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DSHS Authors: 2007 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-diamond2007 Articles (in date order with most recent first)

NAT2 Variation and Idiopathic Talipes Equinovarus (Clubfoot).
Hecht JT, Ester A, Scott A, Wise CA, Iovannisci DM, Lammer EJ et al.
Am J Med Genet A 2007;143(19):2285-91.
Idiopathic talipes equinovarus (ITEV), or isolated clubfoot, is a common developmental anomaly that is characterized by a rigid foot, adducted forefoot, cavus midfoot, equinovarus of the hindfoot, and hypoplastic calf musculature. The etiology of this common birth defect is largely unknown, but genetic factors have been implicated in population and family studies and maternal smoking during pregnancy has been identified as an environmental risk factor. The biotransformation of exogenous substances, such as tobacco smoke, is modulated by numerous genes including N-acetylation genes, NAT1 and NAT2. Functional variants of these genes exist and can be distinguished by genotyping. We hypothesized that variation in NAT1 and NAT2 genes might be associated with ITEV. To test this hypothesis, NAT1 and NAT2 were genotyped in a sample of 56 multiplex ITEV families, 57 trios with a positive family history and 160 simplex trios with ITEV. The results detected a slight decrease in the expected number of homozygotes for the NAT2 normal allele in the Hispanic simplex trios. In addition, in a pilot case-control study of ITEV, there were significantly more slow NAT2 acetylators among the cases. This suggests that slow acetylation may be a risk factor for ITEV. This study is the first to find evidence suggesting a role for a biotransformation candidate gene in the etiology of ITEV and provides a scientific foundation to further explore the contributions of other tobacco metabolism genes in the etiology of clubfoot.

Pattern of Clopidogrel Exposures Reported to Texas Poison Centers during 1998-2004.
Forrester MB.
Clin Toxicol. 2007;45:950-955.
Background. Information on the management of potentially adverse exposures to clopidogrel is limited. Methods. This study examined the distribution of 582 clopidogrel exposures reported to Texas poison control centers during 1998-2004. Results. Eighty-four percent of cases with a reported dose having a dose </=150 mg. Management of 65% of the exposures occurred on site. Of those exposures with a final medical outcome, 73% were classified as no effect. Of those exposures to clopidogrel alone, the most frequent adverse clinical effects were vomiting (2.4%) and dizziness (2.4%). The most frequent treatments were decontamination by dilution (30%), food (12%), and activated charcoal (7%). Conclusion. In the majority of potentially adverse clopidogrel exposures reported to poison control centers the doses are twice the recommended dosage or less. The outcome of such exposures are generally favorable, with few adverse clinical effects occurring.

Multistate Outbreak of Burkholderia Cenocepacia Colonization and Infection Associated with the Use of Intrinsically Contaminated Alcohol-Free Mouthwash.
Kutty PK, Moody B, Gullion JS, Zervos M, Ajluni M, Washburn R, Sanderson R, Kainer MA, Powell TA, Clarke CF, Powell RJ, Pascoe N, Shams A, LiPuma JJ, Jensen B, Noble-Wang J, Arduino MJ, McDonald LC.
Chest. 2007 Dec;132(6):1825-31.
BACKGROUND: No guidelines exist for the type of mouthwash that should be used in patients at increased risk for pneumonia. In 2005, we investigated a multistate outbreak of Burkholderia cenocepacia associated with an intrinsically contaminated alcohol-free mouthwash (AFM). METHODS: We conducted a case-series investigation. We used repetitive extragenic palindromic- polymerase chain reaction typing and pulsed-field gel electrophoresis (PFGE) to characterize available Burkholderia cepacia complex (Bcc) isolates from patients and implicated AFM. Seeding studies were conducted to determine the antimicrobial activity of the AFM. RESULTS: Of the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 had infections or colonizations that were due to B cenocepacia. The median age of these 105 patients was 64 years (range, 6 to 94 years), 52% were women, 55% had evidence of infection, and 2 patients died. Of 139 patient culture specimens, 83 (60%) were from the respiratory tract. Among 103 Bcc patient isolates characterized, 81 (76%) had an indistinguishable PFGE pattern compared to the outbreak strain cultured from implicated lots of unopened AFM; the species was B cenocepacia. Seeding studies showed that the contaminated AFM might have had inadequate amounts of the antimicrobial agent cetylpyridinium chloride. CONCLUSIONS: This intrinsically contaminated AFM led to a geographically dispersed outbreak of B cenocepacia. AFM without therapeutic label claims is regulated by the US Food and Drug Administration as a cosmetic rather than a drug and is therefore subject to limited quality control requirements. Clinicians should be aware that AFM is not sterile. Its use in intubated and other patients with increased risk of aspiration should be avoided.

