BackgroundNasal and sinus symptoms (NSS) are common to many health conditions, including chronic rhinosinusitis (CRS). Few studies have investigated the occurrence and severity of, and risk factors for, acute exacerbations of NSS (AENSS) by CRS status (current, past, or never met European Position Paper on Rhinosinusitis [EPOS] criteria for CRS). MethodsFour seasonal questionnaires were mailed to a stratified random sample of Geisinger primary care patients. Logistic regression was used to identify individual characteristics associated with AENSS occurrence and severity by CRS status (current long-term, current recent, past, never) using EPOS subjective symptoms-only (EPOSS) CRS criteria. We operationalized 3 AENSS definitions based on prescribed antibiotics or oral corticosteroids, symptoms, and symptoms with purulence. ResultsBaseline and at least 1 follow-up questionnaires were available from 4736 subjects. Self-reported NSS severity with exacerbation was worst in the current long-term CRS group. AENSS was common in all subgroups examined and generally more common among those with current EPOSS CRS. Seasonal prevalence of AENSS differed by AENSS definition and CRS status. Associations of risk factors with AENSS differed by definition, but CRS status, body mass index, asthma, hay fever, sinus surgery history, and winter season consistently predicted AENSS. ConclusionsIn this first longitudinal, population-based study of 3 AENSS definitions, NSS and AENSS were both common, sometimes severe, and differed by EPOSS CRS status. Contrasting associations of risk factors for AENSS by the different definitions suggest a need for a standardized approach to definition of AENSS.

The long-term effects of repetitive head impacts due to heading are an area of increasing concern, and exposure must be accurately measured; however, the validity of self-report of cumulative soccer heading is not known. In order to validate HeadCount, a 2-week recall questionnaire, the number of player-reported headers was compared to the number of headers observed by trained raters for a men's and a women's collegiate soccer teams during an entire season of competitive play using Spearman's correlations and intraclass correlation coefficients (ICCs), and calibrated using a generalized estimating equation. The average Spearman's rho was 0.85 for men and 0.79 for women. The average ICC was 0.75 in men and 0.38 in women. The calibration analysis demonstrated that men tend to report heading accurately while women tend to overestimate. HeadCount is a valid instrument for tracking heading behaviour, but may have to be calibrated in women.

Background: The objective of this study was to describe the first US-based study to use the European Position Paper on Rhinosinusitis (EPOS) criteria to study the prevalence of chronic rhinosinusitis (CRS) in a general-population sample.Methods: A CRS symptom questionnaire was mailed to 23 700 primary care patients from Geisinger Clinic, a health system serving 45 counties in Pennsylvania. CRS cases were categorized into four unique subgroups based on EPOS symptoms: obstruction and discharge with no smell loss or pain/pressure; smell loss without pain/pressure; facial pain and/or pressure without smell loss; and both smell loss and pain/pressure. All cases were required to have nasal obstruction or discharge. Logistic regression was used to evaluate potential factors associated with CRS subgroups.Results: We found that 11.9% of patients met criteria for CRS. Prevalence peaked at 15.9% between ages 50 and 59 years and then dropped to 6.8% after age 69. The odds of CRS was higher among patients who were white, younger, smokers, had a history of Medical Assistance, and had other diseases. When CRS subgroups were modeled separately, these associations were no longer significant for some CRS subgroups. Comorbid diseases were most strongly associated with CRS cases who reported smell loss and facial pain and/or pressure and had the weakest associations with CRS cases who did not report these symptoms.Conclusions: CRS is a highly prevalent and heterogeneous condition. Differences in risk factors and health outcomes across symptom subgroups may be indicative of differences in etiology that have implications for disease management.

