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DSHS Authors: 2006 Research Articles by DSHS Staff

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The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services since its formation in September 2004. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by e-mail at library@dshs.state.tx.us by calling (512) 776-7559.

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mrl-diamond2006 Articles (in date order with most recent first)

Characteristics of an Outbreak of West Nile Virus Encephalomyelitis in a Previously Uninfected Population of Horses.
Ward MP, Schuermann JA, Highfield LD, Murray KO.
Vet Microbiol. 2006 Dec 20;118(3-4):255-9.
Equine West Nile virus (WNV) encephalomyelitis cases – based on clinical signs and ELISA serology test results – reported to Texas disease control authorities during 2002 were analyzed to provide insights into the epidemiology of the disease within a previously disease-free population. The epidemic occurred between June 27 and December 17 (peaking in early October) and 1698 cases were reported. Three distinct epidemic phases were identified, occurring mostly in southeast, northwest and then central Texas. Significant (P <0.05) disease clusters were identified in northwest and northern Texas. Most (91.1%) cases had no recent travel history, and most (68.9%) cases had not been vaccinated within the previous 12 months. One-third of cases did not survive, 71.2% of which were euthanatized. The most commonly reported presenting signs included ataxia (69%), abnormal gait (52%), muscle fasciculations (49%), depression (32%) and recumbency (28%). Vaccination status, ataxia, falling down, recumbency and lip droop best explained the risk of not surviving WNV disease. Results suggest that the peak risk period for encephalomyelitis caused by WNV may vary substantially among regions within Texas. Recumbent horses have a poor prognosis for survival. Vaccines, even if not administered sufficiently in advance of WNV infection within a district, may reduce the risk of death by at least 44%.

Increased MECP2 Gene Copy Number as the Result of Genomic Duplication in Neurodevelopmentally Delayed Males.
del Gaudio D, Fang P, Scaglia F, Ward PA, Craigen WJ, Glaze DG, Neul JL, Patel A, Lee JA, Irons M, Berry SA, Pursley AA, Grebe TA, Freedenberg D, Martin RA, Hsich GE, Khera JR, Friedman NR, Zoghbi HY, Eng CM, Lupski JR, Beaudet AL, Cheung SW, Roa BB.
Genet Med. 2006 Dec;8(12):784-92.
Purpose: Mutations in the MECP2 gene are associated with Rett syndrome, an X-linked mental retardation disorder in females. Mutations also cause variable neurodevelopmental phenotypes in rare affected males. Recent clinical testing for MECP2 gene rearrangements revealed that entire MECP2 gene duplication occurs in some males manifesting a progressive neurodevelopmental syndrome. Methods: Clinical testing through quantitative DNA methods and chromosomal microarray analysis in our laboratories identified seven male patients with increased MECP2 gene copy number. Results: Duplication of the entire MECP2 gene was found in six patients, and MECP2 triplication was found in one patient with the most severe phenotype. The Xq28 duplications observed in these males are unique and vary in size from approximately 200 kb to 2.2 Mb. Three of the mothers who were tested were asymptomatic duplication carriers with skewed X-inactivation. In silico analysis of the Xq28 flanking region showed numerous low-copy repeats with potential roles in recombination. Conclusions: These collective data suggest that increased MECP2 gene copy number is mainly responsible for the neurodevelopmental phenotypes in these males. These findings underscore the allelic and phenotypic heterogeneity associated with the MECP2 gene and highlight the value of molecular analysis for patient diagnosis, family members at risk, and genetic counseling.

Adult Atomoxetine Ingestions Reported to Texas Poison Control Centers, 2003-2005.
Forrester MB.
Ann Pharmacother. 2006 Dec;40(12):2136-41.
BACKGROUND: Limited information exists on outcomes from adult ingestions of atomoxetine reported to poison control centers. OBJECTIVE: To identify factors that might affect the outcome of adult atomoxetine ingestions reported to poison control centers. METHODS: Using adult ingestions of atomoxetine alone reported to Texas poison control centers during 2003-2005, the proportion of cases involving serious outcomes was determined for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). RESULTS: Of 64 cases identified, 9 (14%) involved serious outcomes. No serious outcomes were reported with a maximum dose of 100 mg or less. Serious outcomes were significantly more likely to occur with a maximum dose of more than 2 capsules (RR 8.25; 95% CI 1.48 to 83.58), where the circumstances of the exposures involved self-harm or malicious intent (RR 6.02; 95% CI 1.30 to 30.35) or when the patient was already at or en route to a healthcare facility when the poison control center was contacted (RR 18.75; 95% CI 2.10 to 886.83) or was referred to a healthcare facility by the poison control center (RR 22.50; 95% CI 1.81 to 1181.19). CONCLUSIONS: The severity of the outcomes associated with adult atomoxetine ingestions depended on the dose taken and the circumstances of the ingestion. The management of patients with serious outcomes was more likely to involve healthcare facilities. Such information is useful in creating triage guidelines for the management of adult atomoxetine ingestions.

Lupine Calls to Texas Poison Control Centers, 1998–2005.
Forrester MB
Toxicol Environ Chem. 2006;88:739-743.
Many lupine species (Genus Lupinus) contain toxic compounds, although the amount of these substances varies by the plant part and species. This investigation described the epidemiology of 138 lupine exposures reported to Texas poison centers during 1998–2005. Almost 88% of the lupine exposure calls occurred in March and April, and 90% of the calls came from the central portions of the state. Sixty-one percent of the calls involved female patients, and 91% of the patients were age <6 years. The lupine exposure occurred at the patient's own residence in 79% of the cases. Of the reported lupine exposures, 93% were handled outside of health care facilities, and, of those cases with a known medical outcome, few moderate or major effects, and no deaths, were reported. The most frequently noted clinical effect among cases during 2000–2005 was vomiting, affecting 8% of the cases. In conclusion, most reported lupine exposures in Texas came from the central parts of the state, occurred in spring, and involved young children. Typical reported lupine exposures in Texas were not likely to have adverse outcomes.

Pattern of Thiazolidinedione Exposures Reported to Texas Poison Centers During 1998-2004.
Forrester MB.
J Toxicol Environ Health A. 2006 Dec;69(23):2083-93.
Information on the management of potentially adverse exposures to thiazolidinediones, a class of oral antihyperglycemic, is limited. This study examined the distribution of thiazolidinedione exposures reported to Texas poison control centers from 1998 through 2004. There were a total of 581 exposures reported, increasing from 31 in 1998 to 140 in 2004. Of the 286 exposures to thiazolidinediones alone, 60% involved patients age 5 yr or younger and 34% patients age 20 yr or greater. Fifty-four percent of the patients were female. The exposure was unintentional in 94% of the exposures, with therapeutic errors accounting for 26% of the exposures reported. Management of 61% of the exposures occurred on site and 39% at a health care facility. Of those exposures with a final medical outcome, 94% were classified as no effect and no cases with major effects or deaths were reported. An adverse clinical effect was reported for 7% of the exposures, the most frequent of which were hypoglycemia (2%), hyperglycemia (1%), and drowsiness (1%). A treatment was reported for 76% of the exposures. The most frequent treatments were decontamination by being given some sort of food (38%), dilution with substances such as milk (34%), and activated charcoal (20%). In conclusion, this study found that the number of reported potentially adverse thiazolidinedione exposures in Texas increased in recent years. Such exposures generally found few adverse clinical effects and were reversible, although some sort of treatment, particularly decontamination, was administered and a large proportion of exposures were managed at or referred to health care facilities.

Evaluation of the Texas Birth Defects Registry: An Active Surveillance System.
Miller E.
Birth Defects Res A Clin Mol Teratol. 2006 Nov;76(11):787-92.
BACKGROUND: Evaluations of surveillance systems are necessary to determine if the goals of the system are being met, how efficiently the surveillance is being implemented, and if resources are being used appropriately. An evaluation of the Texas Birth Defects Registry was conducted to assess the overall quality of data collection and to examine variations across regions of the state. METHODS: The registry was evaluated by using published guidelines for evaluating public health surveillance systems; the evaluation included staff interviews, process observation, and secondary data analysis. RESULTS: The registry monitors >370,000 births/year through active surveillance, with considerable disparities in workload across regions of the state. Because of the geographic size and substantial population of Texas, data collection is complex. However, the estimated sensitivity of the system appears sufficient, and rates for selected defects are highly comparable with other U.S. active birth-defect surveillance systems. Registry staff continually monitor the quality of data collection and provide additional training. Amid unstable funding, the registry staff have demonstrated optimal foresight and flexibility to adapt and continue quality data collection. Timeliness needs to be improved and more consistent quality assurance is needed across regions of the state. Retaining staff and increasing visibility are essential to providing more stability. CONCLUSIONS: Active surveillance for birth defects is labor-intensive but provides invaluable data for its stakeholders. The Texas Birth Defects Registry has proven to be a quality surveillance system and a beneficial resource for Texas.

A Comparison of Breastfeeding Rates in an Urban Birth Cohort among Women Delivering Infants at Hospitals that Employ and Do Not Employ Lactation Consultants.
Castrucci BC, Hoover KL, Lim S, Maus KC.
J Public Health Manag Pract. 2006 Nov-Dec;12(6):578-85.
OBJECTIVE: To compare rates of breastfeeding at hospital discharge between facilities that employ and do not employ International Board Certified Lactation Consultants (IBCLCs). METHODS: This study used a cross-sectional design. Data from 11,525 birth certificates of Philadelphia residents who delivered in 2003 were used. Breastfeeding was assessed using a question included on the Pennsylvania birth record, "Is the infant being breastfed at discharge?" The Philadelphia Department of Public Health's lactation consultants collected information on number of hours worked annually by IBCLCs by facility. RESULTS: After adjusting for race/ethnicity, education, insurance status, age, marital status, route of delivery, birth weight, and gestational age, delivering in a hospital that employed an IBCLC was associated with a 2.28 (95% confidence interval [CI] =1.98,2.62) times increase in the odds of breastfeeding at hospital discharge. Among women receiving Medicaid, delivering at a hospital that employed IBCLCs was associated with a 4.13 (95% CI =3.22,4.80) times increase in the odds of breastfeeding at hospital discharge. CONCLUSIONS: The findings presented here identify an association between delivering at a facility that employs IBCLCs and breastfeeding at hospital discharge. As the strength of this association is not negligible, particularly for women on Medicaid, these findings may be used to encourage widespread use of IBCLCs.

Identical Genotype B3 Sequences from Measles Patients in 4 Countries, 2005.
Rota J, Lowe L, Rota P, Bellini W, Redd S, Dayan G, van Binnendijk R, Hahné S, Tipples G, Macey J, Espinoza R, et al.
Emerg Infect Dis. 2006 Nov;12(11):1779-81.
Surveillance of measles virus detected an epidemiologic link between a refugee from Kenya and a Dutch tourist in New Jersey, USA. Identical genotype B3 sequences from patients with contemporaneous cases in the United States, Canada, and Mexico in November and December 2005 indicate that Kenya was likely to have been the common source of virus.

Mental Health Quality and Accountability: The Role of Evidence-Based Practices and Performance Measurement.
Ganju V.
Adm Policy Ment Health. 2006 Nov;33(6):659-65.
Both evidence-based practices and performance measurement in mental health systems have been implemented as largely independent initiatives, each facing issues related to system-wide, sustained implementation. A major thrust of this article is that a broader quality and accountability framework is critical for obtaining better outcomes and for incorporating these initiatives into business as usual. This article provides an overview of national initiatives in these areas, lessons learned from implementation efforts, and problems encountered. Building on these experiences, a model for a quality and accountability framework is proposed in which evidence-based practices and performance measurement systems can together provide productive and ongoing synergy.

