the first population-based study quantifying the incidence of nonsynostotic positional plagiocephaly and/or brachycephaly (PPB) in infancy and its association with developmental disorders., Objective: To report the incidence of PPB before age 1 year, the incidence of craniosynostosis, and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Design, Setting, and Participants: This was a retrospective, population-based cohort study of children in the Rochester Epidemiology Project (REP) born in Olmsted County, Minnesota, from January 1, 2008, through December 31, 2012, with follow-up through age 7 years. Data were analyzed from March 2021 to April 2024., Exposure: Physical examination detecting cranial deformity., Main Outcomes and Measures: The primary outcome was the incidence of PPB. Secondary outcomes were the incidence of craniosynostosis and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years., Results: Of 9909 infants (5084 [51.3%] male; 9205 [92.9%] born at term and 704 [7.1%] born preterm) included in the study, 575 had PPB, for a PPB incidence of 5.8% (95% CI, 5.3%-6.3%). The incidence of PPB was 5.3% (95% CI, 4.8%-5.8%) in term infants vs 11.8% (95% CI, 9.4%-14.6%) in preterm infants. The incidence of craniosynostosis was 0.16% (95% CI, 0.09%-0.26%). A developmental disorder was known or suspected in 4.2% (95% CI, 2.7%-6.2%) of infants at the time of PPB diagnosis; among 402 infants with PPB and follow-up through age 7 years, 30 (7.5%; 95% CI, 5.0%-10.7%) had a confirmed developmental disorder by 7 years of age. The prevalence of autism spectrum disorder (ASD) in children with a history of PPB who were followed up to age 7 years was 2.2% (9 of 402 children)., Conclusions and Relevance: This study found that only a small percentage of the infants had positional head deformity significant enough to be documented and/or referred for subspecialty evaluation, and only a small subset of these children went on to have a developmental disorder in childhood. This information is helpful for counseling families about their child's developmental risk at time of PPB diagnosis.

Regular cigarette smoking and cannabis consumption are strongly positively related to each other, yet few studies explore their underlying variation and covariation. We evaluated the genetic and environmental decomposition of variance and covariance of these two traits in twin data from three countries with different social norms and legislation. Data from the Netherlands Twin Register, FinnTwin12/16, and the Minnesota Center for Twin Family Research (total N = 21,617) were analyzed in bivariate threshold models of lifetime regular smoking initiation (RSI) and lifetime cannabis initiation (CI). We ran unstratified models and models stratified by sex and country. Prevalence of RSI was lowest in the Netherlands and prevalence of CI was highest in Minnesota. In the unstratified model, genetic (A) and common environmental factors (C) contributed substantially to the liabilities of RSI (A = 0.47, C = 0.34) and CI (A = 0.28, C = 0.51). The two liabilities were significantly phenotypically (rP = 0.56), genetically (rA = 0.74), and environmentally correlated in the unstratified model (rC = 0.47and rE = 0.48, representing correlations between common and unique environmental factors). The magnitude of phenotypic correlation between liabilities varied by country but not sex (Minnesota rP ~ 0.70, Netherlands rP ~ 0.59, Finland rP ~ 0.45). Comparisons of decomposed correlations could not be reliably tested in the stratified models. The prevalence and association of RSI and CI vary by sex and country. These two behaviors are correlated because there is genetic and environmental overlap between their underlying latent liabilities. There is heterogeneity in the genetic architecture of these traits across country., (© 2024. The Author(s).)

Objectives. To determine mortality risk among those recently released from a Minnesota jail or prison. Methods. Using linked prison, jail, and death records, our retrospective cohort study followed 99 065 people who were released from Minnesota jails and prisons between March 1, 2020, and December 31, 2021. We explored differences between jail and prison exposures regarding mortality using standardized mortality ratios. Results. Adjusting for age and gender, we estimated that the rate of overdose death for people released from jail was 15.5 times that of the Minnesota general population. Overdose death rates for people released from prison were even higher at 28.3 times the rate of the Minnesota general population. Conclusions. Drug overdose was the leading cause of death for people reentering their communities from both jail and prison in Minnesota-with opioids being the leading cause of overdoses. Overdose death relative to the general population was double the estimates from earlier studies among people leaving prison. Providing seamless access to medications for opioid use disorder during and after incarceration is important to lower the risk of death following release. ( Am J Public Health . 2024;114(9):913-922. https://doi.org/10.2105/AJPH.2024.307723).

Background and Objective: No epidemiologic studies have formally assessed the incidence of primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS). Thus, we decided to assess the incidence of these disorders in Olmsted County, MN, between 2011 and 2022, and to characterize clinical, radiographic, and pathologic characteristics of these patients., Methods: This was a retrospective examination of data from a population-based cohort of patients with PPA and PPAOS prospectively identified in Olmsted County, MN, from 2011 to 2022. The incidence of PPA among adults (older than 18 years) was calculated for Olmsted County as the number of patients per 100,000 person-years during the study period. The adult population of Olmsted County was determined by the annual catchment population reported by the Rochester Epidemiological Project for each year 2011-2022. A behavioral neurologist verified the clinical diagnoses and determined subtypes., Results: We identified 10 patients (60% female) within the study period (median age of symptoms onset: 70 years; range: 66-73), 8 with PPA and 2 with PPAOS. Of the 8 patients with PPA (6 female patients, 2 male patients), 2 met criteria for non-fluent variant PPA (nfvPPA), 3 for logopenic variant PPA (lvPPA), and 3 for semantic variant (svPPA). Speech evaluation confirmed the clinical diagnoses in all patients and all showed typical imaging findings consistent with their respective subtype. Six patients (2 PPAOS, 2 nfvPPA, 2 lvPPA) died and 3 underwent autopsy (2 PPAOS, 1 nfvPPA), confirming the pathologic diagnosis of progressive supranuclear palsy. The incidence of PPA + PPAOS was 0.70 persons per 100,000 person-years (95% CI 0.34-1.29 persons per 100,000) during the study period. The incidence of PPAOS was 0.14 persons per 100,000 person-years (95% CI 0.02-0.55 persons per 100,000), whereas for the 8 patients with PPA, the incidence was 0.56 persons per 100,000 person-years (95% CI 0.24-1.10 cases per 100,000). The incidence of nfvPPA was 0.14 persons per 100,000 person-years (95% CI 0.02-0.55), 0.21 persons per 100,000 person-years (95% CI 0.04-0.61) for lvPPA, and 0.21 persons per 100,000 person-years (95% CI 0.04-0.61) for svPPA., Discussion: As a group, PPA and PPAOS are a relatively rare group of diseases. PPAOS has a slightly lower incidence than PPA as a group but similar incidence to the individual PPA variants.

