Narcolepsy risk loci outline role of T cell autoimmunity and infectious triggers in narcolepsy

Narcolepsy type 1 (NT1) is caused by a loss of hypocretin/orexin transmission. Risk factors include pandemic 2009 H1N1 influenza A infection and immunization with Pandemrix®. Here, we dissect disease mechanisms and interactions with environmental triggers in a multi-ethnic sample of 6,073 cases and 84,856 controls. We fine-mapped GWAS signals within HLA (DQ0602, DQB1*03:01 and DPB1*04:02) and discovered seven novel associations (CD207, NAB1, IKZF4-ERBB3, CTSC, DENND1B, SIRPG, PRF1). Significant signals at TRA and DQB1*06:02 loci were found in 245 vaccination-related cases, who also shared polygenic risk. T cell receptor associations in NT1 modulated TRAJ*24, TRAJ*28 and TRBV*4-2 chain-usage. Partitioned heritability and immune cell enrichment analyses found genetic signals to be driven by dendritic and helper T cells. Lastly comorbidity analysis using data from FinnGen, suggests shared effects between NT1 and other autoimmune diseases. NT1 genetic variants shape autoimmunity and response to environmental triggers, including influenza A infection and immunization with Pandemrix®.

Next generation genome-wide association tool: design and coverage of a high-throughput European-optimized SNP array

The success of genome-wide association studies has paralleled the development of efficient genotyping technologies. We describe the development of a next-generation microarray based on the new highly-efficient Affymetrix Axiom genotyping technology that we are using to genotype individuals of European ancestry from the Kaiser Permanente Research Program on Genes, Environment and Health (RPGEH). The array contains 674,517 SNPs, and provides excellent genome-wide as well as gene-based and candidate-SNP coverage. Coverage was calculated using an approach based on imputation and cross validation. Preliminary results for the first 80,301 saliva-derived DNA samples from the RPGEH demonstrate very high quality genotypes, with sample success rates above 94% and over 98% of successful samples having SNP call rates exceeding 98%. At steady state, we have produced 462 million genotypes per week for each Axiom system. The new array provides a valuable addition to the repertoire of tools for large scale genome-wide association studies.

HIV status is an independent risk factor for reporting lower urinary tract symptoms

PURPOSE

HIV/AIDS is a worldwide epidemic. Limited evidence suggests that men infected with HIV/AIDS are at increased risk for lower urinary tract symptoms. We determined whether HIV/AIDS status is an independent risk factor for self-reported bothersome lower urinary tract symptoms in a large contemporary cohort.

MATERIALS AND METHODS

We performed a cross-sectional, Internet based survey of urinary quality of life outcomes in adult HIV infected and HIV uninfected men who have sex with men. The main outcome measure was International Prostate Symptom Score.

RESULTS

Of respondents with complete data 1,507 were HIV uninfected (median age 42 years, mean 43) and 323 HIV infected (median age 45 years, mean 45.1). Of the HIV infected respondents 148 were nonAIDS defining HIV infected and 175 were AIDS defining HIV infected. After adjusting for age and other comorbid conditions, nonAIDS defining HIV infected and AIDS defining HIV infected status increased the odds of severe lower urinary tract symptoms by 2.07 (95% CI 1.04-3.79) and 2.49 (95% CI 1.43-4.33), respectively. HIV infected men had a worse total International Prostate Symptom Score for all domains including quality of life compared to HIV uninfected men. Within the population of men with HIV, those with AIDS had worse mean total International Prostate Symptom Score and all individual International Prostate Symptom Score components relative to nonAIDS defining HIV infected men.

CONCLUSIONS

HIV status is an independent risk factor for bothersome lower urinary tract symptoms. The odds of severe lower urinary tract symptoms are greater in HIV infected men with a history of AIDS.

Regular nonsteroidal anti-inflammatory drug use and erectile dysfunction

PURPOSE

Previous data suggest a potential relationship between inflammation and erectile dysfunction. If it is causal, nonsteroidal anti-inflammatory drug use should be inversely associated with erectile dysfunction. To this end we examined the association between nonsteroidal anti-inflammatory drug use and erectile dysfunction in a large, ethnically diverse cohort of men enrolled in the California Men's Health Study.