Drug Identification Calls from Law Enforcement Received by Texas Poison Control Centers, 2002-2004.
Forrester MB.
J Toxicol Environ Health A. 2006 Nov;69(22):2041-9.
Aside from calls involving human exposures to potentially toxic substances, poison control centers handle other types of calls such as drug identifications (drug IDs). A portion of drug ID requests originates from law enforcement. The objective of this study was to describe such drug ID requests from law enforcement received by Texas poison control centers during 2002-2004. These calls were examined with respect to year of call, location of caller, and type of drug. There were in total 26,752 drug ID calls (involving 27,800 individual drug ID requests) from law enforcement, representing 3% of total calls and 16% of all drug ID calls received. The number of drug ID calls received from law enforcement and the proportion of total calls and all drug ID calls these represented increased from 2002 to 2004. A disproportionate number of the drug ID requests originated from eastern-central Texas. The most frequently involved drugs were analgesics (particularly acetaminophen and hydrocodone), sedatives and related drugs (particularly alprazolam), and muscle relaxants (particularly carisoprodol).

National Estimates and Race/Ethnic-Specific Variation of Selected Birth Defects in the United States, 1999-2001.
Canfield MA, Honein MA, Yuskiv N, Xing J, Mai CT, Collins JS, Devine O, Petrini J, Ramadhani TA, Hobbs CA, Kirby RS.
Birth Defects Res A Clin Mol Teratol. 2006 Nov;76(11):747-56.
BACKGROUND: In the United States, birth defects affect approximately 3% of all births, are a leading cause of infant mortality, and contribute substantially to childhood morbidity. METHODS: Population-based data from the National Birth Defects Prevention Network were combined to estimate the prevalence of 21 selected defects for 1999-2001, stratified by surveillance system type. National prevalence was estimated for each defect by pooling data from 11 states with active case-finding, and adjusting for the racial/ethnic distribution of US live births. We also assessed racial/ethnic variation of the selected birth defects. RESULTS: National birth defect prevalence estimates ranged from 0.82 per 10,000 live births for truncus arteriosus to 13.65 per 10,000 live births for Down syndrome. Compared with infants of non-Hispanic (NH) white mothers, infants of NH black mothers had a significantly higher birth prevalence of tetralogy of Fallot, lower limb reduction defects, and trisomy 18, and a significantly lower birth prevalence of cleft palate, cleft lip with or without cleft palate, esophageal atresia/tracheoesophageal fistula, gastroschisis, and Down syndrome. Infants of Hispanic mothers, compared with infants of NH white mothers, had a significantly higher birth prevalence of anencephalus, spina bifida, encephalocele, gastroschisis, and Down syndrome, and a significantly lower birth prevalence of tetralogy of Fallot, hypoplastic left heart syndrome, cleft palate without cleft lip, and esophageal atresia/tracheoesophageal fistula. CONCLUSIONS: This study can be used to evaluate individual state surveillance data, and to help plan for public health care and educational needs. It also provides valuable data on racial/ethnic patterns of selected major birth defects.

Residential Mobility Patterns and Exposure Misclassification in Epidemiologic Studies of Birth Defects.
Canfield MA, Ramadhani TA, Langlois PH, Waller DK.
J Expo Sci Environ Epidemiol. 2006 Nov;16(6):538-43
Many studies of environmental exposures and birth defects use mothers' addresses at delivery as a proxy for the exposure. The validity of these studies is questionable because birth defects generally occur within 8 weeks of conception and the mother's address at delivery may differ from her address early in pregnancy. In order to assess the extent of this bias, we examined the pattern of maternal residential mobility over the span of 3 months prior to conception through delivery, and associated maternal socio-demographic characteristics. We linked Texas subjects from a national case-control study of birth defects with their corresponding records from the Texas Birth Defects Registry and the Texas live birth certificates. Logistic regression analyses were conducted to assess maternal socio-demographic factors related to mobility during pregnancy. Overall, 33% of case and 31% of control mothers changed residence between conception and delivery. The pattern of mobility was similar for both case and control mothers for each pregnancy period. Multivariate analyses indicated that for case mothers, older age (OR=0.39, 95% CI=0.21-0.70), higher household income (OR=0.35, 95% CI=0.18-0.68), Hispanic ethnicity (OR=0.64, 95% CI=0.44-0.92), and higher parity (OR=0.59, 95% CI=0.38-0.94) were indicators of lower mobility during pregnancy. For control mothers, the same pattern of association was present, however, only older age was significantly associated with low rates of mobility. Studies of birth defects using maternal address at delivery as a proxy for maternal environmental exposures during pregnancy may be subject to considerable nondifferential exposure misclassification due to maternal mobility during pregnancy.

Match Rate and Positional Accuracy of Two Geocoding Methods for Epidemiologic Research.
Zhan FB, Brender JD, De Lima I, Suarez L, Langlois PH.
Ann Epidemiol. 2006 Nov;16(11):842-9.
PURPOSE: This study compares the match rate and positional accuracy of two geocoding methods: the popular geocoding tool in ArcGIS 9.1 and the Centrus GeoCoder for ArcGIS. METHODS: We first geocoded 11,016 Texas addresses in a case-control study using both methods and obtained the match rate of each method. We then randomly selected 200 addresses from those geocoded by using both methods and obtained geographic coordinates of the 200 addresses by using a global positioning system (GPS) device. Of the 200 addresses, 110 were case maternal residence addresses and 90 were control maternal residence addresses. These GPS-surveyed coordinates were used as the "true" coordinates to calculate positional errors of geocoded locations. We used Wilcoxon signed rank test to evaluate whether differences in positional errors from the two methods were statistically significantly different from zero. In addition, we calculated the sensitivity and specificity of the two methods for classifying maternal addresses within 1500 m of toxic release inventory facilities when distance is used as a proxy of exposure. RESULTS: The match rate of the Centrus GeoCoder was more than 10% greater than that of the geocoding tool in ArcGIS 9.1. Positional errors with the Centrus GeoCoder were less than those of the geocoding tool in ArcGIS 9.1, and this difference was statistically significant. Sensitivity and specificity of the two methods are similar. CONCLUSIONS: Centrus GeoCoder for ArcGIS for geocoding gives greater match rates than the geocoding tool in ArcGIS 9.1. Although the Centrus GeoCoder has better positional accuracy, both methods give similar results in classifying maternal addresses within 1500 m of toxic release inventory facilities when distance is used as a proxy of exposure.

Trends of Selected Malformations in Relation to Folic Acid Recommendations and Fortification: An International Assessment.
Botto LD, Lisi A, Bower C, Canfield MA, Dattani N, de Vigan C et al.
Birth Defects Res A Clin Mol Teratol 2006;76(10):693-705.
BACKGROUND: Two crucial issues relative to the benefits and impact of folic acid in the prevention of birth defects are whether supplementation recommendations alone, without fortification, are effective in reducing the population-wide rates of neural tube defects (NTDs), and whether such policies can reduce the occurrence of other birth defects. Using data from 15 registries, we assessed rates and trends of 14 major defects, including NTDs, in areas with official recommendations or fortification to assess the effectiveness of recommendations and fortification on a wide range of major birth defects. METHODS: We evaluated surveillance data through 2003 on major birth defects from population-based registries from Europe, North America, and Australia. All included ascertainment of pregnancy terminations (where legal). Trends before and after policies or fortification were assessed via Poisson regression and were compared via rate ratios. RESULTS: Significant changes in trends were seen for NTDs in areas with fortification but not in areas with supplementation recommendations alone. For other major birth defects, there was an overall lack of major trend changes after recommendations or fortification. However, some significant declines were observed for select birth defects in individual areas. CONCLUSIONS: Recommendations alone remain an ineffective approach in translating the known protective effect of folic acid in population-wide decline in NTD rates. Fortification appears to be effective in reducing NTDs. The effect on other birth defects remains unclear.

Cervical Cancer Survival by Socioeconomic Status, Race/Ethnicity, and Place of Residence in Texas, 1995-2001.
Eggleston KS, Coker AL, Williams M, Tortolero-Luna G, Martin JB, Tortolero SR.
J Womens Health. 2006 Oct;15(8):941-51.
OBJECTIVE: The current study explored whether socioeconomic status (SES), race/ethnicity, and rural residence may be linked to poorer cervical cancer survival by stage at diagnosis. METHODS: Data from 7,237 cervical cancer cases reported to the Texas Cancer Registry from 1995-2001 were used to address the association by stage at diagnosis and cause of death. Zip code-level census data were used to classify residence and to develop a composite variable for SES. Multilevel Cox proportional hazards modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Late stage at diagnosis was a strong predictor of cervical cancer mortality (HR = 6.2, 95% CI 5.5-7.2). SES and race/ethnicity were independently associated with stage at diagnosis. Women residing in areas with lower SES had significantly shorter survival times when diagnosed at an early stage (HR = 3.0, 95% CI 2.1-4.3). Hispanic women had a lower probability of dying from cervical cancer during the follow-up period (HR = 0.7, 95% CI 0.6- 0.8) after adjusting for confounders. The association between lower SES and poorer survival was consistent across all racial/ethnic groups, suggesting the effect of SES may be more important than race. CONCLUSIONS: SES and race/ethnicity were independently associated with poorer cervical cancer survival in this large Texas sample. Further research is needed to investigate the role of optimal treatment and comorbid conditions in the association between SES and cervical cancer survival.

Normal Muscle Respiratory Chain Enzymes Can Complicate Mitochondrial Disease Diagnosis.
Oglesbee D, Freedenberg D, Kramer KA, Anderson BD, Hahn SH.
Pediatr Neurol. 2006 Oct;35(4):289-92.
This report presents a case of mitochondrial respiratory chain deficiency in a neonate with elevated plasma lactate, hypotonia, developmental delay, and dysmorphic features. The initial biochemical analyses of muscle tissue for mitochondrial function were normal. Additional testing on skin fibroblasts performed owing to a high clinical suspicion of a possible mitochondrial disorder indicated a deficiency of mitochondrial complex I. Western blotting of samples obtained both from muscle and fibroblast tissues also revealed an extensive defect in mitochondrial respiratory chain complex I, confirming the diagnosis. These observations underscore the fact that both enzymatic and immunological assays should be undertaken in alternate tissues when muscle biopsies are inconclusive in highly suspected cases.

GIS-Epilink: A Spatial Search Tool for Linking Environmental and Health Data.
Zhan FB, Brender JD, Han Y, Suarez L, Langlois PH.
J Med Syst. 2006 Oct;30(5):405-12.
One inherent characteristic of both environmental data and health data is that they have a location component. This characteristic makes Geographic Information Systems (GIS) an ideal and sometimes indispensable tool for analyzing environmental and health data. Indeed, the past decade witnessed significant efforts in developing GIS tools for supporting epidemiologic research. Despite these efforts, the availability of accessible GIS tools that can be easily used by epidemiologists to link environmental and health data has remained a problem. We present a simple spatial search tool--GIS-EpiLink--that can be used to link environmental and health data when distance between an environmental site and the location of the maternal address of a case or control is used as a proxy for exposure. The tool was used in a research project and it successfully provided the necessary data for epidemiological analyses. This tool should be very useful to epidemiologists in environmental health research.

Comparison of Zolpidem and Zaleplon Exposures in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A. 2006 Oct;69(20):1883-92.
Zolpidem and zaleplon are used for the treatment of insomnia. The objective of this study was to compare the patterns of zolpidem and zaleplon exposures reported to Texas poison control centers during 1998-2004. There were 5842 total reported zolpidem exposures, of which 2918 (50%) were isolated exposures, and 467 total reported zaleplon exposures, of which 201 (43%) were isolated exposures. Zolpidem patients were 62% male and 67% adult. Zaleplon patients were 67% male and 34% adult. The exposure was intentional in 62% of zolpidem and 58% of zaleplon exposures. The exposure occurred at the patient's own residence in 94% of zolpidem and 97% of zaleplon exposures. Management occurred outside of a health care facility for 29% of zolpidem and 32% of zaleplon exposures. The medical outcome involved no symptoms due to exposure for 29% of zolpidem and 44% of zaleplon exposures, a statistically significant difference. Although many of the most frequently reported adverse clinical effects for the two drugs were similar (drowsiness, slurred speech, hallucinations, ataxia, tachycardia, dizziness, confusion, vomiting), the proportion of exposures with a given adverse clinical effect was generally lower for zaleplon. Thus, although zolpidem and zaleplon exposures were generally similar with respect to patient gender and age, exposure reason and site, and management site, zaleplon exposures were less likely to result in minor medical outcomes or manifest as adverse clinical effects.