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Elizabeth M. Dufort reports serving as a public health consultant with Hutton Health Consulting. Ruth Lynfield is an Associate Editor for the American Academy of Pediatrics Red Book (fees received were donated to the Minnesota Department of Health); she also reports receipt of funding from the Infectious Diseases Society of America’s Program Committee for ID Week for attendance at ID Week conferences, receipt of funding from the Council of State and Territorial Epidemiologists (CSTE) for attendance at CSTE meetings, receipt of funding from the National Foundation for Infectious Diseases (NFID) for attendance at NFID meetings, and membership on the executive boards for CSTE and NFID. No other potential conflicts of interest were disclosed.

Cannabis use among individuals with cancer is best understood using survey self-report. As cannabis remains federally illegal, surveys could be subject to nonresponse and measurement issues impacting data quality. We surveyed individuals using medical cannabis for a cancer-related condition in the Minnesota Medical Cannabis Program (MCP). Although survey responders are older, there are no differences by race and ethnicity, gender, or receipt of reduced cannabis registry enrollment fee. Responders made a more recent purchase and more recently completed an independent symptom assessment for the registry than nonresponders, suggesting some opportunity for nonresponse error. Among responders, self-report and MCP administrative data with respect to age, race, gender, registry certification, and cannabis purchase history were similar. Responders were less likely to report receipt of Medicaid than would be expected based on registry low-income enrollment eligibility. Although attention should be paid to potential for nonresponse error, surveys are a reliable tool to ascertain cannabis behavior patterns in this population., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Stress echocardiographic (SE) testing is an important modality in cardiovascular risk stratification and obstructive coronary artery disease assessment. Binary sex-based parameters are classically used for the interpretation of these studies, even among transgender women (TGW). Coronary artery disease is a leading cause of morbidity and mortality in this population. Yet, it remains unclear whether TGW exhibit a distinct stress testing profile from their cisgender counterparts., Methods: Using a matched case-control study design, the authors compared the echocardiographic stress testing profiles of TGW (n = 43) with those of matched cisgender men (CGM; n = 84) and cisgender women (CGW; n = 86) at a single center. Relevant data, including demographics, comorbidities, and cardiac testing data, were manually extracted from the patients' charts., Results: The prevalence of hypertension and dyslipidemia was similar between TGW and CGW and lower than that of CGM (P = .003 and P = .009, respectively). The majority of comorbidities and laboratory values were similar. On average, TGW had higher heart rates than CGM (P = .002) and had lower blood pressures than CGM and CGW (P < .05). TGW's double product and metabolic equivalents were similar to those among CGW and lower than those of CGM (P = .016 and P = .018, respectively). On echocardiography, left ventricular end-diastolic and end-systolic diameters among TGW were similar to those of CGW but lower than those of CGM (P = .023 and P = .018, respectively). Measures of systolic and diastolic function, except for exercise mitral valve E/e' ratio, which was lower in TGW than CGW (P = .029), were largely similar among the three groups. There was no difference in the wall motion score index, and therefore, no difference in the percentage of positive SE test results., Conclusions: This study shows, for the first time, that TGW have a SE profile that is distinct from that of their cisgender counterparts. Larger, multicenter, prospective studies are warranted to further characterize the SE profile of TGW., Competing Interests: Disclosures None., (Copyright © 2024 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objectives: To measure changes in cause of death dynamics in 2019 and 2020 and the relationship between the concurrent occurrence of the COVID-19 pandemic and mortality outcome by race and ethnicity., Patients and Methods: We used resident mortality data from the Minnesota Department of Health (MDH) to conduct a retrospective statistical analysis of deaths in Minnesota in 2019 relative to 2020 to assess changes in mortality in a pre-pandemic and pandemic period., Results: COVID-19 strongly contributed to ethnicity-related mortality disparities in Minnesota. Not only was there a greater proportion of COVID-19 decedents within Black and Hispanic populations, but their average decedent age was markedly lower relative to the White population. The Black population experienced a disproportionate increase in decedents with a 34% increase during 2020 compared to 2019., Conclusions: This retrospective analysis of death dynamics and mortality outcomes in Minnesota from 2019 to 2020 demonstrated an increase in adverse mortality outcomes relative to the pre-pandemic period that disproportionately impacted Black and Hispanic minority populations., (© 2023. W. Montague Cobb-NMA Health Institute.)

Background: Cancer screening trials have required large sample sizes and long time-horizons to demonstrate cancer mortality reductions, the primary goal of cancer screening. We examine assumptions and potential power gains from exploiting information from testing control-arm specimens, which we call the "intended effect" (IE) analysis that we explain in detail herein. The IE analysis is particularly suited to tests that can be conducted on stored specimens in the control arm, such as stored blood for multicancer detection (MCD) tests., Methods: We simulated hypothetical MCD screening trials to compare power and sample size for the standard vs IE analysis. Under two assumptions that we detail herein, we projected the IE analysis for 3 existing screening trials (National Lung Screening Trial [NLST], Minnesota Colon Cancer Control Study [MINN-FOBT-A], and Prostate, Lung, Colorectal, Ovarian Cancer Screening Trial-colorectal component [PLCO-CRC])., Results: Compared with the standard analysis for the 3 existing trials, the IE design could have reduced cancer-specific mortality P values 5-fold (NLST), 33-fold (MINN-FOBT-A), or 14 160-fold (PLCO-CRC) or, alternately, reduced sample size (90% power) by 26% (NLST), 48% (MINN-FOBT-A), or 59% (PLCO-CRC). For potential MCD trial designs requiring 100 000 subjects per arm to achieve 90% power for multicancer mortality for the standard analysis, the IE analysis achieves 90% power for only 37 500-50 000 per arm, depending on assumptions concerning control-arm test-positives., Conclusions: Testing stored specimens in the control arm of screening trials to conduct the IE analysis could substantially increase power to reduce sample size or accelerate trials and could provide particularly strong power gains for MCD tests., (Published by Oxford University Press 2024.)