A Rapid, Standardized, Susceptibility Method for Mycobacterium Tuberculosis using Mycolic Acid Analysis.
Parrish N, Osterhout G, Dionne K, Sweeney A, Kwiatkowski N, Carroll K, Jost KC Jr, Dick J.
J Clin Microbiol. 2007 Dec;45(12):3915-20.
MDR- and XDR-TB are an emerging public health threat compounded by the fact that current susceptibility testing techniques for M. tuberculosis (MTB) require several days to weeks to complete. We investigated the use of HPLC-based quantitation of mycolic acids as a means to rapidly determine drug resistance and susceptibility in MTB. Standard susceptibility testing and determination of minimal inhibitory concentrations (MIC's) of drug susceptible (n=26) and drug resistant strains of MTB including MDR-TB (n=34) was performed using the BACTEC radiometric growth system as the reference method. HPLC-based susceptibilities were performed using current first-line drugs: isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA). Vials were incubated for 72 hours and aliquots removed for HPLC analysis using the Sherlock(R) Mycobacterial Identification System. HPLC quantitation of total mycolic acids (TMAP) was determined for treated and untreated cultures. At 72 hours HPLC agreement with the reference method was 99.5% for INH, EMB, and PZA, and 98.7% for RIF. Inter- and intra-assay reproducibility varied by drug with an average precision of 13.4%. In summary, TMAP is a rapid, sensitive, and accurate method for antibiotic susceptibility testing of all currently used first-line drugs against MTB and offers the potential of susceptibility testing results within hours, rather than days or weeks, for clinical isolates of MTB.

Prevalence of Encephalocele in Texas, 1999-2002.
Wen S, Ethen M, Langlois PH, Mitchell LE.
Am J Med Genet A 2007; 143(18):2150-2155.
Encephaloceles are congenital malformations characterized by a sac-like protrusion of the brain and/or its' covering membranes through an opening in the skull. The etiology of encephalocele is considered to be complex, and in most cases the causes of this condition remain elusive. The present study was undertaken to determine the prevalence of encephalocele among deliveries to Texas residents during 1999-2002, and to identify maternal and demographic factors associated with encephalocele. Data were examined from 125 infants and fetuses with encephalocele and no identified chromosome abnormality; identified in Texas and delivered in 1999-2002. During the same period there were 1,449,943 live births. The birth prevalence of encephalocele and both crude and adjusted prevalence ratios were estimated from these data. Compared with the offspring of White women, encephaloceles were significantly more common among the offspring of Hispanic women (adjusted prevalence ratio: 1.91, 95% confidence interval (CI) 1.34-2.70). In addition, compared to the offspring of women 25-29 years of age, encephaloceles were more common among the offspring of women 20-24 years of age (adjusted prevalence ratio: 1.52, 95% CI 1.01-2.27) and those less than 20 years of age (adjusted prevalence ratio: 1.55, 95% CI 0.98-2.45). These findings add to the existing literature on the descriptive epidemiology of encephalocele.

Using Registry Data to Suggest which Birth Defects May Be More Susceptible to Artifactual Clusters and Trends.
Langlois PH, Scheuerle A.
Birth Defects Res A Clin Mol Teratol. 2007 Nov;79(11):798-805.
BACKGROUND:: Some birth defects appear to be more susceptible than others to artifactual prevalence variability over time or geographically. This article uses an empirical approach to try to identify them. METHODS:: Assumption: Variation in clinical practice and other artifactual sources of variability impact observed variation in prevalence of mild cases more than severe cases for a given birth defect. Approach: Data were examined from Texas Birth Defects Registry deliveries from 1999-2003. For each of 312 delivery hospitals, birth prevalence for mild cases was calculated for birth defect X. The 5(th) percentile was subtracted from the 95(th) percentile to measure spread in the frequency distribution of all hospitals. That was repeated for severe cases. The ratio of the mild:severe spread was calculated for 49 defects, and the defects ranked into quintiles. That was repeated using birth prevalence based on county, and using isolated cases. The percentages of severe cases were calculated and also ranked into quintiles. A sensitivity analysis and simulation were conducted. RESULTS:: Forty-nine birth defects were ranked from those least susceptible to differences in mild:severe prevalence variability (e.g., anencephaly, hypoplastic left heart syndrome) to most susceptible (e.g., atrial septal defect, fetal alcohol syndrome). Resulting quintile ranks based on the three measures were highly correlated, whether based on all cases or isolated cases. CONCLUSIONS:: This empirical approach may be helpful for a number of public health applications. Birth defects and other health outcomes more susceptible to prevalence variability may be more likely to exhibit artifactual trends or clusters.

