The epidemiology of venous thromboembolism in the community.

The incidence of venous thromboembolism exceeds 1 per 1000; over 200,000 new cases occur in the United States annually. Of these, 30% die within 30 days; one-fifth suffer sudden death due to pulmonary embolism. Despite improved prophylaxis, the incidence of venous thromboembolism has been constant since 1980. Independent risk factors for venous thromboembolism include increasing age, male gender, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, central venous catheter/transvenous pacemaker, prior superficial vein thrombosis, and varicose veins; among women, risk factors include pregnancy, oral contraceptives, and hormone replacement therapy. About 30% of surviving cases develop recurrent venous thromboembolism within ten years. Independent predictors for recurrence include increasing age, obesity, malignant neoplasm, and extremity paresis. About 28% of cases develop venous stasis syndrome within 20 years. To reduce venous thromboembolism incidence, improve survival, and prevent recurrence and complications, patients with these characteristics should receive appropriate prophylaxis.

Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study.

BACKGROUND: The incidence rates of venous stasis syndrome and venous ulcer are uncertain, and trends in incidence are unknown. METHODS: We performed a retrospective review of the complete (inpatient and outpatient) medical records of a community population (Olmsted County, Minnesota) to estimate the incidence of venous stasis syndrome and venous ulcer during the 25-year period, 1966 to 1990, and to describe trends in incidence. RESULTS: A total of 1131 patients received a first lifetime diagnosis of venous stasis syndrome. A total of 263 patients received a first lifetime diagnosis of venous ulcer. The overall incidence of venous stasis syndrome and venous ulcer were 76.1 and 18.0 per 100,000 person-years, respectively. The incidence of both was higher in women than in men (83.7 vs 67.4 per 100,000 person-years for venous stasis syndrome; 20.4 vs 14.6 per 100,000 for venous ulcer) and increased with age for both sexes. There was no clear trend in the incidence of venous stasis syndrome over the 25-year period. Compared with 1966 to 1970, the incidence of venous ulcer decreased in 1971 to 1980, but was unchanged after 1981. Among 945 patients with venous stasis only, 60 subsequently had a venous ulcer. The average (+/- SD) time from venous stasis diagnosis to development of a venous ulcer was 5.0 (+/- 5.0) years. CONCLUSION: Venous stasis syndrome and venous ulcer are common, especially in the elderly population. The incidence of venous stasis syndrome has not changed since 1966, and venous ulcer incidence is unchanged since 1981. More accurate identification of patients at risk for venous stasis syndrome and venous ulcer and more effective prevention are needed.

Predicted impact of attaining smoking reduction goals on mortality.

The impact of reducing smoking initiation, increasing smoking cessation, and combination approaches on life expectancy, deaths averted, and life-years gained in a birth cohort of 50,000 persons and in the state population (3.6 million) were analyzed. A 60% reduction in initiation of smoking in adolescents would increase life expectancy by 0.42 years. Over the next 100 years, there would be an additional 18,000 years of life for a birth cohort and an additional 675,000 years of life for the state's population. The reduction in mortality, however, would not begin before 35 years, and only 25% of the benefit would occur in the next 70 years. An increase in smoking cessation would have a smaller impact that would occur sooner. Maximum reduction in mortality could be achieved by reducing initiation and increasing cessation at all ages, but a reduction in mortality would not occur for several decades.

Risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum: a population-based, case-control study.

OBJECTIVE: We sought to determine risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum. STUDY DESIGN: We performed a population-based case-control study. All Olmsted County, Minnesota, residents with a first lifetime deep vein thrombosis or pulmonary embolism during pregnancy or post partum from 1966 to 1990 were identified (N = 90). Where possible, a resident without deep vein thrombosis or pulmonary embolism was matched to each patient by date of the first live birth after the patient's child. The medical records of all remaining patients and all control subjects were reviewed for >25 baseline characteristics, which were tested as risk factors for deep vein thrombosis or pulmonary embolism. RESULTS: In multivariate analysis smoking (odds ratio, 2.4) and prior superficial vein thrombosis (odds ratio, 9.4) were independent risk factors for deep vein thrombosis or pulmonary thrombosis during pregnancy or post partum. CONCLUSION: Venous thromboembolism prophylaxis may be warranted for pregnant women with prior superficial vein thrombosis. Smoking cessation should be recommended, especially during pregnancy and the postpartum period.

