Visual Functioning and Mortality of Age-Related Macular Degeneration Patients in a Colorado Cohort.

OBJECTIVE: To investigate the relationship between visual functioning as measured by the National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) and mortality in patients with various stages of age-related macular degeneration (AMD). DESIGN: Observational cohort study. PARTICIPANTS: Patients with AMD enrolled in the University of Colorado AMD Registry between July 9, 2014 and December 31, 2021 were included. METHODS: Age-related macular degeneration cases were classified into early AMD, intermediate AMD, geographic atrophy, neovascular AMD, or both advanced types of AMD (neovasuclar and geographic atrophy both present) using multimodal imaging and the Beckman and Classification of Atrophy Meetings criteria. Visual Function Questionnaire -25 composite and subscale scores at the time of study enrollment were calculated. Cox proportional hazards modeling was used to assess time to event for mortality utilizing univariate and multivariable models, which adjusted for all variables significantly associated with mortality. The measures of association were hazard ratios (HRs) and 95% confidence intervals (CIs). MAIN OUTCOME MEASURES: All-cause mortality statistics were obtained through a collaborative agreement with the Colorado Department of Public Health and Environment. Death rates through October 19, 2022 were compared by demographics and potential confounders. RESULTS: Analysis was completed on a cohort of 876 patients, of which 180 (20.6%) died during the follow-up period. Average follow-up time for this cohort was 52.5 (standard deviation: 26.6) months. In univariate analysis, composite VFQ-25 score and all subscale scores aside from ocular pain were significantly associated with time to mortality. Additionally, age, AMD category, marital status, history of smoking, and multiple chronic comorbid conditions were significantly associated with time to mortality. In multivariable analysis, for each 10-point increase in a patient's VFQ-25 scores for general health and driving, the risk of death decreased with HR of 0.85 (95% CI: 0.80, 0.91; P < 0.0001) and 0.92 (95% CI: 0.87, 0.97; P = 0.005), respectively. Composite and other subscale scores were not significantly associated with mortality after adjusting for confounding variables. CONCLUSIONS: This cohort of AMD patients had a 20% rate of death in the 52.5-month average follow-up time. Better general health and ability to drive, as measured by the VFQ-25, were each separately associated with significantly lower risk of death among individuals with AMD. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The COVID-19-wildfire smoke paradox: Reduced risk of all-cause mortality due to wildfire smoke in Colorado during the first year of the COVID-19 pandemic.

BACKGROUND: In 2020, the American West faced two competing challenges: the COVID-19 pandemic and the worst wildfire season on record. Several studies have investigated the impact of wildfire smoke (WFS) on COVID-19 morbidity and mortality, but little is known about how these two public health challenges impact mortality risk for other causes. OBJECTIVES: Using a time-series design, we evaluated how daily risk of mortality due to WFS exposure differed for periods before and during the COVID-19 pandemic. METHODS: Our study included daily data for 11 counties in the Front Range region of Colorado (2010-2020). We assessed WFS exposure using data from the National Oceanic and Atmospheric Administration and used mortality counts from the Colorado Department of Public Health and Environment. We estimated the interaction between WFS and the pandemic (an indicator variable) on mortality risk using generalized additive models adjusted for year, day of week, fine particulate matter, ozone, temperature, and a smoothed term for day of year. RESULTS: WFS impacted the study area on 10% of county-days. We observed a positive association between the presence of WFS and all-cause mortality risk (incidence rate ratio (IRR) = 1.03, 95%CI: 1.01-1.04 for same-day exposures) during the period before the pandemic; however, WFS exposure during the pandemic resulted in decreased risk of all-cause mortality (IRR = 0.90, 95%CI: 0.87-0.93 for same-day exposures). DISCUSSION: We hypothesize that mitigation efforts during the first year of the pandemic, e.g., mask mandates, along with high ambient WFS levels encouraged health behaviors that reduced exposure to WFS and reduced risk of all-cause mortality. Our results suggest a need to examine how associations between WFS and mortality are impacted by pandemic-related factors and that there may be lessons from the pandemic that could be translated into health-protective policies during future wildfire events.

High-altitude residence alters blood-pressure course and increases hypertensive disorders of pregnancy.