Pattern of Dipyrone Exposure in Texas, 1998 to 2004.
Forrester MB.
J Med Toxicol 2006;2(3):101-107.
Introduction: Dipyrone is an analgesic and antipyretic agent. The purpose of this study was to describe the pattern of dipyrone exposures reported to poison centers. Methods: Human dipyrone exposures reported to 6 Texas poison centers from 1998 to 2004 were identified. Isolated and non-isolated cases were compared with respect to various factors. Results: When compared to the Census, dipyrone exposures were significantly more likely to have been reported from regions closer to the Mexican border (53% vs 9%). Of 81 dipyrone exposures, 52 (64%) were isolated and 29 (36%) were non-isolated. Most of the dipyrone exposures occurred at the patient’s own residence (72/76 or 95%) and the patients were more likely to be female (54/81 or 67%). Although the majority of both types of dipyrone exposures were adults (47/78 or 60%), children, less than 6 years of age, accounted for a higher proportion of isolated exposures (33% vs 10%) while a higher proportion of non-isolated exposures involved older children (28% vs 8%). Twenty-two percent (11/51) of isolated cases were intentional while 59% (17/29) of non-isolated cases were intentional. Of those cases with a known medical outcome, the medical outcome was no adverse clinical effect for 76% (16/21) of isolated exposures and 42% (8/19) of non-isolated exposures. The specific adverse clinical effects reported for isolated exposures were primarily neurological (n=6), gastrointestinal (n=4), and dermal (n=3). The most frequently reported treatment for isolated exposures was some form of decontamination (n=11). Conclusions: Isolated and non-isolated dipyrone exposures varied with respect to patient age, exposure reason, management site, and medical outcome.

Jimsonweed (Datura stramonium) Exposures in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2006 Oct;69(19):1757-1762.
For centuries, jimsonweed, Datura stramonium, was known to produce hallucinogenic effects. Jimsonweed is easily obtained and may be abused by adolescents. This investigation examined the patterns of jimsonweed exposures reported to Texas poison control centers during 1998–2004. A total of 188 reported human exposures were identified. Seventy-six percent of the exposures occurred in June–October. For those cases where the information was known, the majority were male (82%) and age 13–19 yr (72%). Intentional abuse or misuse accounted for 78% of reported exposures. Eighty-two percent of the reported exposures were at, en route to, or referred to health care facilities, and 89% of those cases with a known medical outcome had moderate or major effects. The most frequently reported clinical effects were hallucination, tachycardia, agitation, mydriasis, and confusion; the most frequently reported treatments were intravenous fluids replacement, activated charcoal, cathartic, and benzodiazepines. The pattern of reported jimsonweed exposures in Texas was consistent with previously published literature.

Human Plague--Four States, 2006.
MMWR Morb Mortal Wkly Rep. 2006 Sep 1;55(34):940-3.
Centers for Disease Control and Prevention (CDC). DSHS contributors: B Nix, R Jones, T Sidwa, J Walker.
Plague is a zoonotic disease caused by the bacterium Yersinia pestis. In 2006, a total of 13 human plague cases have been reported among residents of four states: New Mexico (seven cases), Colorado (three cases), California (two cases), and Texas (one case). This is the largest number of cases reported in a single year in the United States since 1994. Dates of illness onset ranged from February 16 to August 14; two (15%) cases were fatal. The median age of patients was 43 years (range: 13-79 years); eight (62%) patients were female. Five (38%) patients had primary septicemic plague, and the remaining eight (62%) had bubonic plague. Two (15%) patients developed secondary plague pneumonia, leading to administration of antibiotic prophylaxis to their health-care providers. This report summarizes six of the 13 cases, highlighting the severity and diverse clinical presentations of plague and underscoring the need for prompt diagnosis and treatment when plague is suspected.

Interdigital Skin Lesions of the Lower Limbs among Patients with Lymphoedema in an Area Endemic for Bancroftian Filariasis.
Dreyer G, Addiss D, Gadelha P, Lapa E, Williamson J, Dreyer A.
Trop Med Int Health. 2006 Sep;11(9):1475-81.
OBJECTIVES: An estimated 15 million persons suffer from lymphoedema of the leg in filariasis-endemic areas of the world. A major factor in the progression of lymphoedema severity is the incidence of acute dermatolymphangioadenitis (ADLA), which is triggered by bacteria that gain entry through damaged skin, especially in the toe web spaces ('interdigital skin lesions'). Little is known about the epidemiology of these skin lesions or about patients' awareness of them. METHODS: We interviewed and examined 119 patients (89% women) with lymphoedema of the leg in Recife, Brazil, an area endemic for bancroftian filariasis. RESULTS: We detected 412 interdigital skin lesions in 115 (96.6%) patients (mean, 3.5 lesions per patient, range 0-8). The number of interdigital skin lesions was significantly associated with lymphoedema stage (P<0.001) and frequency of ADLA (P<0.0001). Only 20 (16.8%) patients detected their own interdigital skin lesions or considered them abnormal. Patients reported a mean of 3.6 ADLA episodes during the previous 12 months (range, 0-20); reported ADLA incidence was associated with lymphoedema stage (P<0.0001) and the number of interdigital skin lesions detected by the examining physician (P<0.0001). CONCLUSIONS: These data suggest that interdigital skin lesions are a significant risk factor for ADLA and that persons with lymphoedema in filariasis-endemic areas are unaware of their presence or importance. Prevention of ADLA through prompt recognition and treatment of interdigital skin lesions will require that patients be taught to identify lesions, especially between the toes and to recognize them as abnormal.

Human West Nile Virus Neuroinvasive Disease in Texas, 2003 Epidemic: Regional Differences.
Warner RD, Kimbrough RC, Alexander JL, Rush Pierce J Jr, Ward T, Martinelli LP.
Ann Epidemiol. 2006 Sep 12;16(10):749-755.
PURPOSE: Arboviral diseases, such as West Nile virus (WNV) epizootics, tend to be geographically unique because of the biomes that support the vector(s) and reservoir host(s). Understanding such details aids in preventive efforts. We studied the 2003 epidemic of human West Nile neuroinvasive disease (WNND) in Texas because it initially appeared that incidence was not uniform across regions of the state. METHODS: The epidemic was described by age, sex, and region of residence. These variables were used to compare age-specific incidence, standardized cumulative incidence, and age-adjusted relative risk (RR). We verified case data and used routine software, with population estimates from the US Census Bureau. RESULTS: Regardless of sex, risk increased with age. Males had the greater risk (RR, 1.69); however, males aged 5 to 17 years had the greatest RR. Of the five regions compared, two posed more (RRs, 7.98 and 2.14) and one posed less (RR, 0.40) risk than the remainder of the state. Proportions of Culex vector species differed significantly between regions. CONCLUSIONS: During 2003, the risk for WNND varied considerably across Texas. This suggests that various risks for WNV infection deserve additional research for preventive interventions to be regionally appropriate and effective.

Annual Report to the Nation on the Status of Cancer, 1975-2003, Featuring Cancer among U.S. Hispanic/Latino Populations.
Howe HL, Wu X, Ries LA, Cokkinides V, Ahmed F, Jemal A, Miller B, Williams M, Ward E, Wingo PA, Ramirez A, Edwards BK.
Cancer. 2006 Sep 6;107(8):1711-1742.
BACKGROUND: The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate annually to provide U.S. cancer information, this year featuring the first comprehensive compilation of cancer information for U.S. Latinos. METHODS: Cancer incidence was obtained from 90% of the Hispanic/Latino and 82% of the U.S. populations. Cancer deaths were obtained for the entire U.S. population. Cancer screening, risk factor, incidence, and mortality data were compiled for Latino and non-Latino adults and children (incidence only). Long-term (1975-2003) and fixed-interval (1995-2003) trends and comparative analyses by disease stage, urbanicity, and area poverty were evaluated. RESULTS: The long-term trend in overall cancer death rates, declining since the early 1990s, continued through 2003 for all races and both sexes combined. However, female lung cancer incidence rates increased from 1975 to 2003, decelerating since 1991 and breast cancer incidence rates stabilized from 2001 to 2003. Latinos had lower incidence rates in 1999-2003 for most cancers, but higher rates for stomach, liver, cervix, and myeloma (females) than did non-Latino white populations. Latino children have higher incidence of leukemia, retinoblastoma, osteosarcoma, and germ-cell tumors than do non-Latino white children. For several common cancers, Latinos were less likely than non-Latinos to be diagnosed at localized stages. CONCLUSIONS: The lower cancer rates observed in Latino immigrants could be sustained by maintenance of healthy behaviors. Some infection-related cancers in Latinos could be controlled by evidence-based interventions. Affordable, culturally sensitive, linguistically appropriate, and timely access to cancer information, prevention, screening, and treatment are important in Latino outreach and community networks.

Geographic Variation in the Incidence of Colorectal Cancer in the United States, 1998-2001.
Lai SM, Zhang KB, Uhler RJ, Harrison JN, Clutter GG, Williams MA.
Cancer. 2006 Sep 1;107(5 Suppl):1172-80.
BACKGROUND: This study examined the incidence rates and risk factors for colorectal cancer in 9 geographic divisions in the United States. METHODS: The colorectal cancer cases were diagnosed between 1998 and 2001 in 39 states and the District of Columbia (grouped into 9 geographic divisions in the United States). The association between colorectal cancer and geographic division was analyzed using the Poisson regression model controlling for demographics and ecologic measures of education, behavioral factors and colorectal cancer screening data extracted from the Behavioral Risk Factor Surveillance System. RESULTS: The age-adjusted incidence rates of colorectal cancer were highest in the Middle Atlantic division, followed by New England division, East and West North Central divisions, East South Central and South Atlantic divisions, West. South Central and Pacific divisions, with the lowest rate observed in the Mountain division. Old age, male gender, black race, less than a twelfth-grade education, smoking, and no physical activity were significantly associated with higher incidence rates of colorectal cancer, whereas having sigmoidoscopy/colonoscopy in the past 5 years, fecal occult blood test in the past year, and obesity were associated with lower incidence rates of colorectal cancer. The relative ranking of incidence rates of colorectal cancer across divisions changed after adjusting for these factors. CONCLUSIONS: Significant geographic variation in colorectal cancer exists in the United States. Risk factors, including demographics, education, behavior, and screening use, can only partially explain the differences across geographic divisions.

Aripiprazole Exposures Reported to Texas Poison Control Centers during 2002-2004.
Forrester MB.
J Toxicol Environ Health A 2006 Sep;69(18):1719-1726.
Aripiprazole is an oral atypical antipsychotic drug used in the treatment of schizophrenia and potentially other behavior disorders. The purpose of this study was to describe the epidemiology of aripiprazole exposures reported to Texas poison control centers. Human aripiprazole exposures reported to six Texas poison control centers were identified and comparisons were made between isolated and nonisolated cases with respect to various demographic and clinical factors. Of 280 human exposures involving aripiprazole, 35% were isolated and 65% were nonisolated. The patients were female in 52% of isolated and 60% of nonisolated cases. Isolated cases were significantly more likely to involve children <6 yr of age. Fifty-eight percent of isolated cases were unintentional while 68% of nonisolated cases were intentional. Nonisolated cases were much more likely to already be at or en route to a health care facility when the poison control center was contacted. Of those cases with a known medical outcome, no adverse clinical effect was reported in 52% of isolated cases and 35% of nonisolated cases. The adverse clinical effects associated with isolated aripiprazole exposures were mainly neurological, cardiovascular, and gastrointestinal, with the most frequently reported adverse clinical effect being drowsiness or lethargy. The most commonly reported treatments for isolated aripiprazole exposures were single dose of activated charcoal, cathartic, intravenous fluids, dilution, lavage, and antihistamines. In conclusion, isolated and nonisolated aripiprazole exposures varied with respect to patient age, exposure reason, management site, and clinical outcome.