Bone marrow transplantation versus periodic prophylactic blood transfusion in sickle cell patients at high risk of ischemic stroke: a decision analysis.

Measurement of cerebral blood velocity (CBV) by transcranial Doppler has been used to identify patients with sickle cell disease (SCD) who are at high risk of ischemic stroke. This study examines outcomes of bone marrow transplantation (BMT) and periodic blood transfusion (PBT) as a basis for making treatment recommendations for patients who have elevated CBV and no other indications for BMT. Decision analysis was used to compare the number of quality-adjusted life years (QALYs) experienced by a population of patients with SCD at high risk for stroke who were treated with PBT or BMT. Markov models were constructed to represent the clinical course of patients with SCD who were treated with PBT or BMT. Medical literature and expert opinion provided risks of stroke and death for different disease states, estimates of transition probabilities from one clinical state to another, and quality of life. An intention-to-treat analysis and an analysis of treatment received were both performed on hypothetical cohorts of 100 000 patients. Patients with SCD who were managed with a strategy of intending to provide BMT could expect 16.0 QALYs, compared with 15.7 QALYs for a strategy of intending to provide PBT; however, the variation around these estimates was large. In the treatment received analysis, patients compliant with PBT therapy and iron chelation could expect the best outcomes (19.2 QALYs). From a policy perspective, neither BMT nor PBT can be considered the "best" treatment for children with SCD who have abnormal CBV. Abnormal CBV should not be the only criterion for selecting patients with sickle cell for BMT.

Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study.

BACKGROUND: The appropriate duration of oral anticoagulation after a first episode of venous thromboembolism (VTE) is uncertain and depends upon VTE recurrence rates. OBJECTIVE: To estimate VTE recurrence rates and determine predictors of recurrence. METHODS: Patients in Olmsted County, Minnesota, with a first lifetime deep vein thrombosis or pulmonary embolism diagnosed during the 25-year period from 1966 through 1990 (N = 1,719) were followed forward in time through their complete medical records in the community for first VTE recurrence. RESULTS: Four hundred four patients developed recurrent VTE during 10,198 person-years of follow-up. The overall (probable/definite) cumulative percentages of VTE recurrence at 7, 30, and 180 days and 1 and 10 years were 1.6% (0.2%), 5.2% (1.4%), 10.1% (4.1%), 12.9% (5.6%), and 30.4% (17.6%), respectively. The risk of recurrence was greatest in the first 6 to 12 months after the initial event but never fell to zero. Independent predictors of first overall VTE recurrence included increasing age and body mass index, neurologic disease with paresis, malignant neoplasm, and neurosurgery during the period from 1966 through 1980. Independent predictors of first probable/definite recurrence included diagnostic certainty of the incident event and neurologic disease in patients with hospital-acquired VTE. Recurrence risk was increased by malignant neoplasm but varied with concomitant chemotherapy, patient age and sex, and study year. CONCLUSIONS: Venous thromboembolism recurs frequently, especially within the first 6 to 12 months, and continues to recur for at least 10 years after the initial VTE. Patients with VTE with neurologic disease and paresis or with malignant neoplasm are at increased risk for recurrence, while VTE patients with transient or reversible risk factors are at less risk.

Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study.

