L. J. Melton

Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota.

BACKGROUND & AIMSnGastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota.nnnMETHODSnA reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years.nnnRESULTSnThe prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation.nnnCONCLUSIONSnSymptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.

The worldwide problem of osteoporosis: Insights afforded by epidemiology

Osteoporosis is one of the major problems facing women and older people of both sexes. The morbid event in osteoporosis is fracture. However, the definition of osteoporosis should not require the presence of fractures but only a decrease in bone mass that is associated with an unacceptably high risk of fracture. In the USA, approximately 1.5 million fractures annually are attributable to osteoporosis: these include 700,000 vertebral fractures, 250,000 distal forearm (Colles) fractures, 250,000 hip fractures, and 300,000 fractures of other limb sites. The lifetime risk of fractures of the spine (symptomatic), hip, and distal radius is 40% for white women and 13% for white men from 50 years of age onwards. Following a hip fracture, there is a 10%-20% mortality over the subsequent 6 months, 50% of sufferers will be unable to walk without assistance, and 25% will require long-term domiciliary care. Contrary to prevailing opinion, the morbidity and suffering associated with wrist and spine fractures are also considerable. The annual cost of osteoporosis to the US healthcare system is at least

Epidemiology of idiopathic dilated and hypertrophic cardiomyopathy. A population-based study in Olmsted County, Minnesota, 1975-1984.

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Vertebral fractures predict subsequent fractures.

10 billion with similar incidence and cost in other developed countries. These already high costs will increase further with continued aging of the population. In addition, the population explosion in underdeveloped countries will change the demography of osteoporosis; for example, the incidence of hip fracture, and, presumably, other osteoporotic fractures will increase four-fold worldwide during the next 50 years and the attendant costs will threaten the viability of the healthcare systems of many countries. Unless decisive steps for preventive intervention are taken now, a catastrophic global epidemic of osteoporosis seems inevitable.

Fracture Incidence in Olmsted County, Minnesota: Comparison of Urban with Rural Rates and Changes in Urban Rates Over time

Using the records linkage system of the Mayo Clinic and of the Rochester Epidemiology Project, which accesses diagnostic data on the entire population of Olmsted County, Minnesota, we identified 45 new cases of idiopathic dilated cardiomyopathy (DCM) and 19 new cases of hypertrophic cardiomyopathy (HCM) among county residents for the years 1975-1984. Overall age- and sex-adjusted incidence rates were 6.0/100,000 and 2.5/100,000 person-years, respectively. The incidence of DCM doubled from 3.9/100,000 in the first 5 years to 7.9/100,000 person-years in the last 5 years of study. The corresponding change for HCM was from 1.4 to 3.6/100,000 person-years. Age- and sex-adjusted prevalence rates as of January 1, 1985, for DCM and HCM were 36.5/100,000 and 19.7/100,000 population, respectively. The prevalence of DCM in persons less than 55 years old was 17.9/100,000, over a third of whom were New York Heart Association functional Class III or IV at diagnosis. These estimates may be of value in determining the potential use of health care resources, particularly cardiac transplantation.

Forearm fractures as predictors of subsequent osteoporotic fractures

Abstract:This population-based study documents an increase in most types of fractures following the occurrence of a clinically recognized vertebral fracture among 820 Rochester, Minnesota, residents. During 4349 person-years of follow-up, 896 new fractures were observed. Relative to incidence rates in the community, there was a 2.8-fold increase in the risk of any fracture, which was greater in men (standardized incidence ratio (SIR), 4.2; 95% CI, 3.2–5.3) than women (SIR, 2.7; 95% CI, 2.4–3.0). The estimated cumulative incidence of any fracture after 10 years was 70%. The greatest increase in risk was for subsequent fractures of the axial skeleton, in particular a 12.6-fold increase (95% CI, 11–14) in additional vertebral fractures. There was a lesser increase in most limb fractures, including a 2.3-fold increase (95% CI, 1.8–2.9) in hip fractures and a 1.6-fold increase (95% CI, 1.01–2.4) in distal forearm fractures. There was a slightly greater association with distal forearm fractures among those whose first vertebral fracture occurred before age 70 years but a similar relationship with hip fractures, including cervical and intertrochanteric hip fractures separately, regardless of age at the initial vertebral fracture. There was also an equivalent increase in subsequent fracture risk whether the initial vertebral fracture was attributed to severe or moderate trauma. These data show that vertebral fractures represent an important risk factor for fractures in general, not just those of the spine and hip.