Dengue and South Texas: Information for Clinicians.
Ramos M, Abell A, Smith B.
Tex Med. 2006 Aug;102(8):56-8.
Dengue is a mosquito-transmitted, acute viral disease caused by any of four dengue virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). Dengue is endemic in most tropical and subtropical areas of the world. Since 1980, outbreaks of dengue and dengue hemorrhagic fever have been increasingly common in Mexico. South Texas has experienced five outbreaks of dengue since 1980, corresponding with periods of epidemic dengue in Mexico. The most recent dengue outbreak in South Texas occurred in the summer and fall of 2005. This article summarizes the current situation of dengue in South Texas and provides a concise clinical review for the health care practitioner.

Addressing Asthma in Texas: Development of a School-Based Asthma Surveillance Program for Texas Elementary Schools.
Petronella SA, Bricker SK, Perrotta D, Brown C, Brooks EG
J Sch Health. 2006 Aug;76(6):227-34.
To address asthma in the state, in October 2000, the Texas Department of State Health Services (DSHS) and the American Lung Association of Texas held a joint meeting of asthma professionals from across the state, with a primary purpose of identifying major issues and potential strategies and actions to be taken. These discussions became the basis of the 2001 Texas State Asthma Plan, which has since been adopted to guide state efforts in asthma surveillance, management, education, and advocacy. The primary purpose of this project, which was conducted with and funded by the DSHS and the Centers for Disease Control and Prevention, has been to develop and implement an asthma surveillance program for Texas school-aged children. The program has been implemented with a sample (n = 42,409) of students from the Texas Education Agency's region IV. An important goal has been to determine the feasibility of conducting school-based statewide asthma surveillance and assist with establishing a network for ongoing, systematic collection, analysis, interpretation, and dissemination of asthma data. This project is expected to become part of a wider asthma surveillance network that will include mortality, hospital discharge, and Behavioral Risk Factor Surveillance System (BRFSS) data. It will also provide information not typically captured by surveillance programs, including the BRFSS, which rely heavily upon a previous diagnosis of asthma to determine both lifetime and current prevalence of asthma. Results from this project indicate that such reliance on a previous diagnosis may considerably underestimate the prevalence of disease-particularly in the Latino population.

Adaptation and Implementation of an Evidence-based Prevention Counseling Intervention in Texas.
Hitt JC, Robbins AS, Galbraith JS, Todd JD, Patel-Larson A, McFarlane JR, Spikes P, Carey JW.
AIDS Educ Prev. 2006 Aug;18(4 Suppl A):108-18.
HIV prevention counseling linked with testing has been shown to reduce high-risk behaviors and new sexually transmitted diseases in public clinic settings. However, few studies have been conducted evaluating the implementation of such models outside a research setting. This study sought to determine the extent to which the introduction of a standard protocol based on Project RESPECT improves the achievement of HIV prevention counseling goals of existing counseling and testing programs. Four prevention counseling programs contracting with the Texas Department of State Health Services completed a standardized 5-day training and implemented the protocols, counseling tools, and quality assurance (QA) procedures developed for the project. Introduction of the protocol was accomplished with existing program resources and significantly improved prevention counseling. Direct observation of counseling sessions demonstrated a significant improvement in attainment for eight of the nine counseling goals of initial sessions and for all counseling goals of follow-up sessions after the protocol was introduced. Client exit questionnaires reinforced this finding. Significant improvement was also found in use of counseling skills, with improvements in 6 of 10 skills observed in initial sessions and 4 of 10 skills in follow-up sessions. Challenges identified through semistructured interviews with counselors and supervisors included serving non-English-speaking and low-risk clients, mastery of the protocol, the amount of time required for QA, and implementation in settings with severe time constraints.

A Large Outbreak of Brainerd Diarrhea Associated with a Restaurant in the Red River Valley, Texas.
Kimura AC, Mead P, Walsh B, Alfano E, Gray SK, Durso L, Humphrey C, Monroe SS,
Visvesvera G, Puhr N, Shieh WJ, Eberhard M, Hoekstra RM, Mintz ED.
Clin Infect Dis. 2006 Jul 1;43(1):55-61.
BACKGROUND: In June 1996, an outbreak of chronic diarrhea was reported to the Texas Department of Health (Austin). METHODS: We initiated active case finding, performed 2 case-control studies, and conducted an extensive laboratory and environmental investigation. RESULTS: We identified 114 persons with diarrhea that lasted > or = 4 weeks. Symptoms among 102 patients who were studied included urgency (87%), fatigue (86%), fecal incontinence (74%), and weight loss (73%); the median maximum 24-h stool frequency was 15 stools. Diarrhea persisted for > 6 months in 87% and for > 1 year in 70% of patients who were observed. Fifty-one (89%) of 57 ill persons had eaten at a particular restaurant within 4 weeks before onset, compared with 8 (14%) of 59 matched control subjects (matched odds ratio [OR], undefined; 95% confidence interval [CI], 11.2-infinity). At the restaurant, patients were more likely than their unaffected dining companions to have drunk tap water (OR, 2.8; 95% CI, 1.0-9.9) and to have eaten several specific food items, and they were less likely to have drunk iced tea made from boiled water and store-bought ice (OR, 0.3; 95% CI, 0.05-1.0). A multivariable model that included consumption of tap water and salad bar tomatoes best fit the data. The restaurant had multiple sanitary and plumbing deficiencies. Extensive laboratory and environmental testing for bacterial, parasitic, mycotic, and viral agents did not identify an etiologic agent. CONCLUSIONS: The clinical, laboratory, and epidemiologic findings are consistent with those of previous outbreaks of Brainerd diarrhea. To our knowledge, this is the largest reported outbreak of Brainerd diarrhea associated with a restaurant.

Unauthorized Border Crossings and Migrant Deaths: Arizona, New Mexico, and El Paso, Texas, 2002-2003.
Sapkota S, Kohl HW, Gilchrist J, McAuliffe J, Parks B, England B, Flood T, Sewell CM, Perrotta D, Escobedo M, Stern CE, Zane D, Nolte KB.
Am J Public Health 2006 July;96(7):1282-7.
Objectives. We examined the major causes of and risk factors for death among migrants who died while making unauthorized border crossings into the United States from Mexico. Methods. Decedents were included in the study if (1) their remains were found between January 1, 2002, and December 31, 2003, in any US county along the 650-mi (1040-km) section of the US-Mexico border from Yuma, Ariz, to El Paso, Tex; (2) their immigration status was unauthorized; and (3) they were believed to have died during transit from Mexico to the United States. Characteristics of the decedents and causes of and risk factors for their deaths were examined. Results. Among the 409 decedents meeting our inclusion criteria, environmental heat exposure (n=250; 61.1%) was the leading cause of death, followed by vehicle crashes (n=33; 8.1%) and drownings (n=24; 5.9%). Male decedents (n=298; 72.8%) outnumbered female decedents (n=105; 25.6%) nearly 3 to 1. More than half of the decedents were known to be Mexican nationals (n=235; 57.5%) and were aged 20 to 39 years (n=213; 52.0%); the nationality of 148 (36.2%) decedents was undetermined. Conclusions. Deaths among migrants making unauthorized US-Mexico border crossings are due to largely preventable causes. Prevention strategies should target young Mexican men, and focus on preventing them from conceiving plans to cross the border, discouraging them from using dangerous routes as crossing points, and providing search-and-rescue teams to locate lost or injured migrant crossers.

Folic Acid Awareness and Supplementation among Texas Women of Childbearing Age.
Canfield MA, Przybyla SM, Case AP, Ramadhani T, Suarez L, Dyer J.
Prev Med. 2006 Jul;43(1):27-30.
OBJECTIVE: Neural tube defects (NTDs) affect about seven of every 10,000 deliveries in Texas. To reduce the risk for NTDs, women are encouraged to supplement with 400 mcg folic acid daily during their reproductive years. This study examines folic acid awareness, knowledge, and supplementation practices among women of childbearing age (WCBA), including residents of Texas-Mexico border as well as women of Hispanic origin/ethnicity, populations that have NTD rates up to three times higher than the national average. METHODS: We conducted a statewide multistage sample telephone survey among Texas women of childbearing age in 2001. In total 1,196 women age 18 to 44 were interviewed. RESULTS: About 78% of WCBA knew about folic acid, 28% knew that folic acid prevents birth defects, and 25% knew to take folic acid before pregnancy. The prevalence of daily folic acid supplementation among all women of childbearing age was 33%. Education was the strongest predictor of folic acid awareness followed by race/ethnicity and age. Significant predictors of daily folic acid supplementation were education and ethnicity. CONCLUSIONS: Our findings suggest the need for more emphases on strategies to improve the level of folic acid supplementation among low educated women, and race ethnic minority populations.

The Texas Children's Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder.
Pliszka SR, Crismon ML, Hughes CW, Corners CK, Emslie GJ, Jensen PS, McCracken
JT, Swanson JM, Lopez M.
J Am Acad Child Adolesc Psychiatry. 2006 Jun;45(6):642-57.
OBJECTIVE: In 1998, the Texas Department of Mental Health and Mental Retardation developed algorithms for medication treatment of attention-deficit/hyperactivity disorder (ADHD). Advances in the psychopharmacology of ADHD and results of a feasibility study of algorithm use in community mental health centers caused the algorithm to be modified and updated. METHOD: We convened a consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families to revise the algorithms for the pharmacotherapy of ADHD itself as well as ADHD with specific comorbid disorders. New research was reviewed by national experts, and rationales were provided for proposed changes and additions to the algorithms. The changes to the algorithms were discussed and approved both by the national experts and experienced clinicians from the Texas public mental health system. RESULTS: The panel developed consensually agreed-upon algorithms for ADHD with and without comorbid disorders. The major changes included elimination of pemoline as a treatment option, adding atomoxetine to the algorithm, and refining guidelines for treating ADHD with comorbid depression, aggressive behaviors, and tic disorders. CONCLUSIONS: Medication algorithms for ADHD can be modified to keep abreast of developments in the field. Although these evidence- and consensus-based treatment recommendations may be a useful approach to guide the treatment of ADHD in children, additional research is needed to determine how these algorithms can be used to maximally benefit child outcomes.

A Low-intensity Intervention to Prevent Annual Weight Gain in Active Duty Air Force Members.
Robbins AS, Chao SY, Baumgartner N, Runyan CN, Oordt MS, Fonseca VP.
Mil Med. 2006 Jun;171(6):556-61.
Elevated body weight among active duty Air Force (ADAF) members is a substantial and growing problem, and typically results from gaining small amounts of weight each year over many years. We designed a strategy to prevent annual weight gain in ADAF members using self-directed behavior change booklets followed by weekly e-mails about diet and physical activity for a year. The intervention was universally offered to ADAF members meeting selection criteria at five U.S. Air Force bases (n = 3,502); members at 60 other U.S. Air Force bases served as controls (n = 65,089). The intervention was completely effective at preventing weight gain in a subgroup of men (those above the lowest three ranks, with baseline weight above maximum allowable) and in women, while controls continued to gain weight. Since the intervention did not require personalized contact, this approach has promise for large-scale population-based efforts aimed at preventing weight gain in working adults.