BACKGROUND: Reported risk factors for venous thromboembolism (VTE) vary widely, and the magnitude and independence of each are uncertain. OBJECTIVES: To identify independent risk factors for deep vein thrombosis and pulmonary embolism and to estimate the magnitude of risk for each. PATIENTS AND METHODS: We performed a population-based, nested, case-control study of 625 Olmsted County, Minnesota, patients with a first lifetime VTE diagnosed during the 15-year period from January 1, 1976, through December 31, 1990, and 625 Olmsted County patients without VTE. The 2 groups were matched on age, sex, calendar year, and medical record number. RESULTS: Independent risk factors for VTE included surgery (odds ratio [OR], 21.7; 95% confidence interval [CI], 9.4-49.9), trauma (OR, 12.7; 95% CI, 4.1-39.7), hospital or nursing home confinement (OR, 8.0; 95% CI, 4.5-14.2), malignant neoplasm with (OR, 6.5; 95% CI, 2.1-20.2) or without (OR, 4.1; 95% CI, 1.9-8.5) chemotherapy, central venous catheter or pacemaker (OR, 5.6; 95% CI, 1.6-19.6), superficial vein thrombosis (OR, 4.3; 95% CI, 1.8-10.6), and neurological disease with extremity paresis (OR, 3.0; 95% CI, 1.3-7.4). The risk associated with varicose veins diminished with age (for age 45 years: OR, 4.2; 95% CI, 1.6-11.3; for age 60 years: OR, 1.9; 95% CI, 1.0-3.6; for age 75 years: OR, 0.9; 95% CI, 0.6-1.4), while patients with liver disease had a reduced risk (OR, 0.1; 95% CI, 0.0-0.7). CONCLUSION: Hospital or nursing home confinement, surgery, trauma, malignant neoplasm, chemotherapy, neurologic disease with paresis, central venous catheter or pacemaker, varicose veins, and superficial vein thrombosis are independent and important risk factors for VTE.

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

OBJECTIVE: To examine the effectiveness of screening proctosigmoidoscopy, barium enema radiography, and the fecal occult blood test (FOBT) in decreasing colorectal cancer mortality in a community setting. PATIENTS AND METHODS: In this population-based case-control study, cases comprised 218 Rochester, Minn, residents who died of colorectal cancer between 1970 and 1993. Controls were 435 age- and sex-matched residents who did not have a diagnosis of colorectal cancer. Screening proctosigmoidoscopy, barium enema radiography, and FOBT results were documented for the 10 years prior to and including the date of diagnosis of fatal colorectal cancer in cases and for the same period in matched controls. History of general medical examinations and hospitalizations was also recorded. RESULTS: Within the 10 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening proctosigmoidoscopy were 23 (10.6%) of 218 cases vs 43 (9.9%) of 435 controls; at least 1 screening barium enema radiographic study was done in 12 (5.5%) of 218 vs 25 (5.7%) of 435. Within 3 years prior to diagnosis, the percentages of cases vs controls with at least 1 screening FOBT were 27 (12.4%) of 218 vs 44 (10.1%) of 435. Adjusted odds ratios were 1.04 (95% confidence interval [CI], 0.21-5.13) for proctosigmoidoscopy (distal rectosigmoid cancers only), 0.67 (95% CI, 0.31-1.48) for barium enema radiography, and 0.83 (95% CI, 0.45-1.52) for FOBT over the above time periods. CONCLUSION: In this case-control study within a community setting, a colorectal cancer-specific mortality benefit could not be demonstrated for screening by FOBT, proctosigmoidoscopy, or barium enema radiography. Screening frequency was low, which may have contributed to the lack of measurable effects.

Costs, charges, and reimbursements for persons with sickle cell disease.

PURPOSE: The aims of this study were to describe health care costs and charges for patients with sickle cell disease (SCD) and identify predictors of high use. PATIENTS AND METHODS: Patients with SCD were identified by International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes from a university hospital's administrative databases from January 1, 1996, to September 30, 1997. Clinical and administrative data were gathered on each patient for all hospital admissions and ambulatory clinic visits. Logistic regression models were used to determine predictors of high health care use. RESULTS: A total of 947 patients with SCD were identified, 73% of whom resided within three South Carolina counties. On average, there were 0.9 admissions per patient per year and 8.0 outpatient visits per patient per year. Mean inpatient hospital charges, physician charges, and direct hospital costs per admission were $7290, $1589, and $5405, respectively, and the average length of stay was 4.5 days. Mean hospital charges, physician charges, and direct hospital costs per outpatient visit were $305, $169, and $688, respectively. Forty percent of the inpatient hospital charges were accounted for by only 4.2% of the patients. Residing in a distant county and being admitted with a diagnosis of painful respiration were found to be predictors of excessive charges and expenses beyond expected reimbursements. CONCLUSIONS: Patients with SCD are frequent users of health care services. Charges and costs are distributed disproportionately across these patients. Predictors of excessive hospital charges include living geographically distant from the hospital and being admitted with a diagnosis of painful respiration.