OBJECTIVES: To determine whether the full spectrum of hypertensive disorders of pregnancy (HDP) - comprising gestational hypertension; preeclampsia with or without severe features; eclampsia; and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) Syndrome - is increased at high (≥2500 m, 8250 ft) compared with lower altitudes in Colorado independent of maternal background characteristics, and if so their relationship to neonatal well-being. METHODS: A retrospective cohort study was conducted using statewide birth-certificate data to compare the frequency of gestational hypertension, preeclampsia (with or without severe features), eclampsia, HELLP Syndrome, or all HDP combined in 617,958 Colorado women who lived at high vs. low altitude (<2500 m) and delivered during the 10-year period, 2007-2016. We also compared blood-pressure changes longitudinally during pregnancy and the frequency of HDP in 454 high (>2500 m)- vs. low (<1700 m)-altitude Colorado residents delivering in 2013 and 2014, and matched for maternal risk factors. Data were compared between altitudes using t-tests or chi-square, and by multiple or logistic regression analyses to adjust for risk factors and predict specific hypertensive or neonatal complications. RESULTS: Statewide, high-altitude residence increased the frequency of each HDP disorder separately or all combined by 33%. High-altitude women studied longitudinally also had more HDP accompanied by higher blood pressures throughout pregnancy. The frequency of low birth weight infants (<2500 g), 5-min Apgar scores <7, and NICU admissions were also greater at high than low altitudes statewide, with the latter being accounted for by the increased incidence of HDP. CONCLUSIONS: Residence at high altitude constitutes a risk factor for HDP and recommends increased clinical surveillance. The increased incidence also makes high altitude a natural laboratory for evaluating the efficacy of predictive biomarkers or new therapies for HDP.

Trends in Retinopathy of Prematurity over 12 Years in a Colorado Cohort.

PURPOSE: To determine trends in retinopathy of prematurity (ROP) in a Colorado cohort between 2006 and 2017 and compare trends in risk factors between our cohort and statewide data. METHODS: A retrospective cohort study was conducted by the use of records from two registry databases: 1) an academic center's ROP registry, and 2) vital statistics birth data from the Colorado Department of Public Health and Environment (CDPHE). ROP was categorized as severe (type 1 or type 2), low grade (not type 1 or type 2), or no ROP. Other variables included in the analyses were gestational age and birth weight at delivery, and infant mortality. Trends over time were evaluated for both registry databases using generalized linear models. RESULTS: In our ROP registry cohort of 1,267 eligible infants, 134 (10.6%) developed severe ROP and 279 (22%) developed low-grade ROP. We found no overall trend in severe ROP rates (p = .23), and a decreasing trend in rates of low-grade ROP (p < .01) over the study period. Trends in gestational age, birth weight, and mortality rates remained stable during the study period in both the ROP registry and the CDPHE cohorts. CONCLUSION: The rate of severe ROP in our ROP registry cohort did not change over time. There was evidence of a decreasing trend in low grade ROP during the 12-year study period that was not explained by a change in the primary ROP risk factors in either the ROP registry cohort or the Colorado statewide data.

Finding the elusive trauma denominator: Feasibility of combining data sets to quantify the true burden of firearm trauma.

BACKGROUND: Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data. METHODS: We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality. RESULTS: Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied. CONCLUSION: We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Geospatial Monitoring of Body Mass Index: Use of Electronic Health Record Data Across Health Care Systems.

OBJECTIVES: The Colorado BMI Monitoring System was developed to assess geographic (ie, census tract) patterns of obesity prevalence rates among children and adults in the Denver-metropolitan region. This project also sought to assess the feasibility of a surveillance system that integrates data across multiple health care and governmental organizations. MATERIALS AND METHODS: We extracted data on height and weight measures, obtained through routine clinical care, from electronic health records (EHRs) at multiple health care sites. We selected sites from 5 Denver health care systems and collected data from visits that occurred between January 1, 2013, and December 31, 2015. We produced shaded maps showing observed obesity prevalence rates by census tract for various geographic regions across the Denver-metropolitan region. RESULTS: We identified clearly distinguishable areas by higher rates of obesity among children than among adults, with several pockets of lower body mass index. Patterns for adults were similar to patterns for children: the highest obesity prevalence rates were concentrated around the central part of the metropolitan region. Obesity prevalence rates were moderately higher along the western and northern areas than in other parts of the study region. PRACTICE IMPLICATIONS: The Colorado BMI Monitoring System demonstrates the feasibility of combining EHRs across multiple systems for public health and research. Challenges include ensuring de-duplication across organizations and ensuring that geocoding is performed in a consistent way that does not pose a risk for patient privacy.