Introduction Electronic health record (EHR) data enhance opportunities for conducting surveillance of diabetes. The objective of this study was to identify the number of people with diabetes from a diabetes DataLink developed as part of the SUPREME-DM (SUrveillance, PREvention, and ManagEment of Diabetes Mellitus) project, a consortium of 11 integrated health systems that use comprehensive EHR data for research. Methods We identified all members of 11 health care systems who had any enrollment from January 2005 through December 2009. For these members, we searched inpatient and outpatient diagnosis codes, laboratory test results, and pharmaceutical dispensings from January 2000 through December 2009 to create indicator variables that could potentially identify a person with diabetes. Using this information, we estimated the number of people with diabetes and among them, the number of incident cases, defined as indication of diabetes after at least 2 years of continuous health system enrollment. Results The 11 health systems contributed 15,765,529 unique members, of whom 1,085,947 (6.9%) met 1 or more study criteria for diabetes. The nonstandardized proportion meeting study criteria for diabetes ranged from 4.2% to 12.4% across sites. Most members with diabetes (88%) met multiple criteria. Of the members with diabetes, 428,349 (39.4%) were incident cases. Conclusion The SUPREME-DM DataLink is a unique resource that provides an opportunity to conduct comparative effectiveness research, epidemiologic surveillance including longitudinal analyses, and population-based care management studies of people with diabetes. It also provides a useful data source for pragmatic clinical trials of prevention or treatment interventions.

The cohort included 27,362 patients.Mean duration of initial therapy was 212 days.Hyperkalemia -associated outcome incidence estimates varied from 33.6 per 1000 p-y (defined as AV, ED or IP visit with K > 5.5 or a coded hyperkalemia diagnosis within 7 days) to 11.0 per 1000 p-y (defined as IP or ED visit with K > 6 or coded diagnosis within 24 hours).Removing AV had the greatest effect and reducing the timeframe to 24 hours had the least effect on incidence estimates.Conclusions: Modifying hyperkalemia definition criteria resulted in up to a 3-fold difference in b y estimates of hyperkalemiaassociated adverse outcomes.Further work linking these findings to adverse events is critical to decisions regarding appropriate definitions to answer specific study questions.We caution against comparing incidence estimates across published studies without considering the severity implications of differences in hyperkalemia outcomes definitions.

and number of BP readings were 39 and 12.4 at G and 33 and 9.9 at P. The mean number of comorbidities was 3.4 at G and 3.7 at P and, by race, 3.5 for C, 3.9 for AA.Medicare coverage was slightly more common at P (32 vs 29%) and commercial insurance slightly more common at G (63 vs 58%).BP was controlled in a similar proportion of readings overall, 66% and 65% (G and P).Binary logit models were constructed using percent of visits with BP controlled (%vBPc) as the dependent variable as a function of the above factors.Overall, increasing comorbidity was associated with a slightly greater %vBPc (P<0.0001), with an effect size averaging 1-2% for each comorbidity.Increasing number of unrelated comorbidities was associated with better BP control, while the opposite was true for related comorbidities.Stratified analyses conducted because of significant interactions showed the effect of related comorbidities to be more dominant in African Americans than Caucasians, particularly in patients over age 60.Nevertheless, similar effects were seen independent of race, age, gender and insurance.After accounting for race, there were no differences between the urban and rural systems.These findings suggest that race may explain urban-rural contrasts in BP control, and management of comorbidities may complicate control in African Americans more so than in Caucasians.