Clinical course and costs of care for Crohn's disease: Markov model analysis of a population-based cohort.

BACKGROUND & AIMS: Crohn's disease results in substantial morbidity and high use of health services. The aim of this study was to describe the lifetime clinical course and costs of Crohn's disease in a 24-year population-based inception cohort of patients with Crohn's disease in Olmsted County, Minnesota. METHODS: Disease states were defined by medical and surgical treatment. A Markov model analysis calculated time in each disease state and present value of excess lifetime costs in comparison with an age- and sex-matched cohort. RESULTS: For a representative patient, projected lifetime costs were $39,906 per patient using median charges and $125,404 using mean charges. There were 29.1 years (63% of total) without medications. There were 12.7 years (27%) on aminosalicylate therapy, generating $11,467 (29%) in charges, and 3.2 years (7%) on corticosteroid or immunosuppressive therapy, generating $5147 (13%) in charges. Surgery generated $17,526 (44%) in charges. CONCLUSIONS: Most of the clinical course is spent in remission, either medical or surgical. Aminosalicylate therapy accounts for 29% of the costs of care. Surgery has the highest charges but the longest remissions. Treatment strategies that induce remission in mild disease and maintain remission with lower-cost maintenance therapy will have the largest effect on patient outcomes and costs.

Solitary pulmonary nodules: clinical prediction model versus physicians.

OBJECTIVE: To determine whether a clinical prediction model developed to identify malignant lung nodules based on clinical data and radiologic lung nodule characteristics could predict a malignant lung nodule diagnosis with higher accuracy than physicians. MATERIAL AND METHODS: One hundred cases were obtained by using a stratified random sample from a retrospective cohort of 629 patients with newly discovered 4- to 30-mm radiologically indeterminate solitary pulmonary nodules (SPNs) on chest radiography. A chest radiologist, pulmonologist, thoracic surgeon, and general internist made predictions of a malignant lesion and recommendations for management (thoracotomy, transthoracic needle aspiration biopsy, or observation) on the basis of radiologic and clinical data used to develop the clinical prediction rule. The predictions of a malignant lung nodule were compared with the probability of malignant involvement from a previously validated clinical prediction model to identify malignant nodules on the basis of three clinical characteristics (age, smoking status, and history of cancer greater than or equal to 5 years previously) and three radiologic characteristics (nodule diameter, spiculation, and upper lobe location). RESULTS: Receiver operating characteristic analysis showed no significant difference between the logistic model and the physicians' predictions. Calibration curves revealed that physicians overestimated the probability of a malignant lesion in patients with low risk of malignant disease by the prediction rule; this finding suggests a potential for the decision rule to improve the management of patients with SPNs that are likely to be benign. CONCLUSION: The prediction model was not better than physicians' predictions of malignant SPNs. The prediction rule may have potential to improve the management of patients with SPNs that are likely to be benign.

Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study.

BACKGROUND: Because reported survival after venous thromboembolism (VTE) varies widely, we performed a population-based retrospective cohort study to estimate survival, compare observed with expected survival, and determine predictors of short-term (< or =7 days) and long-term survival (>7 days) after VTE. METHODS: We followed the 25-year (1966-1990) inception cohort (n = 2218) of Olmsted County, Minnesota, patients with deep vein thrombosis alone (DVT) or pulmonary embolism with or without deep vein thrombosis (PE+/-DVT) forward in time until death or the last clinical contact. RESULTS: During 14 629 person-years of follow-up, 1333 patients died. Seven-day, 30-day, and 1-year VTE survival rates were 74.8% (DVT, 96.2%; PE+/-DVT, 59.1%), 72.0% (DVT, 94.5%; PE+/-DVT, 55.6%), and 63.6% (DVT, 85.4%; PE+/-DVT, 47.7%), respectively. Observed survival after DVT, PE+/-DVT, and overall was significantly worse than expected for Minnesota whites of similar age and sex (P<.001). More than one third of deaths occurred on the date of onset or after VTE that was unrecognized during life. Short-term survival improved during the 25-year study period, while long-term survival was unchanged. After adjusting for comorbid conditions, PE+/-DVT was an independent predictor of reduced survival for up to 3 months after onset compared with DVT alone. Other independent predictors of both short- and long-term survival included age, body mass index, patient location at onset, malignancy, congestive heart failure, neurologic disease, chronic lung disease, recent surgery, and hormone therapy. Additional independent predictors of long-term survival included tobacco smoking, other cardiac disease, and chronic renal disease. CONCLUSIONS: Survival after VTE, and especially after PE+/-DVT, is much worse than reported, and significantly less than expected survival. Compared with DVT alone, symptomatic PE+/-DVT is an independent predictor of reduced survival for up to 3 months after onset, implying that treatment for the 2 disorders should be different.