Epidemiology of Centipede Exposures Reported to Texas Poison Control Centers, 1998–2004.
Forrester MB.
Toxicol Environ Chem 2006;88(2):213-218.
Centipedes are found globally, including the southern United States. Although centipede bites may cause pain, the bite is generally not considered life threatening. The present retrospective investigation studied the epidemiology of centipede exposures reported to Texas poison control centers. Cases were all human exposures reported during 1998–2004 that involved centipedes. There were totally 851 cases. Among the cases with a known patient age, 16% were less than 6 years of age, 19% were 6–19, and 65% were greater than 19 years. Females accounted for 55% of the patients with known gender. The reported centipede exposures were managed on site (outside of a health care facility) in 93% of the cases. Of the 305 cases with a known clinical outcome, 82% had minor effects. Cases exhibited a seasonal trend, with most of the reports occurring during July–September. There was no clear geographic pattern to the reported centipede exposures, although the highest rate occurred in West Texas. Dermal irritation or pain was reported in 73% of cases and the treatment by decontamination via irrigation was reported for 76% of the cases during 2000–2004.

Maternal Residential Proximity to Waste Sites and Industrial Facilities and Oral Clefts in Offspring.
Brender JD, Zhan FB, Suarez L, Langlois PH, Moody K.
J Occup Environ Med. 2006 Jun;48(6):565-72.
OBJECTIVE: This study examined the association between oral clefts and maternal residential proximity to waste sites or industries. METHODS: In a case-control study, maternal residences at birth of 1781 births with oral clefts and 4368 comparison births were related to locations of waste sites and industrial facilities in Texas through geographic information systems. RESULTS: Compared with women who lived farther, women who lived within a mile of these sites or facilities were not more likely to have offspring with oral clefts. Among women > or =35 years, oral clefts in offspring were associated with living within a mile of industrial facilities (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.3-4.2), especially smelters (OR = 15.0, 95% CI = 2.8-151). CONCLUSION: These findings suggest that maternal residential proximity to industries might be associated with oral clefts in births to older mothers.

Comparison of Residential Geocoding Methods in Population-based Study of Air Quality and Birth Defects.
Gilboa SM, Mendola P, Olshan AF, Harness C, Loomis D, Langlois PH, Savitz DA, Herring AH.
Environ Res. 2006 Jun;101(2):256-62. Epub 2006 Feb 17.
Our population-based case-control study of air quality and birth defects in Texas relied on the geocoding of maternal residence from vital records for the assignment of air pollution exposures during early pregnancy. We attempted to geocode the maternal addresses for 5,338 birth defect cases and 4,574 frequency-matched controls using an automated procedure with standard matching criteria in ArcGIS 8.2 and 8.3. Initially, we matched 7,266 observations (73%). To increase the proportion of successful matches, we used an interactive procedure for the 2,646 addresses that were initially not geocoded by the software. This yielded an additional 985 matches (37%). Using the same 2,646 initially unmatched addresses, we compared the results of this interactive procedure to those of an automated procedure using lower standards. The automated procedure with lower standards yielded more matches (n=1,559, 59%) but with questionable accuracy. We included the interactively geocoded observations in our final data set. Their inclusion did not affect the estimates of air pollution exposure but increased our statistical power to detect associations between air quality and risk of selected birth defects. The geocoded and not geocoded populations differed in the distribution of Latino ethnicity (51% vs 59%) and ethnicity was independently associated with air pollution exposures (P<0.05). Geocoding status also appeared to modify the association between ethnicity and risk of birth defects; Latina women appeared to have a slightly lower risk of birth defects than non-Latina women in the geocoded population and to have a slightly higher risk in the not geocoded population. Incomplete geocoding may have resulted in a selection bias because of the under-representation of Latinas in our study population.

Mycobacterium arupense sp. nov., a Non-Chromogenic Bacterium Isolated from Clinical Specimens.
Cloud JL, Meyer JJ, Pounder JI, Jost KC Jr, Sweeney A, Carroll KC, Woods GL.
Int J Syst Evol Microbiol. 2006 Jun;56(Pt 6):1413-8.
Several Mycobacterium-like organisms related to the Mycobacterium terrae complex have been isolated from clinical samples. In the clinical microbiology laboratory, partial 16S rRNA gene sequencing (approximately the first 500 bp) rather than full 16S rRNA gene sequencing is often used to identify Mycobacterium species. Partial 16S rRNA gene sequence analysis revealed 100 % similarity between 65 clinical isolates and Mycobacterium sp. MCRO 6 (GenBank accession no. X93032). Even after sequencing the nearly full-length 16S rRNA gene, closest similarity was only 99.6 % to Mycobacterium nonchromogenicum ATCC 19530(T). Sequencing of the nearly full-length 16S rRNA gene, the 16S-23S internal transcribed spacer region and the hsp65 gene did not reveal genotypic identity with the type strains of M. nonchromogenicum, M. terrae or Mycobacterium triviale. Although sequence analysis suggested that these clinical isolates represented a novel species, mycolic acid analysis by HPLC failed to distinguish them from M. nonchromogenicum. Therefore, phenotypic analysis including growth characterization, antibiotic susceptibility testing and biochemical testing was performed. These strains from clinical samples should be recognized as representing a novel species of the genus Mycobacterium, for which the name Mycobacterium arupense sp. nov. is proposed. The type strain is AR30097(T) (=ATCC BAA-1242(T) = DSM 44942(T)).

Methylphenidate Abuse in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2006;69:1145-53.
Abstract: Methylphenidate is a stimulant used in the treatment of attention deficit hyperactivity disorder in children and is subject to abuse. This study describes the patterns of methylphenidate abuse and drug identification (ID) calls received by several poison control centers in Texas. Cases were calls involving methylphenidate received by Texas poison control centers during 1998-2004. Drug ID and drug abuse calls were assessed by call year and geographic location. Drug abuse calls were then compared to all other human exposure (nonabuse) calls with respect to various factors. Of 6798 calls received involving methylphenidate, 35% were drug IDs and 56% human exposures. Of the human exposures, 9% involved abuse. The number of drug ID calls and drug abuse calls received per year both declined during the first part of 7-yr period but then increased. Male patients accounted for approximately 60% of both drug abuse and nonabuse calls. Adolescent patients comprised 55% of drug abuse calls and children less than 13 yr old comprised 62% of nonabuse calls. Although the majority of both types of human exposures occurred at the patient's own residence, drug abuse calls were more likely than non-abuse calls to involve exposures at school (15% vs. 6%) and public areas (3% vs. 0.4%). While drug abuse calls were less likely than nonabuse calls to present with no clinical effects (29% vs. 52%), they were more likely to show more serious medical outcomes. Methylphenidate abusers are more likely to be adolescents. Methylphenidate abuse as compared to other exposures is more likely to occur outside of the person's home and to involve more serious medical outcomes.

Valdecoxib Exposures Reported to Texas Poison Centers During 2002-2004.
Forrester MB.
J Toxicol Environ Health A 2006;69:899-905.
Abstract: Valdecoxib is a drug possessing anti-inflammatory and analgesic properties and acts by binding to cyclo-oxygenase-2. The objective of this study was to describe the epidemiology of valdecoxib exposures reported to Texas poison centers. Human valdecoxib exposures reported to six Texas poison centers were identified and comparisons were made between isolated and nonisolated cases with respect to various demographic and clinical factors. Of 328 human valdecoxib calls, 55% were isolated and 45% were nonisolated. Fifty-eight percent of isolated cases involved female patients while 69% of nonisolated cases involved females. Fifty-three percent of isolated cases involved patients of age less than 6 yr, whereas 71% of nonisolated cases involved patients age 20 yr or greater. Eighty-four percent of isolated cases were unintentional and 67% of nonisolated cases were intentional. The patient was managed outside of health care facilities in 84% of isolated cases and 26% of nonisolated cases. Of those cases with a known medical outcome, 92% of isolated cases had no effect and 35% of nonisolated cases had no effect. Among isolated valdecoxib exposures, no particular clinical effect was reported in more than five cases. Isolated and nonisolated valdecoxib exposures varied with respect to patient gender and age, exposure reason, and clinical outcome. Adverse effects for isolated valdecoxib exposure involved only a small portion of patients that reported to the Texas poison control centers.

Uptake and Elimination of Perchlorate in Eastern Mosquitofish.
Bradford CM, Park JW, Rinchard J, Anderson TA, Liu F, Theodorakis CW.
Chemosphere. 2006 Jun;63(9):1591-7.
The purpose of this study was to investigate the uptake and elimination of perchlorate in eastern mosquitofish (Gambusia holbrooki). Fish were exposed to 0.1-1000mg/l sodium perchlorate for 12h, 1, 2, 5, 10, and 30days, and perchlorate was determined in whole body extracts. Perchlorate was not detected in mosquitofish exposed to the low concentrations of perchlorate (0, 0.1, and 1mg/l sodium perchlorate), regardless of the exposure time, whereas it was detected when fish were exposed to 10, 100, and 1000mg/l. The tissue concentrations were approximately 10 times less than that in the water. There was no difference in the uptake of perchlorate depending upon the exposure time, however, a difference in perchlorate uptake depending upon the concentration of the exposure dose (P<0.001) was observed. Uptake (K(u)) and elimination (K(e)) rate constants were 0.09l/mgday and 0.70day(-1), respectively. The half-life (T(1/2)) of perchlorate was 0.99day. Thus, it appears that perchlorate is rapidly taken up and eliminated in eastern mosquitofish. These results are critical and may be used to develop models of fate, effects, and transport of perchlorate in natural systems, as well as to assess ecological risk in affected ecosystems.

Health Department Costs of Managing Persons with Suspected and Noncounted Tuberculosis in New York City, Three Texas Counties, and Massachusetts.
Manangan LP, Moore M, Macaraig M, MacNeil J, Shevick G, Northrup J, Pratt R, Adams LV, Boutotte J, Sharnprapai S, Qualls N.
J Public Health Manag Pract. 2006 May-Jun;12(3):248-53.
OBJECTIVES: To describe persons with suspected (did not meet the national tuberculosis [TB] surveillance case definition) and noncounted TB (met the TB case definition but transferred and were counted by another jurisdiction) and estimate costs incurred by public health departments for managing them. METHODS: We reviewed TB registry, medical records, budgets, bills, salaries, organizational charts, and travel/activity logs from the year 2000 at health departments in New York City (NYC), three Texas (TX) counties (El Paso, Hidalgo, and Webb), and Massachusetts (MA). We also interviewed or observed personnel to estimate the time spent on activities for these patients. RESULTS: In 2000, NYC and MA had more persons with suspected (n = 2,996) and noncounted (n = 163) TB than with counted (n = 1,595) TB. TX counties had more persons with counted TB (n = 179) than with suspected (n = 55) and noncounted (n = 15) TB. Demographic and clinical characteristics varied widely. For persons with suspected TB, NYC spent an estimated $1.7 million, with an average cost of $636 for each person; TX counties spent $60,928 ($1,108 per patient); and MA spent $1.1 million ($3,330 per patient). For persons with noncounted TB, NYC spent $303,148 ($2,180 per patient), TX counties spent $40,002 ($2,667 per patient), and MA spent $84,603 ($3,525 per patient). CONCLUSIONS: Health departments incurred substantial costs in managing persons with suspected and noncounted TB. These costs should be considered when allocating TB program resources.

Ethnic Variation in Symptoms and Response to Risperidone in Youths with Schizophrenia-Spectrum Disorders.
Patel NC, Crismon ML, Shafer A, De Leon A, Lopez M, Lane DC.
Soc Psychiatry Psychiatr Epidemiol. 2006 May;41(5):341-6.
BACKGROUND: Evaluation of symptom presentation and antipsychotic response based on ethnicity in children and adolescents with schizophrenia is limited. The purpose of this naturalistic, retrospective database study was to compare symptom presentation of children and adolescents of different ethnicities with schizophrenia-spectrum disorders, and response to risperidone. METHOD: African-American (n = 38), Caucasian (n = 30), or Hispanic (n = 37) youths started on risperidone were eligible. Child Behavior Checklist (CBCL) total, internalizing, and externalizing scores were evaluated at baseline, 90 days, 1 year, and 2 year intervals. RESULTS: At baseline, Hispanic patients had lower CBCL externalizing scores than African-Americans or Caucasians. African-Americans showed significant differences in CBCL total, internalizing, and externalizing scores at 90 days compared to baseline. Hispanics showed improvement in CBCL internalizing scores over the 2 year period. No significant improvements were observed in Caucasians. African-American patients had significantly lower CBCL total at 90 days compared to Hispanic patients. No significant difference existed in 2 year hospitalization rates between groups. CONCLUSIONS: These findings suggest that ethnicity may play a role in symptom presentation and treatment response to risperidone for children and adolescents with schizophrenia-spectrum disorders. Future studies in children and adolescents are necessary to examine ethnospecific differences in antipsychotic use and treatment response.