Background: African Americans (AAs) face cardiovascular health (CVH) disparities linked to systemic racism. The 2020 police killing of Mr. George Floyd in Minneapolis, Minnesota, alongside the COVID-19 pandemic, exacerbated adverse psychosocial factors affecting CVH outcomes among AAs. This manuscript describes the study protocol and participant characteristics in an ancillary study exploring the relationship between biopsychosocial factors and CVH among AAs., Methods: Using a community-based participatory approach, a mixed-methods ancillary study of 58 AA participants from an overarching randomized control trial (RCT) was conducted. Baseline RCT health assessments (November 2020) provided sociodemographic, medical, and clinical data. Subsequent health assessments (February-December 2022) measured sleep quality, psychosocial factors (e.g., high-effort coping), biomarkers (e.g., cortisol), and cardiovascular diagnostics (e.g., cardio-ankle vascular index). CVH was assessed using the American Heart Association Life's Simple 7 (LS7) (range 0 to 14, poor to ideal) and Life's Essential 8 (LE8) scores (range 0 to 100, low to high). Correlations between these scores will be examined. Focus group discussions via videoconferencing (March to April 2022) assessed psychosocial and structural barriers, along with the impact of COVID-19 and George Floyd's killing on daily life., Results: Participants were predominantly female (67%), with a mean age of 54.6 [11.9] years, high cardiometabolic risk (93% had overweight/obesity and 70% hypertension), and moderate LE8 scores (mean 57.4, SD 11.5)., Conclusion: This study will enhance understanding of the associations between biopsychosocial factors and CVH among AAs in Minnesota. Findings may inform risk estimation, patient care, and healthcare policies to address CVD disparities in marginalized populations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The epidemiology and pathophysiology of heart failure (HF) differ in women and men. Whether these differences extend to the subgroup of patients with advanced HF is not well defined., Methods and Results: This is a retrospective cohort study of all adult Olmsted County, Minnesota residents with advanced HF (European Society of Cardiology criteria) from 2007 to 2017. Differences in survival and hospitalization risks in women and men following advanced HF development were examined using Cox proportional hazard regression and Andersen-Gill models, respectively. Of 936 individuals with advanced HF, 417 (44.6%) were women and 519 (55.4%) were men (self-reported sex). Time from development of HF to advanced HF was similar in women and men (median 3.2 versus 3.6 years). Women were older at diagnosis (mean age 79 versus 75 years), less often had coronary disease and hyperlipidemia, but more often had hypertension and depression ( P <0.05 for each). Advanced HF with preserved ejection fraction was more prevalent in women than men (60% versus 30%, p<0.001). There were no differences in adjusted risks of all-cause mortality (hazard ratio [HR], 0.89 [95% CI, 0.77-1.03]), cardiovascular mortality (HR, 0.85 [95% CI, 0.70-1.02]), all-cause hospitalizations (HR, 1.04 [95% CI, 0.90-1.20]), or HF hospitalizations (HR, 0.91 [95% CI, 0.75-1.11]) between women and men. However, adjusted cardiovascular mortality was lower in women versus men with advanced HF with reduced ejection fraction (HR, 0.72 [95% CI, 0.56-0.93])., Conclusions: Women more often present with advanced HF with preserved ejection fraction and men with atherosclerotic disease and advanced HF with reduced ejection fraction. Despite these differences, survival and hospitalization risks are largely comparable in women and men with advanced HF.

In July 2023, the Minnesota Department of Health (MDH) was notified of possible occupational exposures to anthrax during an outbreak in animals. In consultation with the Centers for Disease Control and Prevention, MDH epidemiologists created a questionnaire that assessed exposure risks and helped determine individual illness monitoring and antibiotic post-exposure prophylaxis needs. This investigation and the resources developed for it could be useful in future scenarios where there are occupational exposures to naturally occurring anthrax.

Background: Although monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma disproportionately affect Black individuals, few epidemiological studies have been conducted on these plasma cell disorders in Africa. Here we describe the prevalence of MGUS in Eswatini and compare our results to the landmark Olmsted County, Minnesota study., Methods: Between 2016 and 2017, 13 339 residents of Eswatini participated in the Swaziland HIV Incidence Measurement Survey, from which a nationally representative biorepository was created. Plasma samples were then randomly selected and analyzed for MGUS. MGUS prevalence in Eswatini was compared with that of Olmsted County. In addition, demographic and HIV-related associations with MGUS were assessed., Results: Of the 515 samples randomly selected, the median age was 50 years (range = 35-80 years); 60% were female; and 38.6% were HIV positive, of whom 82.4% were on antiretroviral therapy. We found that 68 participants had evidence of MGUS, for a prevalence of 13.2%. HIV status was not significantly associated with MGUS (odds ratio = 1.05, 95% confidence interval = 0.62 to 1.77), but among HIV-positive individuals, MGUS was less frequent for patients on antiretroviral therapy (adjusted odds ratio = 0.31, 95% confidence interval = 0.11 to 0.82). The prevalence of conventional MGUS was similar between Eswatini and Olmsted County (3.4% vs 3.2%-3.4%), whereas the incidence of light-chain MGUS was significantly greater in Eswatini (12.3% vs 0.8%)., Conclusion: Our study suggests that the incidence of MGUS is similar between ethnicities and raises the question of whether the current definition of light-chain MGUS reliably reflects a true monoclonal protein precursor state. Perhaps the current definition of light-chain MGUS may be capturing alternate etiologies, such as untreated HIV infection., (© The Author(s) 2024. Published by Oxford University Press.)