Analysis of the Effects on Time Between Divorce Decree and Suicide.

Background: Divorced individuals carry unique suicide risks, from both acute and chronic exposure to stressors from divorce. Aims: Several statewide data sets were linked to assess the relationship between divorce and suicide. Method: Divorced suicide decedents in the Colorado Violent Death Reporting System, 2004-2015, were matched with divorce decree, using multiple identifiers. Statistically significant differences between the linked cohort and all divorced suicide decedents were assessed using chi-square statistics. Kaplan-Meier survival analyses were conducted assessing which demographics and circumstances had a significant effect on the time between divorce and death. Results: The linkage resulted in 381 divorced suicide decedents linked to a divorce decree. Time between divorce and death ranged from less than 1 year to more than 10 years. Age and intimate partner problems both had significant effects on reducing the survival probability at 1 year and beyond. Limitations: Only 14% of divorced suicide decedents were linked to a Colorado divorce decree. There were noted significant differences between the linked cohort and the total divorced suicide population. Conclusion: Better understanding the relationship between divorce and suicide is imperative to design effective prevention programs for this specific population.

Premeditated versus "passionate": patterns of homicide related to intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) is prevalent but underrecognized; at least 25% of United States women experience IPV within their lifetime. We examined the most severe consequence of IPV by exploring the patterns of death from IPV in a statewide database of homicide victims. MATERIALS AND METHODS: This is a retrospective review of the Colorado Violent Death Reporting System from 2004 to 2015. Deaths were coded as IPV if the primary relationship between the suspect and victim fell into the following categories: spouse, ex-spouse, girlfriend/boyfriend, and ex-girlfriend/ex-boyfriend. RESULTS: We identified a total of 2279 homicide victims, with 295 cases of IPV homicide (12.9%). The majority was female victims of a male partner (n = 240, 81.4%). In nearly half of these (n = 108, 45%), the male suspect subsequently died by suicide as part of the same incident. These homicide-suicide incidents were more likely than homicide alone to involve a spousal relationship, more likely to involve firearms and less likely to involve intoxication or preceding arguments. They had a distinct demographic profile from other victims of IPV, mirroring suicide victims in terms of race and estimated income. CONCLUSIONS: These results indicate that there are two distinct groups of female IPV homicides, and recognizing this distinction may allow for the development of more effective trauma prevention strategies. Homicide-suicides showed a more premeditated pattern while homicide alone suggested a crime of passion, with a smaller proportion of firearm deaths and higher rates of positive toxicology findings and preceding conflict in the latter group.

Epidemiology and Molecular Characteristics of Mycoplasma pneumoniae During an Outbreak of M. pneumoniae-associated Stevens-Johnson Syndrome.

BACKGROUND: An increase in Mycoplasma pneumoniae-associated Stevens-Johnson syndrome (SJS) cases at a Colorado pediatric hospital led to an outbreak investigation. We describe the epidemiologic and molecular characteristics of M. pneumoniae among SJS case-patients and surrounding community members during the outbreak. METHODS: M. pneumoniae polymerase chain reaction-positive respiratory specimens from 5 Colorado hospitals and 4 referral laboratories underwent confirmatory polymerase chain reaction testing; positive specimens then underwent multilocus variable-number tandem-repeat analysis (MLVA) and macrolide resistance testing. Three SJS-M. pneumoniae case-patient households were surveyed using a standardized questionnaire, and nasopharyngeal/oropharyngeal swabs were obtained from all consenting/assenting household contacts. International Classification of Diseases, 9th revision codes were used to identify pneumonia cases among Colorado patients 5-21 years of age from January 2009 to March 2014. RESULTS: Three different M. pneumoniae MLVA types were identified among the 5 SJS case-patients with confirmed infection; MLVA type 3-X-6-2 was seen more commonly in SJS case-patients (60%) than in 69 non-SJS community specimens (29%). Macrolide resistance was identified in 7% of community specimens but not among SJS case-patients. Of 15 household contacts, 5 (33%) were M. pneumoniae positive; all MLVA types were identical to those of the corresponding SJS case-patient, although the specimen from 1 contact was macrolide resistant. Overall pneumonia cases as well as those caused by M. pneumoniae specifically peaked in October 2013, coinciding with the SJS outbreak. CONCLUSIONS: The outbreak of M. pneumoniae-associated SJS may have been associated with a community outbreak of M. pneumoniae; clinicians should be aware of the M. pneumoniae-SJS relationship. Household transmission of M. pneumoniae was common within the households investigated.