Investigation of Texas Poison Center Calls Regarding a Chlorine Gas Release: Implications for Terrorist Attack Toxicosurveillance.
Forrester MB.
Texas Medicine, 2006 May;102(5):52-57.
The investigation reported here was conducted to describe the pattern of calls received by the Texas Poison Center Network (TPCN) in relation to a chlorine gas release that resulted from a train collision in Bexar County, Texas, on June 28, 2004, and to test various methods for conducting toxicosurveillance. TPCN received a total of 42 calls; the first call was received approximately 35 minutes after the collision. Calls continued for 10 days after the collision. Comparison of the number of calls received from Bexar County on the collision date with the number of similar calls received in the past revealed that numbers for this collision date were elevated for total calls, total information calls, total human exposure calls, chlorine gas calls, and calls involving coughing or choking, headache, throat irritation, or bronchospasm. When a similar analysis was performed for the entire state, call numbers were elevated only for chlorine gas calls and calls involving bronchospasm.

Risk Behaviors by Ethnicity and Texas-Mexico Border Residence.
Sanderson M, Fernandez ME, Dutton RJ, Ponder A, Sosa D, Peltz G.
Ethnicity and Disease, 2006 Spring;16:514-520.
Objective: To determine whether residence on the Texas-Mexico border would modify the effect of ethnic differences on risk behaviors. Design: We performed an analysis of 1999-2003 cross-sectional data from the Texas Behavioral Risk Factor Surveillance System (BRFSS). Setting: Fifteen Texas-Mexico border counties compared with 239 Texas non-border counties. Participants: 521 White and 1722 Hispanic residents of Texas-Mexico border counties and 16,904 White and 4933 Hispanic residents of Texas non-border counties. Main Outcome Measures: Health risk behaviors including overweight, obesity, physical inactivity, fruit or vegetable consumption, heavy drinking, binge drinking, and smoking. Results: Hispanic women and men were more likely to be overweight, obese, and physically inactive, and less likely to consume fewer than five fruits or vegetables per day than Whites regardless of residence. Ethnic differences in heavy and binge drinking differed by residence and sex. After adjustment for age, educational level, annual household income, perceived general health, and diabetes, most behaviors that were higher or lower remained significant among non-border residents but were no longer significant among border residents. Conclusions: The only evidence of effect modification was binge drinking among males and most associations were weaker among border residents than among non-border residents.

Settlement-funded Tobacco Control in Texas: 2000-2004 Pilot Project Effects on Cigarette Smoking
McAlister AL, Huang P, Ramirez AG.
Public Health Reports 2006 May-June;121:235-238.
Because settlement proceeds allocated for tobacco control in Texas are insufficient for statewide activity at federally recommended funding levels, the Texas Department of State Health Services has used the available funds in quasi-experimental pilot studies in which varying amounts of support are provided for selected parts of the state. Trends in tobacco use were measured in telephone surveys of 7,998 (2000), 5,150 (2002), and 5,721 (2004) adults. Prevalence of cigarette smoking declined by almost one-third in the pilot area where comprehensive and sustained pilot activities to reduce tobacco use were organized at close to the federally recommended funding level. Significantly smaller reductions were observed in other parts of the state. In the group with the highest use, white non-Hispanic men, cigarette consumption declined by half in the pilot area. It is reasonable to expect similar reductions in tobacco use if funds are provided for statewide expansion of the pilot activities.

Celecoxib Exposures Reported to Texas Poison Control Centers from 1999 to 2004.
Forrester MB.
Hum Exp Toxicol 2006;25:261-266.
Concerns have been raised about the safety of celecoxib. This study described the pattern of exposures involving only celecoxib (isolated exposures) reported to Texas poison control centers from 1999 to 2004. The mean dose was 701 mg. The patient age distribution was ?5 years (48%), 6–19 years (8%), and ?20 years (44%). In 78% of cases, exposure was unintentional. Of the exposures, 74% were managed outside of health care facilities. The final medical outcome was classified as no effect for 82% of the cases, and minor effects for 12% of the cases. Adverse clinical effects were listed for 5% of the patients, the most frequently reported being rash (3%), drowsiness (3%), pruritis (2%), and vomiting (2%). The most frequently listed treatment was decontamination by dilution (43%) or food (32%). The majority of isolated celecoxib exposures could be managed outside of health care facilities, and the outcome was generally favorable.

Acute Pesticide-related Illness among Emergency Responders, 1993-2002.
Calvert GM, Barnett M, Mehler LN, Becker A, Das R, Beckman J, Male D, Sievert J, Thomsen C, Morrissey B.
Am J Ind Med. 2006 May;49(5):383-93.
BACKGROUND: Emergency responders are among the first to arrive at a pesticide-related release event. Magnitude, severity, and risk factor information on acute pesticide poisoning among those workers is needed. METHODS: Survey data collected from the SENSOR-Pesticides, CDPR and HSEES programs between 1993 and 2002 from 21 states were reviewed. Acute occupational pesticide-related illness incidence rates for each category of emergency responder were calculated, as were incidence rate ratios (IRR) among emergency responders compared to all other workers employed in non-agricultural industries. RESULTS: A total of 291 cases were identified. Firefighters accounted for 111 cases (38%), law enforcement officers for 104 cases (36%), emergency medical technicians for 34 cases (12%), and 42 cases (14%) were unspecified emergency responders. Among the 200 cases with information on activity responsible for exposure, most were exposed while performing activities related to a pesticide release event (84%) and not involving patient care, while the remainder involved exposure to pesticide- contaminated patients. A majority of cases were exposed to insecticides (51%). Most had low severity illnesses (90%). The incidence rate was highest for firefighters (39.1/million) and law enforcement officers (26.6/million). The IRRs were also elevated for these professions (firefighters, IRR = 2.67; law enforcement officers, IRR = 1.69). CONCLUSIONS: The findings suggest the need for greater efforts to prevent acute occupational pesticide-related illness among emergency responders.

The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology.
Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield Ch, Perry BD, Dube ShR, Giles WH.
Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86.
BACKGROUND: Childhood maltreatment has been linked to a variety of changes in brain structure and function and stress-responsive neurobiological systems. Epidemiological studies have documented the impact of childhood maltreatment on health and emotional well-being. METHODS: After a brief review of the neurobiology of childhood trauma, we use the Adverse Childhood Experiences (ACE) Study as an epidemiological "case example" of the convergence between epidemiologic and neurobiological evidence of the effects of childhood trauma. The ACE Study included 17,337 adult HMO members and assessed 8 adverse childhood experiences (ACEs) including abuse, witnessing domestic violence, and serious household dysfunction. We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a "dose response" relationship of the ACE score to 18 selected outcomes and to the total number of these outcomes (comorbidity). RESULTS: Based upon logistic regression analysis, the risk of every outcome in the affective, somatic, substance abuse, memory, sexual,and aggression related domains increased in a graded fashion as the ACE score increased (P <0.001). The mean number of comorbid outcomes tripled across the range of the ACE score. CONCLUSIONS: The graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions.

Seasonal Variations in the Initiation of Smoking among Adolescents.
Colwell B, Ramirez N, Koehly L, Stevens S, Smith DW, Creekmur S.
Nicotine Tob Res. 2006 Apr;8(2):239-43.
Numerous studies have identified a variety of reasons that youths give for starting smoking. Few efforts have been made, however, to identify seasonal variations in initiation. This study was an attempt to fill that void. We examined data from 342 youths participating in a mandated smoking education and cessation program in Texas. Data were collected based on responses to questions in participant workbooks, including an item asking participants about the month in which they started smoking. A total of 47% of the participants indicated that they started smoking in May through August (chi2 = 91.42, df = 3). Post-hoc analyses indicated that significantly more youths than expected began smoking in May and June, whereas significantly fewer youths than expected began smoking in September and November. Unsupervised time out of school during the first months of summer vacation is a period of increased danger for smoking initiation. The significantly lower rates during September seem to be related to the beginning of school.

High School Athletic Departments as Sentinel Surveillance Sites for Community-associated Methicillin-resistant Staphylococcal Infections.
Barr B, Felkner M, Diamond PM.
Texas Medicine, April 2006:102(4):56-61.
Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging infection in athletes. Our study assessed MRSA burden in Texas 4A and 5A high school athletic departments by contacting 447 licensed athletic trainers (LATs) regarding skin infections in athletes; 186 (41.6%) responded. Sixty LATs reported MRSA in their athletic departments. The largest MRSA outbreak (23 infected persons) occurred in football players. The trainers also reported MRSA in wrestlers, volleyball players, cross-country runners, nonathlete students, and adults. Students and adults involved in high school athletics require MRSA intervention because of their large numbers and extensive contacts. Physicians should be aware of the potential for MRSA and should culture rather than treat empirically, communicate with school health staff to maximize surveillance for affected students when MRSA occurs in their student community, and contact their health department when the number of students with MRSA meets the unusual group expression, outbreak, or unusual severity criteria.

Epidemiology of Jellyfish Stings Reported to Poison Centers in Texas.
Forrester, M.B.
Human & Experimental Toxicology, 2006 April, 25(4):183-186.
This study examined the relationship between selected factors and all human exposures involving jellyfish stings reported to Texas poison centers. Cases were obtained retrospectively from calls to poison centers in Texas and included all reported human exposures during 1998–2004 involving jellyfish stings. The distribution of cases was determined for a variety of demographic and clinical parameters. There were 423 total cases. Among the cases with a known patient age, 19.8% were <6 years of age, 53.5% were age 6–19 years, and 26.7% were >19 years of age. Males accounted for 52% of the cases. Of the 118 cases with a known clinical outcome, 0.8% had no effect, 80.5% had minor effects, and 18.6% had moderate effects. Counties along the Gulf Coast accounted for 72.3% of the calls. This information can be used to identify those portions of the population most at need of education regarding the prevention and treatment of jellyfish stings.

Maternal Exposure to Arsenic, Cadmium, Lead, and Mercury and Neural Tube Defects in Offspring.
Brender JD, Suarez L, Felkner M, Gilani Z, Stinchcomb D, Moody K, Henry J, Hendricks K.
Environmental Research, 2006;101(1):132-139.
Arsenic, cadmium, lead, and mercury are neurotoxins, and some studies suggest that these elements might also be teratogens. Using a case-control study design, we investigated the relation between exposure to these heavy metals and neural tube defects (NTDs) in offspring of Mexican-American women living in 1 of the 14 Texas counties bordering Mexico. A total of 184 case-women with NTD-affected pregnancies and 225 control-women with normal live births were interviewed about their environmental and occupational exposures during the periconceptional period. Biologic samples for blood lead and urinary arsenic, cadmium, and mercury were also obtained for a subset of these women. Overall, the median levels of these biomarkers for heavy metal exposure did not differ significantly (P>0.05) between case- and control-women. However, among women in the highest income group, case-women were nine times more likely (95% confidence interval (CI) 1.4-57) than control-women to have a urinary mercury 5.62mug/L. Case-women were 4.2 times more likely (95% CI 1.1-16) to report burning treated wood during the periconceptional period than control-women. Elevated odds ratios (ORs) were observed for maternal and paternal occupational exposures to arsenic and mercury, but the 95% CIs were consistent with unity. The 95% CIs of the ORs were also consistent with unity for higher levels of arsenic, cadmium, lead, and mercury in drinking water and among women who lived within 2 miles at the time of conception to industrial facilities with reported emissions of any of these heavy metals. Our findings suggest that maternal exposures to arsenic, cadmium, or lead are probably not significant risk factors for NTDs in offspring. However, the elevated urinary mercury levels found in this population and exposures to the combustion of treated wood may warrant further investigation.