Screening digital rectal examination and prostate cancer mortality: a population-based case-control study.

OBJECTIVES: Although digital rectal examination (DRE) for the detection of prostate cancer has been recommended by many professional groups and has become part of the general physical examination, no randomized clinical trial has demonstrated the efficacy or effectiveness of this practice. We conducted a population-based case-control study to evaluate the association between DRE and prostate cancer mortality. METHODS: With the resources of the Rochester Epidemiology Project, all 173 men who died of prostate cancer in Olmsted County from 1976 to 1991, who were resident at the time of diagnosis, were identified. For each case, two control patients were drawn from the population, matched for residence at the time of diagnosis in the case, birth date, and duration of medical record in Olmsted County. Trained nurse abstractors reviewed the community medical records for up to 10 years before the date of diagnosis in the case for mention of DRE and specific findings associated with each mention. RESULTS: Case subjects were less likely than control subjects to have had any DRE in the 10 years before diagnosis (matched odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.31, 0.84). When limited to DREs without mention of signs or symptoms that might raise suspicion of prostate cancer, the association was even stronger (OR = 0.31; 95% CI = 0.19, 0.49). Adjustment for educational attainment, marital status, and comorbid conditions did little to alter the associations. CONCLUSIONS: These results demonstrate a strong inverse association between DRE and prostate cancer mortality. If further research concludes this association to be causal, screening DREs may have prevented as many as 50% to 70% of deaths due to prostate cancer that might have occurred in the absence of screening.

Crohn's disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival.

BACKGROUND & AIMS: Many centers worldwide have reported an increased incidence of Crohn's disease, but population-based data in North America are sparse. We studied the incidence and prevalence of Crohn's disease in Olmsted County, Minnesota, and examined temporal trends in incidence and survival. METHODS: Residents diagnosed with Crohn's disease between 1970 and 1993 were incidence cases, and residents with Crohn's disease who were alive on January 1, 1991, were prevalence cases. Cases from previous studies were reconfirmed. Rates were adjusted using 1990 U.S. Census figures for whites. Incidence trends were evaluated with a Poisson regression model. Survival from diagnosis was compared with that expected for U.S. north-central whites. RESULTS: Between 1940 and 1993, 225 incidence cases were identified, for an adjusted incidence rate of 5.8 per 100,000 person-years. On January 1, 1991, there were 145 residents with Crohn's disease, an adjusted prevalence rate of 133 per 100,000, 46% higher than that seen in 1980. Incidence rates before 1964 were significantly lower than those of 1989-1993. Observed survival was less than expected (P = 0.007). CONCLUSIONS: The incidence of Crohn's disease has stabilized since the 1970s at a rate higher than that seen previously. Prevalence has increased by 46% since 1980. Overall survival is slightly decreased.

Expert panel assessment of appropriateness of abdominal aortic aneurysm surgery: global judgement versus probability estimation.

