Estella M. Geraghty

Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study.

RATIONALE Although obstructive sleep apnea is associated with physiological perturbations that increase risk of hypertension and are proatherogenic, it is uncertain whether sleep apnea is associated with increased stroke risk in the general population. OBJECTIVES To quantify the incidence of ischemic stroke with sleep apnea in a community-based sample of men and women across a wide range of sleep apnea. METHODS Baseline polysomnography was performed between 1995 and 1998 in a longitudinal cohort study. The primary exposure was the obstructive apnea-hypopnea index (OAHI) and outcome was incident ischemic stroke. MEASUREMENTS AND MAIN RESULTS A total of 5,422 participants without a history of stroke at the baseline examination and untreated for sleep apnea were followed for a median of 8.7 years. One hundred ninety-three ischemic strokes were observed. In covariate-adjusted Cox proportional hazard models, a significant positive association between ischemic stroke and OAHI was observed in men (P value for linear trend: P = 0.016). Men in the highest OAHI quartile (>19) had an adjusted hazard ratio of 2.86 (95% confidence interval, 1.1-7.4). In the mild to moderate range (OAHI, 5-25), each one-unit increase in OAHI in men was estimated to increase stroke risk by 6% (95% confidence interval, 2-10%). In women, stroke was not significantly associated with OAHI quartiles, but increased risk was observed at an OAHI greater than 25. CONCLUSIONS The strong adjusted association between ischemic stroke and OAHI in community-dwelling men with mild to moderate sleep apnea suggests that this is an appropriate target for future stroke prevention trials.

Implementation of a deidentified federated data network for population-based cohort discovery

Objective The Cross-Institutional Clinical Translational Research project explored a federated query tool and looked at how this tool can facilitate clinical trial cohort discovery by managing access to aggregate patient data located within unaffiliated academic medical centers. Methods The project adapted software from the Informatics for Integrating Biology and the Bedside (i2b2) program to connect three Clinical Translational Research Award sites: University of Washington, Seattle, University of California, Davis, and University of California, San Francisco. The project developed an iterative spiral software development model to support the implementation and coordination of this multisite data resource. Results By standardizing technical infrastructures, policies, and semantics, the project enabled federated querying of deidentified clinical datasets stored in separate institutional environments and identified barriers to engaging users for measuring utility. Discussion The authors discuss the iterative development and evaluation phases of the project and highlight the challenges identified and the lessons learned. Conclusion The common system architecture and translational processes provide high-level (aggregate) deidentified access to a large patient population (>5 million patients), and represent a novel and extensible resource. Enhancing the network for more focused disease areas will require research-driven partnerships represented across all partner sites.

Overwhelming Parasitemia with Plasmodium falciparum Infection in a Patient Receiving Infliximab Therapy for Rheumatoid Arthritis

We describe a 45-year-old woman receiving infliximab therapy for rheumatoid arthritis who developed an overwhelming Plasmodium falciparum infection with cerebral malaria. Physicians should be aware that patients receiving tumor necrosis factor inhibitors, such as infliximab, may be at increased risk of life-threatening malarial infections.

Use of spatial epidemiology and hot spot analysis to target women eligible for prenatal women, infants, and children services.

OBJECTIVES We used a geographic information system and cluster analyses to determine locations in need of enhanced Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program services. METHODS We linked documented births in the 2010 California Birth Statistical Master File with the 2010 data from the WIC Integrated Statewide Information System. Analyses focused on the density of pregnant women who were eligible for but not receiving WIC services in Californias 7049 census tracts. We used incremental spatial autocorrelation and hot spot analyses to identify clusters of WIC-eligible nonparticipants. RESULTS We detected clusters of census tracts with higher-than-expected densities, compared with the state mean density of WIC-eligible nonparticipants, in 21 of 58 (36.2%) California counties (P < .05). In subsequent county-level analyses, we located neighborhood-level clusters of higher-than-expected densities of eligible nonparticipants in Sacramento, San Francisco, Fresno, and Los Angeles Counties (P < .05). CONCLUSIONS Hot spot analyses provided a rigorous and objective approach to determine the locations of statistically significant clusters of WIC-eligible nonparticipants. Results helped inform WIC program and funding decisions, including the opening of new WIC centers, and offered a novel approach for targeting public health services.