Pilot Test of Prenatal Surveillance for Birth Defects in South Texas.
Ethen MK, Canfield MA, Trevino J.
Birth Defects Res A Clin Mol Teratol. 2007 Nov;79(11):788-91.
BACKGROUND:: The Texas Birth Defects Registry (TBDR) does not access prenatal diagnostic facilities to ascertain cases. Objectives of the study were to determine how many cases may be missing from the registry as a result, and to assess the feasibility and utility of prenatal surveillance for birth defects, through a pilot test in one region of Texas. METHODS:: A trained abstractor reviewed medical records of all patients with abnormal ultrasound findings during 2004 in all prenatal diagnostic facilities in Texas Health Region 11 (n = 6 facilities). When birth defects were prenatally detected, demographic and diagnostic data were abstracted. Prenatal abstractions were matched to cases in the TBDR. Those that did not match to registry cases were matched to vital records to determine where and when the pregnancy ended; delivery hospital medical records were reviewed for these cases. RESULTS:: Approximately 760 patient charts were reviewed at prenatal diagnostic facilities and 365 were abstracted. Of these, 165 (45%) matched to cases in the TBDR. Delivery medical records were located and reviewed for 177 prenatal abstractions, with 170 (47%) indicating at delivery no defects monitored by the registry. Delivery records for one (0.3%) prenatal abstraction were not found by the hospital. Date and place of delivery were unknown for 22 (6%) prenatal abstractions. Only eight additional infants and fetuses (one twin pair) eligible for the registry were identified. CONCLUSIONS:: For Texas Health Service Region 11, it is not necessary to conduct surveillance in prenatal diagnostic facilities, and to do so would be very labor-intensive.

Uptake, Elimination, and Relative Distribution of Perchlorate in Various Tissues of Channel Catfish.
Park JW, Bradford CM, Rinchard J, Liu F, Wages M, Waters A, Kendall RJ, Anderson TA, Theodorakis CW.
Environ Sci Technol. 2007 Nov 1;41(21):7581-6.
This study was undertaken to determine the kinetics of uptake and elimination of perchlorate in channel catfish, Ictalurus punctatus. Perchlorate--an oxidizer used in solid fuel rockets, fireworks, and illuminating munitions--has been shown to effect thyroid function, causing hormone disruption and potential perturbations of metabolic activities. For the uptake study, catfish were exposed to 100 mg/L sodium perchlorate for 12 h to 5 d in the laboratory. Perchlorate in tissues was analyzed using ion chromatography. The highest perchlorate concentrations were found in the head and fillet, indicating that these tissues are the most important tissues to analyze when determining perchlorate uptake into large fish. To calculate uptake and elimination rate constants for fillet, gills, G-I tract, liver, and head, fish were exposed to 100 ppm sodium perchlorate for 5 days, and allowed to depurate in clean water for up to 20 days. The animals rapidly eliminated the perchlorate accumulated showing the highest elimination in fillet (Ke = 1.67 day(-1)) and lowest elimination in liver (Ke = 0.79 day(-1)).