This study examines the association between community incarceration rates, household incarceration, and the mental health of parents and children. Participant families had children ages 5-9 (n = 1307) from the African American, Latinx, Hmong, Somali/Ethiopian, Native American, and White communities in the Twin Cities, Minnesota. Linear mixed models were used to estimate associations between parent and child mental health, household incarceration exposure, and census tract race, ethnicity and gender-specific incarceration rates matched to the family's home address and race/ethnicity. Findings indicated that living in census tracts with elevated incarceration rates of men from your same racial or ethnic group was significantly associated with psychological distress in parents and externalizing behaviors in boys, regardless of household exposure to incarceration. The association between incarceration rates and externalizing behaviors was only observed among girls with exposure to household incarceration. Policies that deconstruct pervasive racism in penal systems are needed to improve population mental health., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Despite effective vaccines against influenza, pneumococcus, and COVID-19, uptake has been suboptimal., Research Question: Although disparities in vaccination by race and ethnicity have been observed, what is the role of other sociodemographic factors in US vaccine uptake?, Study Design and Methods: We conducted a population-based study using the Rochester Epidemiology Project (REP), a comprehensive medical records linkage system, to assess effects of sociodemographic factors including race, ethnicity, individual-level socioeconomic status (SES) via the housing-based socioeconomic status index, education, population density (urban or nonurban), and marital status with uptake of influenza, pneumococcal, and COVID-19 vaccination in high-risk adults. Adults at high risk of invasive pneumococcal disease residing in four counties in southeastern Minnesota who were aged 19 to 64 years were identified. Vaccination data were obtained from the Minnesota Immunization Information Connection and REP from January 1, 2010, through December 31, 2021., Results: We identified 45,755 residents. Most were White (82%), non-Hispanic (94%), married (56%), and living in an urban setting (81%), with three-quarters obtaining at least some college education (74%). Although 45.1% were up to date on pneumococcal vaccines, 60.1% had completed the primary COVID-19 series. For influenza and COVID-19, higher SES, living in an urban setting, older age, and higher education positively correlated with vaccination. Magnitude of differences in race, education, and SES widened with booster vaccines., Interpretation: This high-risk population is undervaccinated against preventable respiratory diseases, especially influenza and pneumococcus. Although national data reported improvement of disparities in COVID-19 vaccination uptake observed early in the pandemic, our data demonstrated gaps related to race, education level, SES, and age that widened with booster vaccines. Communities with high social vulnerabilities often show increased risk of severe disease outcomes, yet demonstrate lower uptake of preventive services. This highlights the need to understand better vaccine compliance and access in rural, lower SES, less-educated, Black, Hispanic, and younger populations, each of which were associated independently with decreased vaccination., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: R. M. J. holds shares of Johnson & Johnson stock through an inheritance and has served on safety review committees and data and safety monitoring committees for Merck in the last 3 years. None declared (J. R. F., A. J. M., A. M. L., L J. F. R., Y. J. J., C. W., C. C. K.)., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Borrelia miyamotoi is an emerging tickborne pathogen that has been associated with central nervous system infections in immunocompromised patients, albeit infrequently. We describe a case-patient in Minnesota, USA, who had meningeal symptoms of 1 month duration. B. miyamotoi infection was diagnosed by Gram staining on cerebrospinal fluid and confirmed by sequencing.

Accurate and timely mortality surveillance is crucial for elucidating risk factors, particularly for emerging diseases. We compared use of COVID-19 keywords on death certificates alone to identify COVID-19 deaths in Minnesota, USA, during 2020-2022, with use of a standardized mortality definition incorporating additional clinical data. For analyses, we used likelihood ratio χ 2 and median 1-way tests. Death certificates alone identified 96% of COVID-19 deaths confirmed by the standardized definition and an additional 3% of deaths that had been classified as non-COVID-19 deaths by the standardized definition. Agreement between methods was >90% for most groups except children, although agreement among adults varied by demographics and location at death. Overall median time from death to filing of death certificate was 3 days; decedent characteristics and whether autopsy was performed varied. Death certificates are an efficient and timely source of COVID-19 mortality data when paired with SARS-CoV-2 testing data.

Objective: To determine whether body composition derived from medical imaging may be useful for assessing biologic age at the tissue level because people of the same chronologic age may vary with respect to their biologic age., Methods: We identified an age- and sex-stratified cohort of 4900 persons with an abdominal computed tomography scan from January 1, 2010, to December 31, 2020, who were 20 to 89 years old and representative of the general population in Southeast Minnesota and West Central Wisconsin. We constructed a model for estimating tissue age that included 6 body composition biomarkers calculated from abdominal computed tomography using a previously validated deep learning model., Results: Older tissue age associated with intermediate subcutaneous fat area, higher visceral fat area, lower muscle area, lower muscle density, higher bone area, and lower bone density. A tissue age older than chronologic age was associated with chronic conditions that result in reduced physical fitness (including chronic obstructive pulmonary disease, arthritis, cardiovascular disease, and behavioral disorders). Furthermore, a tissue age older than chronologic age was associated with an increased risk of death (hazard ratio, 1.56; 95% CI, 1.33 to 1.84) that was independent of demographic characteristics, county of residency, education, body mass index, and baseline chronic conditions., Conclusion: Imaging-based body composition measures may be useful in understanding the biologic processes underlying accelerated aging., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the incidence, clinical characteristics, and outcomes of acute dacryocystitis among a large, population-based cohort of children born with congenital nasolacrimal duct obstruction (CNLDO) over a 10-year period., Methods: This multicenter retrospective, population-based cohort study included all patients diagnosed with acute dacryocystitis in a cohort of patients diagnosed with CNLDO before age 5 years in Olmsted County, Minnesota, United States of America from January 1, 1995, through December 31, 2004., Results: Of 1,998 patients with CNLDO, there were 70 cases (36 female [(51%)]) of acute dacryocystitis during the study, yielding an incidence rate of 243 per 100,000 children (95% CI, 170-316). Mean age at diagnosis was 9.0 months. Patients who developed dacryocystitis were significantly less likely to be born via C-section (OR = 0.29, P = 0.009). Less than half of patients with dacryocystitis were treated with oral/intravenous antibiotics (46%), but whose who were had a significantly higher odds of requiring probing (OR = 8.50, P = 0.004). Spontaneous CNLDO resolution was significantly less likely to occur in patients diagnosed with acute dacryocystitis compared with those without (OR = 2.46, P = 0.001). The median age of spontaneous resolution in the dacryocystitis group (6.0 months) was significantly older than the uncomplicated CNLDO group (P = 0.012)., Conclusions: Pediatric acute dacryocystitis is an uncommon complication of CNLDO and is associated with both a lower likelihood of and older age at spontaneous resolution of CNLDO symptoms., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Intimate partner sexual violence (IPSV) is a substantial public health issue faced by youth, with disparities along lines of race, gender, and sexual orientation. Using an intersectional framework, the current study describes the prevalence of self-reported IPSV victimization across intersecting social positions among adolescents. High school students who completed the 2019 Minnesota Student Survey were asked whether they had ever experienced IPSV. Using exhaustive Chi-Square Automatic Interaction Detection (eCHAID), responses were modeled using five indicators: racial/ethnic identity, transgender/genderqueer/genderfluid identity, sex assigned at birth, sexual orientation, and school location. The prevalence of IPSV victimization within each end group identified by the eCHAID varied from 2.6% to 32.0%. The highest prevalence of IPSV among all students was observed in subgroups defined by multiple marginalized social positions; for example, 32.0% among lesbian, gay, bisexual, queer, pansexual, or questioning (LGBQ+) students of color who were transgender, genderqueer, genderfluid or unsure of their gender, and assigned male at birth; 22.8% among LGBQ+ students assigned female at birth and enrolled in a Greater Minnesota (outside of the Twin Cities) school; and 22.2% among Native+ or missing race LGBQ+ students assigned female at birth and enrolled in a metropolitan school. Within the eCHAID decision tree, several subsamples of students were split into two more subsamples with a twofold or greater statistically significant difference in IPSV victimization prevalence between them. Findings from this study highlight notable disparities in the prevalence of IPSV victimization among Minnesota youth and demonstrate the importance of detailing the distribution of interpersonal violence outcomes across youth with multiple marginalized identities. Findings suggest that disparities reported along one categorical axis only may miss important nuances in how risk for IPSV is distributed. Population health researchers should utilize methods that allow for the explication of complex intersections that characterize individuals' social positions in estimating the prevalence of sexual violence., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Phenomenon: Existing literature, as well as anecdotal evidence, suggests that tiered clinical grading systems may display systematic demographic biases. This study aimed to investigate these potential inequities in-depth. Specifically, this study attempted to address the following gaps in the literature: (1) studying grades actually assigned to students (as opposed to self-reported ones), (2) using longitudinal data over an 8-year period, providing stability of data, (3) analyzing three important, potentially confounding covariates, (4) using a comprehensive multivariate statistical design, and (5) investigating not just the main effects of gender and race, but also their potential interaction. Approach: Participants included 1,905 graduates (985 women, 51.7%) who received the Doctor of Medicine degree between 2014 and 2021. Most of the participants were white ( n  = 1,310, 68.8%) and about one-fifth were nonwhite ( n  = 397, 20.8%). There were no reported race data for 10.4% ( n  = 198). To explore potential differential grading, a two-way multivariate analysis of covariance was employed to examine the impact of race and gender on grades in eight required clerkships, adjusting for prior academic performance. Findings: There were two significant main effects, race and gender, but no interaction effect between gender and race. Women received higher grades on average on all eight clerkships, and white students received higher grades on average on four of the eight clerkships (Medicine, Pediatrics, Surgery, Obstetrics/Gynecology). These relationships held even when accounting for prior performance covariates. Insights: These findings provide additional evidence that tiered grading systems may be subject to systematic demographic biases. It is difficult to tease apart the contributions of various factors to the observed differences in gender and race on clerkship grades, and the interactions that produce these biases may be quite complex. The simplest solution to cut through the tangled web of grading biases may be to move away from a tiered grading system altogether.