Demographic, Risk, and Spatial Factors Associated With Over-the-Counter Syringe Purchase Among Injection Drug Users

Since 2005, California law allowed over-the-counter (OTC) syringe sales pending local authorization. Although pharmacy sales of OTC syringes are associated with reduced injection-mediated risks and decreases in human immunodeficiency virus infection rates, little is known about the factors associated with syringe purchase among injection drug users (IDUs). Using a cross-sectional design, the authors applied targeted sampling to collect quantitative survey data from IDUs (n = 563) recruited in San Francisco, California, during 2008. They also compiled a comprehensive list of retail pharmacies, their location, and whether they sell OTC syringes. They used a novel combination of geographic information system and statistical analyses to determine the demographic, behavioral, and spatial factors associated with OTC syringe purchase by IDUs. In multivariate analyses, age, race, injection frequency, the type of drug injected, and the source of syringe supply were independently associated with OTC syringe purchases. Notably, the prevalence of OTC syringe purchase was 53% lower among African-American IDUs (adjusted prevalence ratio = 0.47, 95% confidence interval: 0.33, 0.67) and higher among injectors of methamphetamine (adjusted prevalence ratio = 1.35, 95% confidence interval: 1.07, 1.70). Two neighborhoods with high densities of IDUs had limited access to OTC syringes. Increased access to OTC syringes would potentially prevent blood-borne infectious diseases among IDUs.

Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants

OBJECTIVE The objective of this study was to estimate travel-related and environmental savings resulting from the use of telemedicine for outpatient specialty consultations with a university telemedicine program. METHODS The study was designed to retrospectively analyze the telemedicine consultation database at the University of California Davis Health System (UCDHS) between July 1996 and December 2013. Travel distances and travel times were calculated between the patient home, the telemedicine clinic, and the UCDHS in-person clinic. Travel cost savings and environmental impact were calculated by determining differences in mileage reimbursement rate and emissions between those incurred in attending telemedicine appointments and those that would have been incurred if a visit to the hub site had been necessary. RESULTS There were 19,246 consultations identified among 11,281 unique patients. Telemedicine visits resulted in a total travel distance savings of 5,345,602 miles, a total travel time savings of 4,708,891 minutes or 8.96 years, and a total direct travel cost savings of

Putting Youth on the Map: A Pilot Instrument for Assessing Youth Well-Being

2,882,056. The mean per-consultation round-trip distance savings were 278 miles, average travel time savings were 245 minutes, and average cost savings were

Zika virus: Endemic and epidemic ranges of Aedes mosquito transmission

156. Telemedicine consultations resulted in a total emissions savings of 1969 metric tons of CO2, 50 metric tons of CO, 3.7 metric tons of NOx, and 5.5 metric tons of volatile organic compounds. CONCLUSIONS This study demonstrates the positive impact of a health systems outpatient telemedicine program on patient travel time, patient travel costs, and environmental pollutants.

Is crime associated with over-the-counter pharmacy syringe sales? Findings from Los Angeles, California

Extant measures of adolescent well-being in the United States typically focus on negative indicators of youth outcomes. Indices comprised of such measures paint bleak views of youth and orient action toward the prevention of problems over the promotion of protective factors. Their tendency to focus analyses at a state or county geographic scale produces limited information about localized outcome patterns that could inform policymakers, practitioners and advocacy networks. We discuss the construction of a new geo-referenced index of youth well-being based on positive indicators of youth development. In demonstrating the index for the greater Sacramento, California region of the United States, we find that overall youth well-being falls far short of an optimal outcome, and geographic disparities in well-being appear to exist across school districts at all levels of our analysis. Despite its limitations, the sub-county geographic scale of this index provides needed data to facilitate local and regional interventions.

Neighborhood Socioeconomic Status and Cognitive Trajectories in a Diverse Longitudinal Cohort

As evidence linking Zika virus with serious health complications strengthens, public health officials and clinicians worldwide need to know which locations are likely to be at risk for autochthonous Zika infections. We created risk maps for epidemic and endemic Aedes-borne Zika virus infections globally using a predictive analysis method that draws on temperature, precipitation, elevation, land cover, and population density variables to identify locations suitable for mosquito activity seasonally or year-round. Aedes mosquitoes capable of transmitting Zika and other viruses are likely to live year-round across many tropical areas in the Americas, Africa, and Asia. Our map provides an enhanced global projection of where vector control initiatives may be most valuable for reducing the risk of Zika virus and other Aedes-borne infections.