Carbon Monoxide Poisonings after Two Major Hurricanes--Alabama and Texas, August-October 2005.
Centers for Disease Control and Prevention (CDC). DSHS contributors: J Villanacci, PhD, J Ryan, MD, C Barton, DVM, PhD, P McGaha, DO
MMWR Morb Mortal Wkly Rep. 2006 Mar 10;55(9):236-9.
Hurricanes Katrina and Rita struck the U.S. Gulf Coast on August 29, 2005, and September 24, 2005, respectively, causing widespread damage and leaving approximately 4 million households without electrical power. Despite public health measures to prevent carbon monoxide (CO) poisonings after major power outages, multiple CO poisonings were reported in Gulf Coast states in the wake of these hurricanes. The Alabama Department of Public Health and Texas Department of State Health Services asked CDC to assist in investigating the extent and causes of these hurricane-related CO poisonings. The investigation identified 27 incidents of CO poisoning resulting in 78 nonfatal cases and 10 deaths in hurricane-affected counties in Alabama and Texas, nearly all of which were caused by gasoline-powered generators. Most of the generators involved were placed outside but close to the home to power window air conditioners (ACs) or connect to central electric panels. Few homes had functioning CO detectors. CDC continues to recommend that generators be placed far from homes, away from window ACs, and that CO detectors be used by all households operating gasoline-powered appliances (e.g., generators and gas furnaces), with batteries replaced yearly. Although the risk for CO poisoning likely decreases as generators are placed further from the home, additional studies are needed to establish a safe distance for generator placement.

Hepatitis C Virus Seroprevalence: Selected Health Care Settings in Texas.
Melville SK, Heseltine G, Delamater E, Gilani Z, Hendricks K, Suarez L.
Texas Medicine, March 2006;102(3):56-61.
This study describes the burden of hepatitis C virus (HCV) infection in Texas through a series of seroprevalence studies in various health care settings. We assessed antibodies to HCV on excess blood samples from clients attending drug treatment centers (DTCs), sexually transmitted disease (STD) clinics, and publicly funded HIV (human immunodeficiency virus) testing sties. Clients attending DTCs had the highest seroprevalence at 73.0%, followed by those presenting at HIV testing sites (10.9%) and STD clinics (5.8%). Injection drug users had much higher seroprevalence than nonusers. Hepatitis C infection seroprevalences were higher in older clients than in younger clients. This investigation supports integrating HCV counseling and testing services into existing HIV and STD services since these populations share risk factors for bloodborne and sexually transmitted diseases. The reported prevalence of HCV can be used as a baseline measurement to monitor the effectiveness of screening for HCV.

Deaths Associated with Hypocalcemia from Chelation Therapy--Texas, Pennsylvania, and Oregon, 2003-2005.
Centers for Disease Control and Prevention (CDC). DSHS contributors: RA Beauchamp, MD, TM Willis, TG Betz, MD, J Villanacci, PhD
MMWR Morb Mortal Wkly Rep. 2006 Mar 3;55(8):204-7. Reprinted in JAMA. 2006;295:2131-2133.
Chelating agents bind lead in soft tissues and are used in the treatment of lead poisoning to enhance urinary and biliary excretion of lead, thus decreasing total lead levels in the body. During the past 30 years, environmental and dietary exposures to lead have decreased substantially, resulting in a considerable decrease in population blood lead levels (BLLs) and a corresponding decrease in the number of patients requiring chelation therapy. Chelating agents also increase excretion of other heavy metals and minerals, such as zinc and, in certain cases, calcium. This report describes three deaths associated with chelation-therapy--related hypocalcemia that resulted in cardiac arrest. Several drugs are used in the treatment of lead poisoning, including edetate disodium calcium (CaEDTA), dimercaperol (British anti-Lewisite), D-penicillamine, and meso-2,3-dimercaptosuccinic acid (succimer). Health-care providers who are unfamiliar with chelating agents and are considering this treatment for lead poisoning should consult an expert in the chemotherapy of lead poisoning. Hospital pharmacies should evaluate whether continued stocking of Na2EDTA is necessary, given the established risk for hypocalcemia, the availability of less toxic alternatives, and an ongoing safety review by the Food and Drug Administration (FDA). Health-care providers and pharmacists should ensure that Na2EDTA is not administered to children during chelation therapy.

Tuberculosis Control Activities after Hurricane Katrina--New Orleans, Louisiana, 2005.
Centers for Disease Control and Prevention. DSHS contributors: C Wallace, PE Cruise
Morb Mortal Wkly Rep. March 31, 2006 / 55(12);332-335.
On August 29, 2005, when Hurricane Katrina struck the U.S. Gulf Coast, 130 Louisiana residents in the greater New Orleans area were known to be undergoing treatment for tuberculosis (TB) disease. Standard treatment and cure of TB requires a multidrug regimen administered under directly observed therapy (DOT) for at least 6 months (1). This report updates previous information (2) and summarizes TB cases reported as of December 31, 2005, among persons undergoing TB treatment in the New Orleans area when Hurricane Katrina made landfall and among persons who were evacuated and subsequently received a diagnosis of TB in other parts of the country. By October 13, 2005, through intensive local, state, and national efforts involving both government and private sector partners, all 130 TB patients from the New Orleans area had been located and, if still indicated, had resumed TB treatment. As a result of heightened public health surveillance among Hurricane Katrina evacuees, six other New Orleans evacuees began treatment (i.e., two persons with known TB and four with previously undiagnosed TB) after arriving in other states. The success of these post-disaster TB control measures affirms the utility of alternative data sources during health-related emergencies and the importance of maintaining a strong TB control component in the public health sector.

Pattern of Sildenafil Calls to Texas Poison Control Centers, 1998-2004.
Forrester MB, Artalejo L.
J Toxicol Environ Health A. 2006 Mar;69(6):497-503.
Sildenafil, a popular medication approved for the treatment of erectile dysfunction, is often misused. This study sought to describe the patterns of sildenafil calls to poison control centers in Texas during 1998-2004. Data on all sildenafil calls reported to the Texas Poison Center Network were analyzed. There were 628 sildenafil calls, 36% of which were human exposures and 44% were drug identifications. The number of calls increased during 1998-2003 but leveled off in 2004. The sildenafil exposure was isolated in 70% of the human exposure calls and involved other substances in 30% of the calls. Nonisolated exposures were more likely than isolated exposures to be intentional, involve males, occur in adults, and involve more serious problems as reflected by higher rates of health care facility treatment usage and more severe medical outcomes. The most frequently reported clinical effects were dizziness, tachycardia, erythema, and drowsiness. Most sildenafil calls were for human exposures or drug identification. The characteristics of human exposures such as the exposure reason and medical outcome were dependent on the presence of other substances.

Linking Environmental Hazards and Birth Defects Data.
Brender JD, Zhan FB, Suarez L, Langlois PH, Gilani Z, Delima I et al.
Int J Occup Environ Health 2006;12(2):126-33.
The authors describe methods for linking birth certificate and birth defect registry data to potential environmental hazards and assess potential confounding factors. Cases of selected birth defects from the Texas Birth Defects Registry were linked to their respective birth/fetal death records. Comparison births were randomly selected from the 1996-2000 Texas birth records. Maternal addresses were related through a geographic information system to boundaries of hazardous waste sites and point locations of industries. Approximately 89% of maternal addresses of case births and 88% of comparison births were successfully related in distance to these sites and industries. Maternal characteristics associated with living within one mile of these sites included belonging to any group besides non-Hispanic white and having lower education attainment (< 16 years) or a residence within the city limits. In linking environmental and health outcome databases, researchers should be aware of factors that may confound associations between exposure and outcomes.

Exposure to Fumonisins and the Occurrence of Neural Tube Defects along the Texas-Mexico Border.
Missmer SA, Suarez L, Felkner M, Wang E, Merrill AH Jr, Rothman KJ, Hendricks KA.
Environ Health Perspect. 2006 Feb;114(2):237-41.
Along the Texas-Mexico border, the prevalence of neural tube defects (NTDs) among Mexican-American women doubled during 1990-1991. The human outbreak began during the same crop year as epizootics attributed to exposure to fumonisin, a mycotoxin that often contaminates corn. Because Mexican Americans in Texas consume large quantities of corn, primarily in the form of tortillas, they may be exposed to high levels of fumonisins. We examined whether or not maternal exposure to fumonisins increases the risk of NTDs in offspring using a population-based case-control study. We estimated fumonisin exposure from a postpartum sphinganine:sphingosine (sa:so) ratio, a biomarker for fumonisin exposure measured in maternal serum, and from maternal recall of periconceptional corn tortilla intake. After adjusting for confounders, moderate (301-400) compared with low (< or = 100) consumption of tortillas during the first trimester was associated with increased odds ratios (ORs) of having an NTD-affected pregnancy (OR = 2.4; 95% confidence interval, 1.1-5.3). No increased risks were observed at intakes higher than 400 tortillas (OR = 0.8 for 401-800, OR = 1.0 for > 800). Based on the postpartum sa:so ratio, increasing levels of fumonisin exposure were associated with increasing ORs for NTD occurrences, except for the highest exposure category (sa:so > 0.35). Our findings suggest that fumonisin exposure increases the risk of NTD, proportionate to dose, up to a threshold level, at which point fetal death may be more likely to occur. These results also call for population studies that can more directly measure individual fumonisin intakes and assess effects on the developing embryo.

Flunitrazepam Abuse and Malicious Use in Texas, 1998-2003.
Forrester MB.
Subst Use Misuse. 2006;41(3):297-306.
Flunitrazepam is a potent benzodiazepine that is subject to abuse and malicious use. This study describes the patterns of flunitrazepam abuse and malicious use calls received by Texas poison centers during 1998-2003. The distribution of calls by year of call, geographic location of caller, patient gender and age, exposure site, and medical outcome were determined. There was no clear annual trend for abuse calls, but there was a consistent decline in the number of malicious use calls. A significantly higher percentage of abuse calls originated in south and west Texas and of malicious use calls in west Texas. Most abuse patients were males (55%) and adolescents (76%), and most of the exposures occurred in patient's own residence (68%), followed by school (16%). Most of the malicious use patients were females (93%) and adults (74%), and the greatest proportion of the exposures occurred in public areas (47%), followed by the patient's own residence (26%). The highest percentage of both abuse (48%) and malicious use (55%) involved minor effects. However, malicious use calls were significantly less likely to involve no effect (2% vs. 21%) and more likely to involve moderate effects (36% vs. 23%). Reported flunitrazepam abuse and malicious use calls in Texas differed with respect to geographic location of the caller, patient gender and age, exposure site, and medical outcome. Poison centers and health care providers might want to consider these differences when targeting populations for education and prevention efforts.

Alprazolam Abuse in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A. 2006 Feb;69(3):237-43.
Alprazolam (Xanax) is used in the treatment of anxiety, depression, and panic attacks, and is subject to abuse. The objective of this study was to describe the patterns of alprazolam abuse and drug identification (ID) calls received by several poison control centers. Cases were alprazolam calls received by 6 poison control centers during 1998-2004. Of 25,954 alprazolam calls received, 42% were drug ID calls and 51% were human exposure calls, of which 18% were abuse calls. The number of drug ID calls and the number of abuse calls both increased during the 7-yr period. Male patients accounted for 54% of abuse calls and females for 66% of nonabuse calls. Adolescent patients comprised 43% of abuse calls but only 12% of nonabuse calls. Although the majority of both types of human exposures occurred at the patient's own residence, abuse exposures were more likely than other exposures to occur at school (9% vs. 1%) and public areas (6% vs. 1%). While abuse calls were less likely than nonabuse calls to have no adverse clinical effects (19% vs. 23%), they were more likely to have minor medical outcomes (60% vs. 50%). Alprazolam abuse in Texas appears to be increasing. Alprazolam abusers are more likely to be male and often adolescent. Alprazolam abuse as compared to other exposures is more likely to occur outside of the person's home. Alprazolam abuse is more likely to involve some sort of adverse medical outcome.