Background and Aims: Severe aortic stenosis (AS) is the guideline-based indication for aortic valve replacement (AVR), which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment., Methods: All adults residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤ 1 cm2, aortic valve area index ≤ 0.6 cm2/m2, mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, Doppler velocity index ≤ 0.25) were counted to define trends in incidence, presentation, treatment, and outcome., Results: Incident severe AS was diagnosed in 1069 community residents. The incidence rate was 52.5 [49.4-55.8] per 100 000 patient-year, slightly higher in males vs. females and was almost unchanged after age and sex adjustment for the US population 53.8 [50.6-57.0] per 100 000 residents/year. Over 20 years, severe AS incidence remained stable (P = .2) but absolute burden of incident cases markedly increased (P = .0004) due to population growth. Incidence trend differed by sex, stable in men (incidence rate ratio 0.99, P = .7) but declining in women (incidence rate ratio 0.93, P = .02). Over the study, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt (from 1.3 [0.1-3.3] years in 1997-2000 to 0.5 [0.2-2.1] years in 2013-16, P = .001) but undertreatment remained prominent (>40%). Early AVR was associated with survival benefit (adjusted hazard ratio 0.55 [0.42-0.71], P < .0001). Despite these improvements, overall mortality (3-month 8% and 3-year 36%), was swift, considerable and unabated (all P ≥ .4) throughout the study., Conclusions: Over 20 years, the population incidence of severe AS remained stable with increased absolute case burden related to population growth. Despite stable severe AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease lethality did not yet decline. These population-based findings have important implications for improving AS management pathways., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: To determine the incidence of carotid-cavernous fistula (CCF) and describe the neuro-ophthalmic manifestations and eventual clinical outcomes., Methods: This was a population-based, retrospective cohort study using the Rochester Epidemiology Project to identify patients aged 18 years or older residing in Olmsted County, MN, diagnosed with CCF from 1997 to 2019. The medical records were reviewed for ophthalmic signs and symptoms, including conjunctival chemosis, proptosis, orbital bruit, diplopia, ophthalmoplegia, orbital pain, ocular hypertension, and blurred vision. Also determined was the number of patients with CCF found incidentally on neuroimaging, without clinical manifestations., Results: Ten patients were diagnosed with a CCF between 1997 and 2019 with an overall incidence rate of 0.37 per 100,000 per year (95% CI 0.20-0.68). The median age was 50.5 years (range 23-74 years), 6 (60%) were female, and 9 were White and 1 patient was Korean. Three patients (30%) were asymptomatic and found incidentally on imaging that was obtained for unrelated reasons, and one patient's ocular details were unavailable because she passed away from severe head trauma. The following neuro-ophthalmologic or ocular manifestations were identified in the remaining 6 patients: chemosis/conjunctival injection (n = 6), cranial nerve (CN) VI palsy (n = 6), CN III palsy (n = 2), proptosis (n = 4), ocular/orbital pain (n = 3), audible orbital bruit (n = 2), ocular hypertension (n = 1), and blurred vision (n = 1). Of those patients with symptomatic CCFs, all underwent treatment except for one that spontaneously resolved. None of the patients suffered a stroke or cerebral hemorrhage. The 3 patients with incidentally discovered CCFs were asymptomatic and did not require treatment., Conclusions: This is the first population-based study to show a low incidence rate of CCFs, supporting the notion that it is an uncommon condition. Neuro-ophthalmic manifestations are common, especially chemosis/conjunctival injection and CN VI palsy. Up to a third of patients with CCF can be asymptomatic and may be found incidentally on neuroimaging during the evaluation for unrelated symptoms., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