OBJECTIVE: To compare an expert panel's global assessment of appropriateness of elective surgery for abdominal aortic aneurysms (AAA) with their assessment of the effect of surgery on the probability of 5-year mortality. METHODS: Nine expert panel members rated the appropriateness of 120 scenarios for elective AAA repair on a nine-point scale, and also estimated the 5-year probability of AAA-related death and of non-AAA related death among 30-day survivors of AAA surgery and among patients with unoperated AAA. These probabilities were used to determine differences in 5-year probability of mortality of surgery vs. no surgery for each scenario. Three categories of appropriateness were defined based on these differences: inappropriate (< 0%), equivocal (0-5%), and appropriate (> 5%). RESULTS: The distribution of scenarios was inappropriate (39%), equivocal (12%), and appropriate (49%) based on probability estimates and inappropriate (43%), equivocal (22%), and appropriate (36%) based on global assessment. There was poor agreement between the two methods, with a Kappa coefficient = 0.28 (95% CI: 0.23 to 0.32). Although a higher proportion of scenarios were rated as appropriate using probability estimation rather than global judgment, the level of agreement among members of the panel was similar, Kappa coefficient = 0.07 (95% CI: -0.07 to 0.72). CONCLUSIONS: Experts disagree about the appropriate indications for elective surgery for AAA. Explicit estimates used in a decision analysis may provide a better assessment of appropriate indications than the global judgment of experts. Global assessment of the appropriateness of AAA surgery based on panel members' review of research evidence for increased survival appears to include implicitly their valuation of outcomes.

Risk factors for 30-day mortality in elderly patients with lower respiratory tract infection. Community-based study.

BACKGROUND: Pneumonia is a major cause of death in the elderly, but there are few studies of risk factors for death that include both ambulatory and nursing home patients. OBJECTIVE: To assess factors associated with 30-day mortality in a population-based study of older adults with lower respiratory tract infection. METHODS: Identification of (1) a previously identified retrospective cohort of all residents of Rochester, Minn, aged 65 years or older who experienced a first episode of pneumonia or bronchitis during a calendar year and (2) the risk factors associated with 30-day mortality through review of complete inpatient and ambulatory medical records. Logistic regression was used to identify significant independent risk factors for 30-day mortality. RESULTS: A total of 413 adults aged 65 years or older were identified. The independent factors for 30-day mortality were atypical symptoms (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.14-11.60), neurologic illness (OR, 3.92; 95% CI, 1.47-6.59), current diagnosis of cancer (OR, 6.2; 95% CI, 2.40-15.99), and recent or current use of antibiotics (OR, 3.13; 95% CI, 1.45-6.77). CONCLUSIONS: Malignancy and neurologic disease are well-recognized conditions that identify patients with lower respiratory tract infections who have a high risk of death within 30 days. An atypical presentation with confusion, lethargy, poor eating, or recent or current antibiotic use also identifies patients, with a high risk of 30-day mortality.

Organizing pneumonia. Features and prognosis of cryptogenic, secondary, and focal variants.

BACKGROUND: Organizing pneumonia (OP) is a non-specific response to many types of lung injury. Clinicians frequently encounter pathology reports of OP in patients with no underlying condition (cryptogenic OP, also known as BOOP or bronchiolitis obliterans OP) or in association with drugs or nonpulmonary disease. The goals of this study are to describe the clinical course and outcomes in patients with 3 clinical variants of OP. METHODS: A retrospective study of patients with OP seen at the Mayo Clinic, Rochester, Minn, from January 1, 1984, through June 30, 1994, was conducted. Initial features were obtained from medical records. Chest radiographs and pathology specimens were reviewed for this study. Resolution, relapse, and survival were obtained from medical records and a follow-up patient questionnaire. RESULTS: Seventy-four patients had pathologically confirmed OP. Organizing pneumonia was classified into 3 clinical groups: symptomatic cryptogenic OP; symptomatic OP related to underlying hematologic malignant neoplasm, collagen vascular disease, or drugs (secondary OP); and asymptomatic OP presenting as a focal nodule (focal OP). Thirty-seven patients (50%) had cryptogenic OP and 27 patients (36%) had secondary OP. No difference was found between cryptogenic and secondary OP in type or severity of symptoms, signs, laboratory and pulmonary function tests, or radiologic or pathologic findings. Corticosteroids were given at a similar initial dose (prednisone, about 50 mg/d). Resolution of symptoms was more frequent in patients with cryptogenic OP than those with secondary OP. Relapse was infrequent in both of these groups. Five-year survival was higher in patients with cryptogenic OP (73%) than in secondary OP (44%), and respiratory-related deaths were more frequent in patients with secondary OP. Organizing pneumonia was an asymptomatic focal rounded opacity in 10 patients (14%), most often detected on chest radiograph and diagnosed on lung biopsy done for suspicion of lung cancer. Patients with focal OP required no treatment and had no relapse or respiratory-related deaths. CONCLUSIONS: Clinical classification of OP is useful to predict clinical course and outcome. Cryptogenic OP most often was a symptomatic bilateral lung process that had an overall favorable prognosis with prolonged corticosteroid therapy. Patients with secondary OP had a high mortality rate when the disease was associated with predisposing conditions or drugs. Patients with asymptomatic focal OP had an excellent prognosis.