Previous Suicide Attempt and Its Association With Method Used in a Suicide Death.

INTRODUCTION: Non-fatal suicide attempts are a risk factor for suicide, but less is known about its effect on the method of injury used in an eventual suicide death. This study examines the association between history of non-fatal suicide attempt and the risk of a poisoning suicide versus firearm or hanging suicide in Colorado. METHODS: Nine years (2004-2012, N=7,020) of suicide deaths in Colorado were compiled through the National Violent Death Reporting System. With these data, a retrospective cohort study was conducted in 2015, examining the risk associated with a history of suicide attempt and an eventual suicide death by poisoning versus a firearm or hanging suicide death. Multivariable log-binomial regression modeling was used to analyze the possible confounders of age and county type and gender as an effect modifier. RESULTS: Suicide decedents with evidence of prior suicide attempt were twice as likely to eventually die by suicide via self-poisoning rather than by firearm injury (relative risk=1.94, 95% CI=1.8, 2.1, p<0.001). A significant interaction (p<0.001) between prior attempt and gender was identified and the relationship between prior attempt and method (poisoning versus firearm) was stronger among male than female suicides (female attempt history, 1.16, 95% CI=1.07, 1.27, p<0.001; male attempt history, 1.91, 95% CI=1.69, 2.16, p<0.001). CONCLUSIONS: Individuals with a history of non-fatal suicide attempt are more likely to die by suicide via poisoning rather than firearm. Gender has a significant effect on this association. This information can be useful when discussing means restriction and suicide prevention efforts.

Sudden infant death syndrome and residential altitude.

BACKGROUND: Theories of sudden infant death syndrome (SIDS) suggest hypoxia is a common pathway. Infants living at altitude have evidence of hypoxia; however, the association between SIDS incidence and infant residential altitude has not been well studied. METHODS: We performed a retrospective cohort study by using data from the Colorado birth and death registries from 2007 to 2012. Infant residential altitude was determined by geocoding maternal residential address. Logistic regression was used to determine adjusted association between residential altitude and SIDS. We evaluated the impact of the Back to Sleep campaign across various altitudes in an extended cohort from 1990 to 2012 to assess for interaction between sleep position and altitude. RESULTS: A total of 393 216 infants born between 2007 and 2012 were included in the primary cohort (51.4% boys; mean birth weight 3194 ± 558 g). Overall, 79.6% infants resided at altitude <6000 feet, 18.5% at 6000 to 8000 feet, and 1.9% at >8000 feet. There were no meaningful differences in maternal characteristics across altitude groups. Compared with residence <6000 feet, residence at high altitude (>8000 feet), was associated with an adjusted increased risk of SIDS (odds ratio 2.30; 95% confidence interval 1.01-5.24). Before the Back to Sleep campaign, the incidence of SIDS in Colorado was 1.99/1000 live births and dropped to 0.57/1000 live births after its implementation. The Back to Sleep campaign had similar effect across different altitudes (P = .45). CONCLUSIONS: Residence at high altitude was significantly associated with an increased adjusted risk for SIDS. Impact of the Back to Sleep campaign was similar across various altitudes.

Assessment of the quality of publicly reported central line-associated bloodstream infection data in Colorado, 2010.