COVID-19 disproportionately affects people experiencing homelessness or incarceration. While homelessness or incarceration alone may not impact vaccine effectiveness, medical comorbidities along with social conditions associated with homelessness or incarceration may impact estimated vaccine effectiveness. COVID-19 vaccines reduce rates of hospitalization and death; vaccine effectiveness (VE) against severe outcomes in people experiencing homelessness or incarceration is unknown. We conducted a retrospective, observational cohort study evaluating COVID-19 vaccine VE against SARS-CoV-2 related hospitalization (positive SARS-CoV-2 molecular test same week or within 3 weeks prior to hospital admission) among patients who had experienced homelessness or incarceration. We utilized data from 8 health systems in the Minnesota Electronic Health Record Consortium linked to data from Minnesota's immunization information system, Homeless Management Information System, and Department of Corrections. We included patients 18 years and older with a history of experiencing homelessness or incarceration. VE and 95% Confidence Intervals (CI) against SARS-CoV-2 hospitalization were estimated for primary series and one booster dose from Cox proportional hazard models as 100*(1-Hazard Ratio) during August 26, 2021, through October 8, 2022 adjusting for patient age, sex, comorbid medical conditions, and race/ethnicity. We included 80,051 individuals who had experienced homelessness or incarceration. Adjusted VE was 52% (95% CI, 41-60%) among those 22 weeks or more since their primary series, 66% (95% CI, 53-75%) among those less than 22 weeks since their primary series, and 69% (95% CI: 60-76%) among those with one booster. VE estimates were consistently lower during the Omicron predominance period compared with the combined Omicron and Delta periods. Despite higher exposure risk, COVID-19 vaccines provided good effectiveness against SARS-CoV-2 related hospitalizations in persons who have experienced homelessness or incarceration., (© 2023. The Author(s).)

Background: To evaluate the population-based frequency and severity of multiple sclerosis (MS)-related ocular diseases., Methods: Retrospective, population-based study examining patients with MS between January 1, 1998 and December 31, 2011. Patients were identified using the Rochester Epidemiology Project, which is a record-linkage system of medical records for all patient-physician encounters among Olmsted County, Minnesota residents. Diagnosis of MS was confirmed based on neuroimaging, cerebrospinal fluid studies, and serum studies for each patient according to the 2017 McDonald criteria. Patient data were obtained using the medical records and followed through April 1, 2018., Results: Of the 116 patients with MS, 66% were female and the median age of onset was 36 years (interquartile range 27.5-43.5 years). About half (61/116, 53%) had MS-related neuro-ophthalmic manifestations during their disease course, and about one-fourth (33/116, 28%) had visual symptoms as their presenting symptom of MS, most commonly as optic neuritis (26/116, 22%). Optic neuritis was the leading MS-related ocular condition (37%), followed by internuclear ophthalmoplegia (16%) and nystagmus (13%). Optic neuritis was mostly unilateral (40/43, 93%), with 16% (6/43) having a visual acuity of 20/200 or worse at nadir but ultimately 95% (35/37) improving to a visual acuity of 20/40 or better., Conclusions: This study provides the population-based frequency of MS-related ocular disease, which demonstrates a high frequency of ocular manifestations in MS both at disease onset and during the disease course, emphasizing the utility of neuro-ophthalmologists, or collaboration between neurologists and ophthalmologists, in the care of patients with MS., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by North American Neuro-Ophthalmology Society.)

Trichinellosis is a parasitic zoonotic disease transmitted through the consumption of meat from animals infected with Trichinella spp. nematodes. In North America, human trichinellosis is rare and is most commonly acquired through consumption of wild game meat. In July 2022, a hospitalized patient with suspected trichinellosis was reported to the Minnesota Department of Health. One week before symptom onset, the patient and eight other persons shared a meal that included bear meat that had been frozen for 45 days before being grilled and served rare with vegetables that had been cooked with the meat. Investigation identified six trichinellosis cases, including two in persons who consumed only the vegetables. Motile Trichinella larvae were found in remaining bear meat that had been frozen for >15 weeks. Molecular testing identified larvae from the bear meat as Trichinella nativa, a freeze-resistant species. Persons who consume meat from wild game animals should be aware that that adequate cooking is the only reliable way to kill Trichinella parasites and that infected meat can cross-contaminate other foods., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. David M. Berman reports that he is a paid laboratory medical consultant for Precision Health Solutions and reports ownership of company shares in Karius, Inc. No other potential conflicts of interest were disclosed.

Shiga toxin-producing Escherichia coli (STEC) transmission occurs in ruminant contact settings and can lead to post-diarrheal hemolytic uremic syndrome (HUS). We investigated whether exposure setting (ruminant exposure from living or working on a farm, visiting a farm or animal contact venue, or both) influenced HUS development among individuals with laboratory-confirmed STEC infections using Minnesota surveillance data from 2010 to 2019. Logistic regression was performed to determine whether exposure setting was associated with HUS independent of age, gender, stx2 gene detection, and county ruminants per capita. Among confirmed STEC cases, ruminant exposure only from living or working on a farm was not significantly associated with HUS compared to cases without any ruminant exposure (OR: 1.25; 95% CI: 0.51, 3.04). However, ruminant exposure only from visiting a farm or public animal contact venue was associated with HUS (OR: 2.53; 95% CI: 1.50, 4.24). Exposure from both settings was also associated with HUS (OR: 3.71; 95% CI: 1.39, 9.90). Exposure to ruminants when visiting farms or animal contact venues is an important predictor of HUS, even among people who live or work on farms with ruminants. All people, regardless of routine ruminant exposure, should take care in settings with ruminants to avoid infection with STEC.

Importance: Corticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown., Objective: To determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures., Design, Setting, and Participants: This cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose., Exposure: Receipt of any CSI during the study period., Main Outcomes and Measures: The primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis., Results: A total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non-high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk., Conclusions and Relevance: In this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.

Background: Long-term outcomes of sterile lead management strategies of lead abandonment (LA) or transvenous lead extraction (TLE) remain unclear., Methods: We performed a retrospective study of a population residing in southeastern Minnesota with follow-up at the Mayo Clinic and its health systems. Patients who underwent LA or TLE of sterile leads from January 1, 2000, to January 1, 2011, and had follow-up for at least 10 years or until their death were included., Results: A total of 172 patients were included in the study with 153 patients who underwent LA and 19 who underwent TLE for sterile leads. Indications for subsequent lead extraction arose in 9.1% (n = 14) of patients with initial LA and 5.3% (n = 1) in patients with initial TLE, after an average of 7 years. Moreover, 28.6% of patients in the LA cohort who required subsequent extraction did not proceed with the extraction, and among those who proceeded, 60% had clinical success and 40% had a clinical failure. Subsequent device upgrades or revisions were performed in 18.3% of patients in the LA group and 31.6% in the TLE group, with no significant differences in procedural challenges (5.2% vs. 5.3%). There was no difference in 10-year survival probability among the LA group and the TLE group (p = .64)., Conclusion: An initial lead abandonment strategy was associated with more complicated subsequent extraction procedures compared to patients with an initial transvenous lead extraction strategy. However, there was no difference in 10-year survival probability between both lead management approaches., (© 2024 Wiley Periodicals LLC.)