Background: HMORN leadership charged several Workgroups to check and describe Virtual Data Warehouse (VDW) data areas, provide observations on data quality across sites, and recommend needed actions.Availability of laboratory (lab) results data in the VDW in a standardized format is desirable, but across HMORN sites, lab content is either incompletely developed or not built at all.Further, there is little consistency across sites with regard to the approach to adding lab content.The work of the VDW Lab Content Area Workgroup (Lab Workgroup) therefore focused on developing a standardized approach to incorporating lab content.We describe development and implementation efforts to create and maintain a standardized lab result content area across HMORN sites.Methods: The Lab Workgroup identified priorities: 1) Establishing standardized naming conventions for variables; 2) Determining test results to be initially incorporated; 3) Encouraging site-specific exploration and development of lab information system content as well as lab department contacts; 4) Developing a lab test reference document; 5) Serving as content area experts; and 6) Conducting content quality checks.A list of possible tests to incorporate was circulated to HMORN sites.The Lab Workgroup wrote code to generate descriptive data and data checks across sites for glycated hemoglobin (HGBA1C) and serum potassium result content.A lab test metadata table was posted for site data managers to complete.Results: Incorporation of chemistry tests that were most often requested for research was identified as an initial priority.Microbiology and tumor markers content were other high priority areas.Standardized lab variable naming conventions were determined for the list of initial tests.Results of data checks for HGBA1C and potassium concentration results will focus on describing the extent and quality of these files at sites, as well as identify potential issues to be addressed.Sites were surveyed about the barriers, facilitators, and priority of adding lab content to VDW. Results of all this work as well as an excerpt from the lab test reference document will be presented.Conclusions: The availability of lab test results information in the VDW in a standardized, extractable format across HMORN sites is a technological advance in data availability and sharing.The work described here will provide important initial insights into the lab content area potential of the HMORN VDW.

Eric D Newman, MD, Virginia R Lerch, MPH, JB Jones, PhD, MBA and Walter F Stewart, PhD, MPH Eric D Newman, MD, Department of Rheumatology, Geisinger Clinic; Virginia R Lerch, MPH, Geisinger Center for Health Research; JB Jones, PhD, MBA, Geisinger Center for Health Research; Walter F Stewart, PhD, MPH, Geisinger Center for Health Research

Joseph A Boscarino, PhD, MPH, Stuart N Hoffman, DO, Glenn Gerhard, MD, John Han, MD, MS, Margaret Rukstalis, MD, Porat M Erlich, PhD and Walter F Stewart, PhD, MPH Joseph A Boscarino, PhD, MPH, Geisinger Center for Heath Research; Stuart N Hoffman, DO, Department of Neurology, Geisinger Health System; Glenn Gerhard, MD, Weis Center, Geisinger Health System; John Han, MD, MS, Pain Management Center, Geisinger Health System; Margaret Rukstalis, MD, Geisinger Center for Health Research; Porat M Erlich, PhD, Geisinger Center for Health Research; Walter F Stewart, PhD, MPH, Geisinger Center for Health Research

Though symptomatic medication overuse is believed to play a role in progression from episodic headaches (EH) to chronic daily headaches (CDH), population-based data on this topic are limited. Our objective was to describe patterns of medication use among CDH and EH sufferers in a general population sample. We compared medications used to treat headache in CDH cases and EH controls identified from a large population-based computer-assisted telephone interview survey. CDH began within 5 years of the computer-assisted telephone interview. Questions on medication use focused on treatment prior to the onset of CDH for cases and on an equivalent period in the past for controls. We asked about the likelihood of treating, time waiting to treat, number of different medications used, first, second and third most frequently used headache pain medication, and total treatment days. Questions were also asked about the use of medication for non-headache pain. Current treatment patterns and past treatment patterns were assessed. Likelihood of use of specific medications was compared between CDH cases and EH controls after adjusting for age, sex, primary headache type and number of medications taken to treat pain. Our sample consists of 206 CDH cases and 507 EH controls. CDH subjects were more likely than EH controls to use over-the-counter/caffeine combination products, triptans, opioid compounds and 'other' prescription pain medications. Use of aspirin was protective. After adjustment, aspirin and ibuprofen were (negatively) associated with CDH [OR 0.5 (0.3-0.9), OR 0.7 (0.5-1.0)] and opioids remained positively associated with CDH [OR 2.3 (1.3-3.9)]. For past use, CDH was positively associated with over-the-counter/caffeine combination products and opioid compounds and was negatively associated with use of aspirin. Only ibuprofen remained (negatively) associated with CDH after adjustment [OR 0.6 (0.4-0.9)]. After adjusting for demographic factors, primary headache type and number of medications taken, CDH sufferers are more likely to use opioid-combination analgesics, and less likely to use aspirin or ibuprofen, than EH sufferers.