Screwworms.
Alexander JL.
J Am Vet Med Assoc. 2006 Feb 1;228(3):357-67.
New World and Old World screwworms pose threats to the livestock industry in the United States and other countries. Diligence on the part of veterinarians, physicians, and their respective staffs is essential to protect the livestock industry.

Linking Teratogen Information Service and Birth Defects Registry Databases to Improve Knowledge of Birth Defect Status.
Archer NP, Langlois PH, Case AP, Wolfe LJ.
Birth Defects Res A Clin Mol Teratol. 2006 Feb;76(2):126-8.
BACKGROUND: Although teratogen information services (TISs) obtain maternal exposure information from their callers, such services often do not know if the pregnancies were affected by a birth defect. This study attempted to improve the completeness of this information for Texas Teratogen Information Service (TTIS) callers by linking their records with the Texas Birth Defects Registry (TBDR) and Texas birth certificates (TBCs). METHODS: A total of 344 expectant mothers called TTIS with expected dates of delivery between 1 January 2000 and 31 December 2001. These pregnancies were linked with TBDR and TBC data. The percentages of pregnancies with known birth defect information both before and after the linkage were compared. RESULTS: The TTIS originally collected birth defect status information for 101 of the 344 callers (29.4%) and 0.6% of all 344 callers or 2.0% of callers with birth defect status information had a pregnancy affected by a birth defect. Linking TTIS records with TBDR and TBC data helped to raise the percentage of callers with birth defect status information from 29.4% to 71.5%. Among those callers, the percentage known to have birth defects increased from 2.0% to 4.1%. The sensitivity of TTIS follow-up calls in identifying birth defects was 50%, and the specificity was 100%. CONCLUSIONS: Linking TTIS caller records with TBDR and TBC data significantly increased both the percentage of pregnancies with birth defect status information and the percentage of pregnancies identified as affected by birth defects. Such linkage may be a good approach by which TISs can increase the completeness of their birth defect status information. Birth Defects Research (Part A), 2006. (c) 2006 Wiley-Liss, Inc.

Patterns of Exposures at School among Children Age 6-19 Years Reported to Texas Poison Centers, 1998-2002.
Forrester MB.
J Toxicol Environ Health A. 2006 Feb;69(4):263-8.
Although children and adolescents spend a large amount of time in school, there is little information on the factors involved in school exposures that are reported to poison centers. This study used data involving exposures among children age 6-19 yr reported to 6 Texas poison centers during 1998-2002. The distribution of school and nonschool exposures was determined for various demographic and other factors, and comparisons were made between the two types of exposures. The lowest proportion of reported school exposures occurred in June-August and the next lowest proportion occurred in December-January; nonschool exposures were more constant throughout the year. Males accounted for 58% of school exposures and 49% of nonschool exposures. The exposure was unintentional in 74% of school and 67% of nonschool exposures. Ingestion was the most frequently reported exposure route for school (64%) and nonschool (76%) exposures. Among those cases with known medical outcome, the most frequently reported medical outcome involved minor effects for both school exposures (58%) and nonschool exposures (46%). Nonpharmaceuticals were involved in 75% of school exposures and 48% of nonschool exposures. The most frequently reported substances involved in school exposures were arts, crafts, and office supplies (18%), while the most frequently reported substances involved in nonschool exposures were analgesics (17%). This information may allow school administrators and health care providers to implement prevention strategies.

Integrated Versus Parallel Treatment of Co-Occurring Psychiatric and Substance Use Disorders.
Mangrum LF, Spence RT, Lopez M.
J Subst Abuse Treat. 2006 Jan;30(1):79-84.
The study examines 1-year treatment outcomes of 216 individuals with co-occurring severe and persistent mental illness and substance use disorders who were assigned to an integrated or parallel treatment condition. Comparisons indicated that the integrated group achieved greater reductions in the incidence of psychiatric hospitalization and arrest. The results of this study support the enhanced effectiveness of integrated treatment in decreasing the use of higher cost crisis-oriented services in clients with severe mental illness and substance use disorders.

A Pandemic Flu: Not If, but When. SARS was the Wake-up Call We Slept Through.
Pascoe N.
Texas Nursing 2006 Jan;80(1):6-10.
If an influenza pandemic struck today, borders might close, the global economy would be severely impacted, international vaccine supplies and health are systems would be overwhelmed, and some people might panic. To limit the fallout, the industrialized world must create a detailed response strategy involving the public and private sectors. Some experts feel we are overdue for a flu pandemic and the SARS pandemic of 2003 could have been the wake up call to begin preparations. Fortunately there is some assistance coming from the federal government. On January 12, U.S. Department of Health & Human Services Secretary Mike Leavitt announced funding to assist in the preparation for a pandemic flu response. $100 million is being provided initially with another $250 million due later this year to assist states in pandemic flu preparedness. Texas' initial allocation is $5,875,044. While some believe that the AI (H5N1) causing illness and deaths in Asia and Turkey will be the pandemic flu strain, there is no guarantee that will occur. Thus, without knowing which strain may lead to a pandemic, development and manufacturing of a vaccine is delayed.

Improved National Prevalence Estimates for 18 Selected Major Birth Defects -- United States, 1999 -- 2001.
Centers for Disease Control and Prevention (CDC). DSHS contributors: Canfield MA, Ramadhani TA
MMWR Morb Mortal Wkly Rep. 2006 Jan 6;54(51&52);1301-5.
Continuing efforts are needed to improve surveillance for birth defects, which are the leading cause of infant mortality in the United States (1). Although state and local surveillance data indicate that approximately 3% of births are affected by any of 45 birth defects, no national estimates based on population-based birth defects surveillance have been available for specific types of birth defects other than neural tube defects (spina bifida and anencephaly). This report describes estimates of national prevalence and number of affected births in the United States each year during 1999--2001 for 18 selected major birth defects. The findings indicated that 10 of the 18 defects affected more than 1,000 infants each year in the United States. The conditions with the highest prevalence included orofacial clefts, which affect approximately 6,800 infants annually, and Down syndrome, which affects approximately 5,500 infants annually. Population-based national prevalence estimates of birth defects can help determine resource needs for basic and public health research and assist in planning for the health-care and educational needs of the U.S. population.

Correlates of Intake of Folic Acid-containing Supplements among Pregnant Women.
Carmichael SL, Shaw GM, Yang W, Laurent C, Herring A, Royle MH, Canfield M; National Birth Defects Prevention Study.
Am J Obstet Gynecol. 2006 Jan;194(1):203-10.
OBJECTIVE: This study describes the timing and correlates of folic acid supplement intake among pregnant women. STUDY DESIGN: Data from 2518 women with estimated delivery dates from 1997 to 2000, collected for the National Birth Defects Prevention Study, a population-based case-control study, were analyzed. Multinomial logistic regression was used to identify correlates of supplement intake. RESULTS: Fifty-three percent of women began taking folic acid supplement during the periconceptional period, 35% during early pregnancy, and 8% during late pregnancy (ie, 3 months before through 1 month after conception, 2-3 months after conception, or more than 3 months after conception, respectively). Women who did not take folic acid supplement periconceptionally tended to be nonwhite, speak Spanish, have low education, be younger than 25 years old, be nulliparous, smoke, have no previous miscarriage and no fertility treatments, begin prenatal care and become aware of their pregnancy after the first trimester, have nonplanned pregnancies, and eat less breakfast cereal. CONCLUSION: This study identifies correlates of folic acid supplement intake, which may contribute to the design of interventions to improve intake during early pregnancy.

Characteristics that Predict Locating and Interviewing Mothers Identified by a State Birth Eefects Registry and Vital Records.
Gilboa SM, Mendola P, Olshan AF, Savitz DA, Herring AH, Loomis D, Langlois PH, Keating K.
Birth Defects Res A Clin Mol Teratol. 2006 Jan;76(1):60-5.
BACKGROUND: State vital records are often used to select population-based controls in record-linkage studies of birth defects. However, locating and contacting individuals based on these data sources to collect additional data can be a challenge. METHODS: A large case-control study of air quality and birth defects was conducted in 7 Texas counties in which cases were selected from the Texas Birth Defects Registry and controls from state vital records. In 2004, data from these sources were used to trace mothers of cases and controls who delivered babies in the year 2000 (n=2477) for participation in a computer-assisted telephone interview. A number of factors that predicted whether an individual would be located and interviewed were identified. RESULTS: Between March and August 2004, 38% of the mothers were located, and 38% of the located mothers were interviewed. Case mothers were more likely than control mothers to be located (44 vs. 30%) and, if located, to be interviewed (43 vs. 31%). We compared the characteristics of mothers who were not located (case n=760; control n=777), mothers who were located but not interviewed (case n=344; control n=236), and mothers who were interviewed (case n=256; control n=104). Among both cases and controls, older mothers (>or=30 years) were more likely than younger mothers to be located, and non-Hispanic black mothers were least likely to be located and interviewed. CONCLUSIONS: Despite the utility of vital records as a source of population-based controls in record-linkage analyses, the poor response rate discourages the use of these data sources to contact individuals for a follow-up study 4 years after delivery. Copyright (c) 2005 Wiley-Liss, Inc.

Carisoprodol Abuse in Texas, 1998-2003.
Forrester MB.
J Med Toxicol 2006;2:8-13.
ABSTRACT: Introduction: Texas poison centers identified carisoprodol as a skeletal muscle relaxant that is subject to abuse, and this investigation explores the abuse reported by Texas poison centers. Methods: This study used data from six Texas poison centers to describe the epidemiology of carisoprodol abuse and drug identification (ID) calls from 1998 to 2003. Results: Drug ID and abuse calls were 217% higher in 2003 than in 1998. Although eastern and central Texas contains 43% of the state’s population, this region reported 77% of all drug ID calls and 64% of abuse calls. Male patients accounted for 51% of abuse calls and 37% of other human exposure calls. Patients from 13 to 19 years of age accounted for 17% of abuse calls and 9% of other human exposure calls. Among those human exposure calls with a known medical outcome, a higher percentage of abuse calls involved minor effects while a greater proportion of other human exposure calls involved outcomes that ranged from moderate effects to death. Conclusions: Carisoprodol abuse is increasing in Texas and is substantially more common in the eastern part of the state. Carisoprodol abuse is much more likely, than other types of adverse carisoprodol exposures, to involve males and adolescents; and it less likely to involve adverse medical outcomes.

Public Perceptions about Trust in Emergency Risk Communication: Qualitative Research Findings.
Wray, R., Rivers, J., Whitworth, A., Jupka, K., Clements, B.
Int J Mass Emerg Disasters. 2006;24(1):45–75.
Communication to the general public is a critical component of effective emergency response following terrorism events. Trust is essential to effective communication. Four Schools of Public Health conducted focus groups across the country with different ethnic groups to inform development of public messages and strategies in the event of an emergency. Secondary analysis of the transcripts was conducted to explore factors related to trust in government. General lack of confidence in the government’s ability to respond was associated with concerns about preparedness, lack of disclosure and dedication. Local officials and emergency responders were more trusted than federal officials, and were associated with greater levels of disclosure and empathy. Past experience contributed to perceptions of trust. Urban groups were more concerned about officials’ honesty; whereas rural groups were concerned about resource allocation. Local organizations and agencies were most trusted, as well as the United States Centers for Disease Control and Prevention (CDC), United States Federal Emergency Management Agency (FEMA) and the American Red Cross (ARC). The findings lead to recommendations related to allocation of emergency response resources for underserved areas; integration of local and federal agencies in emergency response preparedness and communication; and an emphasis on full disclosure, action steps, and leadership in emergency response communication. 


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Last updated July 16, 2014