Secular trends in the epidemiology and outcome of Barrett's oesophagus in Olmsted County, Minnesota

Abstract: Using the data resources of the Rochester Epidemiology Project, we carried out a descriptive study of fracture incidence among the residents of Olmsted County, Minnesota. During the 3-year period 1989–91, 2901 County residents ≥u200935 years of age experienced 3665 separate fractures. The age- and sex-adjusted (to 1990 United States whites) incidence of any fracture was 2205 per 100u2009000 person-years (95% CI, 2123 to 2286) and that of all fractures was 2797 per 100u2009000 (95% CI, 2705 to 2889). Age-adjusted fracture rates were 40% greater among women. Incidence rates increased with age in both sexes. One-third of the fractures involved the hip, spine or distal forearm – the skeletal sites traditionally associated with osteoporosis. The age- and sex-adjusted incidence of fractures due to moderate trauma (2205 per 100u2009000 person-years; 95% CI, 2106 to 2303) was twice that of fractures due to more severe trauma (1164 per 100u2009000; 95% CI, 1106 to 1223) and 12 times that of pathological fractures (178 per 100u2009000; 95% CI, 133 to 222). Overall fracture rates were 15% greater among residents of the central city of Rochester compared with the rural portion of Olmsted County. The incidence of limb fractures among Rochester residents was 14% higher than comparable rates documented for this community 20 years earlier in 1969–71, due mainly to a substantial increase in the incidence of leg fractures.

Epidemiology of hip fractures: Implications of the exponential increase with age

Abstract: To assess the ability of distal forearm fractures to predict future fractures, we conducted a population-based retrospective cohort study among the 1288 residents (243 men, 1045 women) of Rochester, Minnesota age 35 years or older who experienced their first distal forearm fracture in 1975–94. During 9664 person-years of follow-up, 548 patients experienced 1109 subsequent fractures, excluding 195 that occurred on the same day as the index forearm fracture. The cumulative incidence of any subsequent fracture was 55% by 10 years and 80% by 20 years following the initial distal forearm fracture. Compared to expected fracture rates in the community, the risk of a hip fracture following the index forearm fracture was increased 1.4-fold in women (95% CI, 1.1–1.8) and 2.7-fold in men (95% CI, 0.98–5.8). In women, the risk of hip fracture differed by age, as we had found in a previous study. Women over age 70 had a 1.6-fold increase (95% CI, 1.2–2.0) in subsequent hip fracture risk whereas women who sustained their first forearm fracture before age 70 years did not have significantly increased risk. By contrast, vertebral fractures were significantly increased at all ages, with a 5.2-fold increase (95% CI, 4.5–5.9) in risk among women and a 10.7-fold increase (95% CI, 6.7–16.3) among men following a first distal forearm fracture. The increased risk in men suggests that a sentinel forearm fracture should not be ignored. Among the women, we also found a missed opportunity for intervention as hormone replacement therapy was underutilized.

Direct Medical Costs Attributable to Osteoporotic Fractures

BACKGROUND The incidence of oesophageal adenocarcinoma has increased greatly. Barretts oesophagus is a known risk factor. AIMS To identify changes in the incidence, prevalence, and outcome of Barretts oesophagus in a defined population. SUBJECTS Residents of Olmsted County, Minnesota, with clinically diagnosed Barretts oesophagus, or oesophageal or oesophagogastric junction adenocarcinoma. METHODS Cases were identified using the Rochester Epidemiology Project medical records linkage system. Records were reviewed with follow up to 1 January 1998. RESULTS The incidence of clinically diagnosed Barretts oesophagus (>3 cm) increased 28-fold from 0.37/100 000 person years in 1965–69 to 10.5/100 000 in 1995–97. Of note, gastroscopic examinations increased 22-fold in this same time period. The prevalence of diagnosed Barretts oesophagus increased from 22.6 (95% confidence interval (CI) 11.7–33.6) per 100 000 in 1987 to 82.6/100 000 in 1998. The prevalence of short segment Barretts oesophagus (<3 cm) in 1998 was 33.4/ 100 000. Patients with Barretts oesophagus had shorter than expected survival but only one patient with Barretts oesophagus died from adenocarcinoma. Only four of 64 adenocarcinomas occurred in patients with previously known Barretts oesophagus. CONCLUSIONS The incidence and prevalence of clinically diagnosed Barretts oesophagus have increased in parallel with the increased use of endoscopy. We infer that the true population prevalence of Barretts oesophagus has not changed greatly, although the incidence of oesophageal adenocarcinoma increased 10-fold. Many adenocarcinomas occurred in patients without a previous diagnosis of Barretts oesophagus, suggesting that many people with this condition remain undiagnosed in the community.

Impact of Hip and Vertebral Fractures on Quality-Adjusted Life Years

Of the fractures linked with osteoporosis, hip fractures are most important in terms of death, functional dependence, and social cost. Reduction of these adverse outcomes depends on preventing hip fractures, which are caused by falling on a biomechanically compromised proximal femur. Skeletal strength depends on the amount of bone and its structural arrangement, whereas the traumatic load on the proximal femur is dictated by the orientation of the fall and other factors. One or several of these underlying mechanisms account for the various risk factors that have been identified for hip fracture, including greater incidence rates among women than men and among white than nonwhite populations. However, the exponentially increasing incidence of hip fractures with age indicates that a complex interplay of factors determines the risk of fracture in each person. The multifactorial nature of the problem suggests that hip fractures will be difficult to prevent even as the fractures and their associated costs continue to rise with the increased number of older people. However, the variability of hip fracture rates within high risk populations in Europe and North America reflects the existence of other powerful risk factors that, if identified, might provide the basis for more effective interventions.