The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules.

BACKGROUND: A clinical prediction model to identify malignant nodules based on clinical data and radiological characteristics of lung nodules was derived using logistic regression from a random sample of patients (n = 419) and tested on data from a separate group of patients (n = 210). OBJECTIVE: To use multivariate logistic regression to estimate the probability of malignancy in radiologically indeterminate solitary pulmonary nodules (SPNs) in a clinically relevant subset of patients with SPNs that measured between 4 and 30 mm in diameter. PATIENTS AND METHODS: A retrospective cohort study at a multispecialty group practice included 629 patients (320 men, 309 women) with newly discovered (between January 1, 1984, and May 1, 1986) 4- to 30-mm radiologically indeterminate SPNs on chest radiography. Patients with a diagnosis of cancer within 5 years prior to the discovery of the nodule were excluded. Clinical data included age, sex, cigarette-smoking status, and history of extrathoracic malignant neoplasm, asbestos exposure, and chronic interstitial or obstructive lung disease; chest radiological data included the diameter, location, edge characteristics (eg, lobulation, spiculation, and shagginess), and other characteristics (eg, cavitation) of the SPNs. Predictors were identified in a random sample of two thirds of the patients and tested in the remaining one third. RESULTS: Sixty-five percent of the nodules were benign, 23% were malignant, and 12% were indeterminate. Three clinical characteristics (age, cigarette-smoking status, and history of cancer [diagnosis, > or = 5 years ago]) and 3 radiological characteristics (diameter, spiculation, and upper lobe location of the SPNs) were independent predictors of malignancy. The area (+/-SE) under the evaluated receiver operating characteristic curve was 0.8328 +/- 0.0226. CONCLUSION: Three clinical and 3 radiographic characteristics predicted the malignancy in radiologically indeterminate SPNs.

Epiglottitis in adults and children in Olmsted County, Minnesota, 1976 through 1990.

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.

High-grade astrocytomas: resource use, clinical outcomes, and cost of care.

OBJECTIVE: To describe the clinical course, survival, resource use, and direct medical costs of care for patients with high-grade astrocytomas. MATERIAL AND METHODS: All patients with grade 3 or 4 astrocytoma who resided in Olmsted County, Minnesota, or one of the six adjacent counties and had a tissue diagnosis first made between 1987 and 1992 were studied. Clinical characteristics, initial management, use of resources, clinical course, survival, and medical charges were analyzed. RESULTS: Sixty-four patients, with a mean age of 62 years, were identified; 81% had glioblastoma multiforme. Approximately 60% underwent surgical resection, 80% had radiotherapy, and 50% had chemotherapy for initial management. After initial treatment (median duration, 116 days), approximately 75% of patients had a course with stable disease (median duration, 198 days). The overall median duration of survival was 323 days; lower grade and younger age were significantly associated with longer median survival-for example, 1,493 days for patients younger than 65 years with grade 3 astrocytomas and 205 days for patients 65 years old or older with grade 4 astrocytomas. The mean total direct medical charges were $67,887. CONCLUSION: In most patients with high-grade astrocytomas, a substantial period elapsed before disease progressed. Although the overall median duration of survival was less than 1 year, younger patients, especially those with grade 3 astrocytomas, had a longer survival. The management of patients with high-grade astrocytomas uses substantial health-care resources.