Objectives: Surveillance systems for unexplained deaths that might have an infectious etiology are rare. We examined the Minnesota Department of Health Unexplained Deaths and Critical Illnesses of Possible Infectious Etiology and Medical Examiner Infectious Deaths (UNEX/MED-X) surveillance system,-a system that expanded postmortem surveillance for infectious diseases during the COVID-19 pandemic by leveraging standard (medical examiner [ME]) and expanded (mortuary) surveillance to identify COVID-19-related deaths., Methods: MEs, coroners, or morticians collected postmortem swabs from decedents with an infectious prodrome or with SARS-CoV-2 exposure before death but with no known recent infectious disease testing. The Minnesota Department of Health Public Health Laboratory used nucleic acid amplification, viral culture, and standard algorithms to test specimens collected postmortem for SARS-CoV-2, influenza virus, and other infectious pathogens. We reviewed UNEX/MED-X data from March 2, 2020, through December 31, 2021, and characterized decedents by location of swab collection (ie, ME or mortuary)., Results: From March 2, 2020, through December 31, 2021, the UNEX/MED-X surveillance system received samples from 182 decedents from mortuaries and 955 decedents from MEs. Mortuary decedents were older than ME decedents (median age, 78 vs 46 y). Seventy-three mortuary decedents (40.1%) and 197 ME decedents (20.6%) had SARS-CoV-2 detections. The UNEX/MED-X system identified 212 COVID-19-related deaths, representing 2.0% of total COVID-19-related deaths in Minnesota. Eighty-nine decedents (42.0%) were from racial and ethnic minority populations, representing 6.1% more COVID-19-related deaths among people from racial and ethnic minority populations than would have been detected without this surveillance system., Practice Implications: Expanded and standard UNEX/MED-X surveillance builds capacity and flexibility for responding to emerging public health threats. Similar programs should be considered elsewhere as resources allow., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose/aim: To report the birth prevalence and natural history of congenital corneal opacities among a population-based cohort of children., Materials and Methods: The medical records of patients <5 years diagnosed with a congenital onset corneal opacity while residing in Olmsted County, Minnesota, from January 1, 1977, through December 31, 2016, were retrospectively reviewed., Results: Fourteen patients were diagnosed with a congenital corneal opacity during the 40-year study period for a birth prevalence of 1 in 5188 live births. The mean age at diagnosis was 7.5 months (range 0-48 months) and 9 (64.3%) were males. Four patients had congenital glaucoma, 4 had limbal dermoids, 2 had sclerocornea, and 1 patient each had Descemet's tear from birth trauma, herpes simplex virus type 1 keratitis, corneal leukoma, and an undiagnosed scar. Six (42.8%) patients required treatment for their underlying corneal opacity including the four patients with congenital glaucoma. The other 8 (57.1%) patients had a clear central axis. Four (28.6%) of 14 patients required amblyopia therapy, and 4 (28.6%) developed strabismus. Four (28.6%) patients had associated systemic conditions. During a mean follow up of 5.4 years (range 1.3-27.0 years), the median best corrected visual acuity (BCVA) was logmar 0.16 (20/25) (range 20/20-hand motion) with one patient with unilateral BCVA less than 20/60 and one patient with bilateral BCVA less than 20/60., Conclusions: In this 40-year cohort, congenital corneal opacities were relatively rare and the result of a variety of disorders. Although amblyopia and strabismus occurred commonly, most patients had good visual outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In the United States (US), COVID-19 vaccination rates among non-US-born individuals (i.e., refugees, immigrants, and migrants [RIM]) are variable. Understanding baseline COVID-19 vaccine coverage among these populations and determining if disparities exist is essential for quality improvement initiatives and public health interventions., Methods: Baseline COVID-19 vaccination rates for both primary series and booster doses were calculated at four health systems located in Minnesota, Colorado, and Pennsylvania participating in the Minnesota Department of Health's Center of Excellence in Newcomer Health. Patients aged ≥5 years as of 1/1/22, seen for ≥1 primary care visit during 7/1/2019-6/30/22 were included. Descriptive statistics were calculated for three measures of COVID-19 vaccine coverage during 12/14/2020-6/30/2022: 1) initiation of primary series; 2) completion of primary series; 3) completion of first booster. We calculated vaccine coverage rates for the entire population and stratified by subgroup including country of origin, refugee status, and primary language preference., Results: We included 1,624,573 patients eligible for COVID-19 primary series vaccine and 907,749 eligible for COVID-19 booster vaccination. The percent of eligible patients who completed a COVID-19 primary series (63.4 %) and booster dose (66.2 %) were similar. Completion of the primary series was higher for non-US-born persons (72.7 %) compared with US born persons (65.4 %), similar among refugees (63.5 %) and non-refugees (63.4 %), and lower in patients with language preference other than English (62.7 %) compared with English preferring patients (63.6 %). Booster completion was lower for non-US-born persons (61.8 %), refugees (46.7 %), and patients with language preference other than English (55.3 %) compared with US-born (70 %), non-refugees (66.3 %), and English preferring patients (67.3 %) respectively., Conclusions: This evaluation identified disparities in COVID-19 vaccination rates among non-US-born persons and persons with a language preference other than English living in the US. Targeted outreach efforts may be beneficial in reaching these populations., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Blain Mamo reports financial support was provided by Centers for Disease Control and Prevention., (Copyright © 2024 The Author(s). Published by Elsevier India Pvt Ltd. All rights reserved.)