BACKGROUND: Validation of self-reported health care-associated infection data is essential to verify correct understanding of definition criteria, surveillance practices, and reporting integrity. Recent studies have found significant under-reporting of central line-associated bloodstream infections (CLABSI) leading Colorado Department of Public Health and Environment to examine the quality of Colorado's CLABSI data. METHODS: Trained Colorado Department of Public Health and Environment staff members performed onsite validation visits that included interviews with infection preventionists to assess surveillance practices and retrospective chart reviews of patients with positive blood cultures in specific intensive care units (adult and neonatal) and long-term acute care hospitals during the first quarter of 2010. RESULTS: Fifty-five CLABSIs from the original sample were identified; 33 (60%) in the adult intensive care unit, 7 (12.7%) in the neonatal intensive care unit, and 15 (27.3%) in the long-term acute care hospital. Of the 55 CLABSIs identified by reviewers, 18 (32.7%) were not reported by the hospitals, 37 CLABSIs (67.3%) were reported correctly into the National Healthcare Safety Network, and 1 CLABSI was over-reported. CONCLUSIONS: There was wide variation noted in surveillance practices as well as in application of definition criteria. With 33% under-reported cases, it was concluded that ongoing validation of health care-associated infection data is necessary.

Survival of infants with neural tube defects in the presence of folic acid fortification.

OBJECTIVE: Neural tube defects (NTDs) are preventable through preconceptional and periconceptional folic acid intake. Although decreases in the prevalence of NTDs have been reported since folic acid fortification of United States grain products began, it is not known whether folic acid plays a role in reducing the severity of occurring NTDs. Our aim was to determine whether survival among infants born with spina bifida and encephalocele has improved since folic acid fortification and to measure the effects of selected maternal, pregnancy, and birth characteristics on first-year (infant) survival rates. METHODS: A retrospective cohort study was conducted and included 2841 infants with spina bifida and 638 infants with encephalocele who were born between 1995 and 2001 and were registered in any of 16 participating birth defects monitoring programs in the United States. First-year survival rates for both spina bifida and encephalocele cohorts were measured with Kaplan-Meier estimation; factors associated with improved chances of first-year survival, including birth before or during folic acid fortification, were measured with Cox proportional-hazards regression analysis. RESULTS: Infants with spina bifida experienced a significantly improved first-year survival rate of 92.1% (adjusted hazard ratio: 0.68; 95% confidence interval: 0.50-0.91) during the period of mandatory folic acid fortification, compared with a 90.3% survival rate for those born before fortification. Infants with encephalocele had a statistically nonsignificant increase in survival rates, ie, 79.1% (adjusted hazard ratio: 0.76; 95% confidence interval: 0.51-1.13) with folic acid fortification, compared with 75.7% for earlier births. CONCLUSIONS: Folic acid may play a role in reducing the severity of NTDs in addition to preventing the occurrence of NTDs. This phenomenon contributes to our understanding of the efficacy of folic acid. Additionally, as survival of NTD-affected infants improves, health care, education, and family support must expand to meet their needs.

Case fatality among infants with congenital malformations by lethality.

OBJECTIVE: Infant mortality rates continue to show that congenital anomalies are the leading cause of infant death in the United States. However, studies of factors contributing to increased mortality across different types of congenital anomalies have been limited. The objective of this study was to assess whether the likelihood of infant mortality varied by maternal race and ethnic group while considering the severity of the birth defect. METHODS: A retrospective cohort analysis was conducted using data from Colorado's statewide, population-based birth defects surveillance system (CRCSN). The cohort included infants, born between 1995 and 2000 to Colorado resident mothers, who were diagnosed with major congenital malformations stratified by degree of lethality. Multiple logistic regression was performed for each level of lethality, and included the following potential explanatory variables: maternal race/ethnicity, clinical gestation, birth weight, maternal education level, maternal age, and sex of child. RESULTS: Within the low/very low lethality cohort, maternal race/ethnicity of Black/non-Hispanic was associated with increased risk of infant mortality, OR 2.81 (1.41-5.19), as were low and very low birth weight, OR 2.21 (1.12-4.04) and 19.31 (11.84-31.01), respectively. Maternal race/ethnicity was not a significant risk factor in either high or very high lethality groups; however, the interaction between birth weight and gestational age significantly increased the risk of mortality. CONCLUSIONS: Through the use of statewide, population-based birth defects surveillance data, a disparity in infant mortality has been identified in a specific subset of the population that could be investigated further and targeted for prevention activities.