MATERIALS AND METHODS

This prospective cohort study enrolled male members of the Kaiser Permanente managed care plans who were 45 to 69 years old beginning in 2002. Erectile dysfunction was assessed by questionnaire. Nonsteroidal anti-inflammatory drug exposure was determined by automated pharmacy data and self-reported use.

RESULTS

Of the 80,966 men in this study 47.4% were considered nonsteroidal anti-inflammatory drug users based on the definitions used and 29.3% reported moderate or severe erectile dysfunction. Nonsteroidal anti-inflammatory drug use and erectile dysfunction strongly correlated with age with regular drug use increasing from 34.5% in men at ages 45 to 49 years to 54.7% in men 60 to 69 years old with erectile dysfunction increasing from 13% to 42%. The unadjusted OR for the association of nonsteroidal anti-inflammatory drugs and erectile dysfunction was 2.40 (95% CI 2.27, 2.53). With adjustment for age, race/ethnicity, smoking status, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, coronary artery disease and body mass index, a positive association persisted (adjusted OR 1.38). The association persisted when using a stricter definition of nonsteroidal anti-inflammatory drug exposure.

CONCLUSIONS

These data suggest that regular nonsteroidal anti-inflammatory drug use is associated with erectile dysfunction beyond what would be expected due to age and comorbidity.

Pneumococcal vaccination and risk of acute myocardial infarction and stroke in men

CONTEXT

Multiple studies have shown that preventing influenza by vaccination reduces the risk of vascular events. However, the effect of pneumococcal polysaccharide vaccine on vascular events remains controversial.

OBJECTIVE

To examine the association between pneumococcal vaccination and risk of acute myocardial infarction (MI) and stroke among men.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study of Kaiser Permanente Northern and Southern California health plans with 84 170 participants aged 45 to 69 years from the California Men's Health Study who were recruited between January 2002 and December 2003, and followed up until December 31, 2007. The cohort was similar to the population of health plan members and men who responded to a general health survey in California on important demographic and clinical characteristics. Demographic and detailed lifestyle characteristics were collected from surveys. Vaccination records were obtained from the Kaiser Immunization Tracking System.

MAIN OUTCOME MEASURE

Incidence of acute MI and stroke during the follow-up period in men who had no history of such conditions.

RESULTS

During follow-up, there were 1211 first MIs in 112,837 vaccinated person-years (10.73 per 1000 person-years) compared with 1494 first MI events in 246,170 unvaccinated person-years (6.07 per 1000 person-years). For stroke, there were 651 events in 122,821 vaccinated person-years (5.30 per 1000 person-years) compared with 483 events in 254,541 unvaccinated person-years (1.90 per 1000 person-years). With propensity score adjustment, we found no evidence for an association between pneumococcal vaccination and reduced risk of acute MI (adjusted hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.98-1.21) or stroke (adjusted HR, 1.14; 95% CI, 1.00-1.31). An inverse association was also not found in men of different age and risk groups. The results appeared to be consistent, because using more specific International Classification of Diseases, Ninth Revision codes for the outcome definition did not change the estimations.

CONCLUSION

Among a cohort of men aged 45 years or older, receipt of pneumococcal vaccine was not associated with subsequent reduced risk of acute MI and stroke.

Mixed urinary incontinence: greater impact on quality of life

PURPOSE

We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women.

MATERIALS AND METHODS

We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence.

RESULTS

More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models.

CONCLUSIONS

In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

Concordance of chart abstraction and patient recall of intrapartum variables up to 53 years later

OBJECTIVE

The purpose of this study was to determine the concordance of patient recall compared with chart abstraction for distant intrapartum variables and to evaluate predictors of concordance.