An ongoing, severe outbreak of highly pathogenic avian influenza virus (HPAI) A H5N1 clade 2.3.4.4b has been circulating in wild and domestic bird populations throughout the world, reaching North America in 2021. This HPAI outbreak has exhibited unique characteristics when compared to previous outbreaks. The global distribution of disease, prolonged duration, extensive number of species and individual wild birds affected, and the large impact on the global poultry industry have all exceeded historical impacts of previous outbreaks in North America. In this study, we describe the results of HPAI surveillance conducted at The Raptor Center, a wildlife rehabilitation hospital at University of Minnesota (Saint Paul, MN, U.S.A.), from March 28th-December 31, 2022. All wild raptors admitted to the facility were tested for avian influenza viruses using polymerase chain reaction (PCR) testing. All non-negative samples were submitted to the United States Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) National Veterinary Services Laboratories for confirmatory HPAI testing and genetic sequencing. During the study period, 996 individual birds representing 20 different species were tested for avian influenza, and 213 birds were confirmed HPAI positive. Highly pathogenic avian influenza surveillance conducted at The Raptor Center contributed 75% of the HPAI positive raptor detections within the state of Minnesota, located within the Mississippi flyway, significantly augmenting state wildlife surveillance efforts. The viral genotypes observed in birds sampled at The Raptor Center were representative of what was seen in wild bird surveillance within the Mississippi flyway during the same time frame. Wildlife rehabilitation centers provide an opportune situation to augment disease surveillance at the human, wildlife and domestic animal interface during ongoing infectious disease outbreaks., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Confinement facilities are high-risk settings for the spread of infectious disease, necessitating timely surveillance to inform public health action. To identify jail-associated COVID-19 cases from electronic laboratory reports maintained in the Minnesota Electronic Disease Surveillance System (MEDSS), Minnesota, USA, the Minnesota Department of Health developed a surveillance system that used keyword and address matching (KAM). The KAM system used a SAS program (SAS Institute Inc., https://www.sas.com) and an automated program within MEDSS to identify confinement keywords and addresses. To evaluate KAM, we matched jail booking data from the Minnesota Statewide Supervision System by full name and birthdate to the MEDSS records of adults with COVID-19 for 2022. The KAM system identified 2,212 cases in persons detained in jail; sensitivity was 92.40% and specificity was 99.95%. The success of KAM demonstrates its potential to be applied to other diseases and congregate-living settings for real-time surveillance without added reporting burden.

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objective: To contemporaneously reappraise the incidence-rate, prevalence, and natural history of hypertrophic cardiomyopathy (HCM) in Olmsted County, Minnesota, from 1984 to 2015., Patients and Methods: A validated medical-record linkage system collecting information for residents of Olmsted County was used to identify all cases of HCM between January 1, 1984, and December 31, 2015. After adjudication of records from Mayo Clinic and Olmsted Medical Center, data relating to diagnoses and outcomes were abstracted. The calculated incidence rate and prevalence were standardized to the US 1980 White population (age- and sex-adjusted) and compared with a prior study examining the years 1975-1984., Results: Two hundred seventy subjects with HCM were identified. The age- and sex-adjusted incidence rate was 6.6 per 100,000 person-years, and the point prevalence of HCM on January 1, 2016, was 89 per 100,000 population. The incidence rate and point prevalence of HCM on January 1, 2016, standardized to the US 1980 White population (age- and sex-adjusted), were 6.7 (95% CI, 7.1 to 8.8) per 100,000 person-years and 81.5 per 100,000 population, respectively. The incidence rate of HCM increased each decade since the index study. Individuals with HCM had a higher overall standardized mortality rate than the general population with an observed to expected HR of 1.44 (95% CI, 1.21 to 1.71; P<.001) which improved by each decade., Conclusion: The incidence and prevalence of HCM are higher than rates reported from a prior study in the same community examining the years 1975-1984, but lower than other study cohorts. The risk of mortality in HCM remains higher than expected, albeit with improvement in rates of mortality observed each decade during the study period., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To investigate the prevalence of myopia and high myopia in Olmsted County, Minnesota, from 1966 to 2019., Design: Retrospective, cross-sectional, trend study., Methods: Manifest refractions or lens prescription were converted to spherical equivalent (SE) to estimate the prevalence of adult myopia and high myopia. Age, sex, race, and visual acuity were recorded. Subjects with an SE of -0.5 diopters (D) or less were considered to have myopia; those with an SE of -6.0 D or less were considered to have high myopia. Exclusion criteria included visually significant cataract, pseudophakia, prior refractive surgery, or age less than 18 years., Results: Among 81,706 sampled subjects, the myopia prevalence increased from 33.9% (95% CI, 31.1-36.8) in the 1960s to 57.1% (95% CI, 56.6-57.6) in the 2010s (P < .001). The high myopia prevalence increased from 2.8% (95% CI, 1.95-3.98) in the 1960s to 8.3% (95% CI, 8.08-8.62) in the 2010s (P < .001). Both male (32.0%-55.1%, P < .001) and female (40.6%-58.5%, P < .001) subjects experienced increasing myopia prevalence from the 1960s to the 2010s; both male (2.6%-7.4%, P < .001) and female (3.4%-9.1%, P < .001) subjects also had higher high myopia prevalence rates from the 1960s through the 2010s. Increasing myopia and high myopia prevalence was detected by decade in nearly all age groups (excluding 18- to 24-year-old high myopia subjects). White and Asian subjects had the highest myopia prevalence, whereas Black subjects had the lowest. From the 2000s to the 2010s, White (53.3%-57.0%, P < .001) and Black (41.0%-47.0%, P = .001) subjects had significant increases in myopia prevalence. The mean SE decreased from the 1960s (-0.42 D; 95% CI, -0.59 to +2.49) to the 2010s (-1.85 D; 95% CI, -1.88 to +2.96) (P < .001)., Conclusions: From 1966 to 2019 in Olmsted County, Minnesota, there was a 68% and 199% increase in myopia and high myopia prevalence, respectively., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Primary cutaneous melanoma incidence is increasing in elderly individuals. This population-based cohort examines incidence and mortality rates among adults aged 61 years and older with cutaneous melanoma., Materials and Methods: Using the Rochester Epidemiology Project, patients aged 61 years of age or older with a first lifetime diagnosis of cutaneous melanoma between January 1, 1970 and December 31, 2020 were identified., Results: The age- and sex-adjusted incidence rate increased from 16.4 (95% CI, 8.2-24.6) per 100,000 person-years in 1970 to 1979 to 201.5 (95% CI, 185.1-217.8) per 100,000 person-years in 2011 to 2020 (12.3-fold increase). There was a 16.0x increase in males and an 8.5× increase in females. Melanoma incidence has stabilized in males (1.2-fold increase, p = .11) and continues to significantly increase in females (2.7-fold increase, p < .001). Older age at diagnosis was significantly associated with an increased risk of death (HR 1.23 per 5-year increase in age at diagnosis, 95% CI, 1.02-1.47)., Conclusion: Melanoma incidence continues to increase since 1970. The incidence has risen in elderly females, but has stabilized in males. Mortality has decreased throughout this period., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)