STUDY DESIGN

A random sample from a cohort of diverse women aged 40-74 years. Intrapartum variables reported by participants were compared with the medical record. Outcomes were assessed for sensitivity, specificity, positive predictive value, and negative predictive value. Multivariate logistic regression was used to determine predictors of concordance of patient recall.

RESULTS

Four hundred one births among 178 women were analyzed. Recall of cesarean delivery had the highest concordance (sensitivity, 0.98; specificity, 1.00; positive predictive value, 1.00; negative predictive value, 0.99). Laceration that required repair had the lowest concordance (sensitivity, 0.37; specificity, 0.68; positive predictive value, 0.34; negative predictive value, 0.81). No variables predicted concordance of recall for all variables.

CONCLUSION

The concordance of patient recall to chart abstraction for intrapartum variables varies widely, although with a pattern of greater specificity and negative predictive value of recall. This should be kept in mind during patient interviews and in the performance of clinical research.

Progress in pediatric asthma surveillance I: the application of health care use data in Alameda County, California

INTRODUCTION

The ability to conduct community-level asthma surveillance is increasingly crucial for public health programming and child health advocacy. We explored the potential and limitations of health care use records from both public and private sources for asthma surveillance in a California county.

METHODS

We combined administrative patient record data from Kaiser Permanente of Northern California and Medi-Cal (the California Medicaid program) for Alameda County residents during 2001. We assessed the resulting data set for completeness, population representation, consistency with external data, and internal indicator consistency.

RESULTS

Our resulting data set included records for 226,383 children younger than 18 years. Completeness of Medicaid data was affected by managed care market share, reducing our usable data set size to 176,789, approximately equal to one of every two children in the county or one of every 3 person-months. External data documenting hospitalization rates due to asthma were poorly correlated with hospitalization rates (r = 0.2120, P = .20) but highly correlated with emergency department visits (r = 0.8607, P <.001) in the resulting data set. High internal consistency of indicators suggested that the data set represented a broad spectrum of health care access and quality of care congruent with clinical aspects of the disease.

CONCLUSION

The utility of these data is affected by logistical and administrative factors, including the health care payment structure and the market shares of care providers. These factors can be expected to similarly affect the utility of this approach in other counties. Our ability to generate county-level health statistics for comparison with other locations was limited, although the data set appeared well suited for within-county geographic analysis. In light of these findings, these data have the potential to expand the local health surveillance capacity of communities.

Progress in pediatric asthma surveillance II: geospatial patterns of asthma in Alameda County, California

INTRODUCTION

As with many diseases, the epidemic of asthma among children over the past few decades has been shaped by a social and environmental context that is becoming progressively more evident. Commonly used methods for asthma surveillance, however, are based on national rather than local data. The purpose of this study was to develop high-resolution asthma surveillance techniques responsive to the needs of health care professionals and local child health and social justice advocates.

METHODS

We assembled a working data set of health care use records from 2001 from public and private sources covering 1.7 million person-months among children younger than 18 years in Alameda County, California. Health care use was categorized by type and analyzed by census tract demographic information. Images of the geographic distribution of health service events were created using density estimation mapping with overlapping 0.5-mile (805-m) radius spatial buffers, and statistical significance (two-tailed P & .05) was estimated using a Monte Carlo simulation algorithm.

RESULTS

High-poverty communities had higher rates of emergency department visits due to asthma than low-poverty communities but had lower rates for indicators of quality primary asthma care. Geospatial analysis enabled visualization of this phenomenon; it further detected areas with elevated emergency department visit rates and potentially related environmental hazards in and around communities of concern. Areas of the county not previously considered to be deeply burdened by asthma were identified as having high emergency department visit rates.

CONCLUSION

The assembly and high-resolution geospatial analysis of health care use data contributed to a more detailed depiction of pediatric asthma disparities than was previously available to community members, public health professionals, and clinicians. Information generated using these techniques facilitated discussion among stakeholders of the environmental and social contexts of asthma and health disparities in general. Proceedings of group evaluations suggested that the material aided in the translation of data describing spatial variations in health event risk to address specific community experiences and concerns.