Using E-Mail to Notify Pseudonymous E-Mail Sexual Partners.
Vest JR, Valadez AM, Hanner A, Lee JH, Harris PB.
Sex Transm Dis. 2007 Nov;34(11):840-5.
OBJECTIVE: Quantify the factors associated with reporting sexual partners only known by, or able to be contacted by, an e-mail address (pseudonymous partners) and evaluate the efforts of provider partner notification when only an e-mail address was available. STUDY DESIGN: Persons with pseudonymous e-mail sexual partners were compared with unmatched controls. Associations were quantified by odds ratios and the effectiveness of provider partner notification attempts was assessed by comparison of outcomes of pseudonymous e-mail sexual partners and sexual partners with traditional contact information. RESULTS: Factors associated with having pseudonymous e-mail sexual partners included: male sex, white non-Hispanic, history of prior sexually transmitted diseases, multiple sexual partners, and reporting male-to-male sexual contact. Efforts at provider partner notification via e-mail were successful with 49.7% of pseudonymous partners notified and 40.1% evaluated. CONCLUSIONS: Internet-based forms of communications can be utilized as means to contact and identify risk partners. If this avenue is not utilized, public health agencies may be unable to intervene with a potentially growing percentage of at-risk persons.

Valsartan Ingestions among Adults Reported to Texas Poison Control Centers, 2000 To 2005.
Forrester MB.
J Med Toxicol. 2007;3:157-163.
Introduction: Little data exist on potentially adverse valsartan ingestions reported to poison control centers. Methods: Using adult ingestions of valsartan reported to Texas poison control centers during 2000-2005, I determined the proportion of cases involving serious outcomes for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Results: Thirteen (7%) of 185 total cases involved serious outcomes. Serious outcomes were significantly more likely to occur with a maximum dose 320 mg (RR 9.06, CI 1.30-100.14) or 4 tablets (RR 9.00, CI 2.07-39.11) or where the circumstances of the exposures involved self-harm or malicious intent (RR 17.28, CI 4.98-67.13). Conclusions: The severity of the medical outcome associated with adult valsartan ingestions depended on the dose and the circumstances of the ingestion. Such information is useful for creating triage guidelines for the management of adult valsartan ingestions.

Are Birth Defects More Prevalent along the Texas-Mexico Border?
Langlois PH, Canfield MA, Suarez L.
Texas Medicine. 2007 Nov;103(11):53-59.
The objective of this descriptive epidemiologic study was to determine if the prevalence of birth defects in Texas is higher along the border with Mexico. We used statewide Texas Birth Defects Registry data from Hispanic deliveries from 1999 through 2002. Birth prevalence ratios were calculated to compare border and nonborder occurrence of 165 birth defects as well as of “any monitored birth defect.” Poisson regression was used to calculate the prevalence ratio (PR) and its 95% confidence interval (CI) and to adjust for potential confounders. Cases of “any birth defect” were 7% less prevalent among border Hispanics than among Hispanics living elsewhere; the PR was 0.93 (95% CI 0.91-0.96). The adjusted PR was 1.01. Isolated cases were more prevalent in border areas (unadjusted PR = 1.07, 95% CI = 1.03-1.11) but severe cases (which should be less susceptible to detection bias) were less prevalent (unadjusted PR = 0.88, 95% CI = 0.83-0.93). In the crude analysis of 165 birth defects, 2 defects were both strongly and significantly more prevalent in border areas and 26 were less prevalent. Analysis of severe cases showed 3 defects were more prevalent and 19 were less prevalent. We concluded that whether based on the analysis of “any birth defect” or counting numbers of specific defects, birth defects in Texas are not more prevalent along the border with Mexico.

Awareness and Attitudes Regarding Prenatal Testing among Texas Women of Childbearing Age.
Case AP, Ramadhani TA, Canfield MA, Wicklund CA.
J Genet Couns. 2007 Oct;16(5):655-61.
Despite increased visibility and availability of prenatal testing procedures, very little is known about the attitudes among the populace toward these procedures. Using a computer assisted telephone interview of pregnant and non-pregnant women of childbearing age we analyze awareness and attitudes regarding prenatal tests among a diverse group of women of childbearing age in Texas. We also examine maternal characteristics associated with awareness and the willingness to undergo these procedures. While 89% were aware that such tests are available, younger, black and less educated women were less likely to know about prenatal tests for birth defects. Seventy-two percent of respondents said they would want their baby tested while Hispanic and black women were significantly more likely to express an interest than non-Hispanic whites. This study demonstrates the variability of knowledge and beliefs and confirms the importance of taking time to understand an individual's personal beliefs, knowledge and attitudes about prenatal diagnosis.

Maternal Exposures to Hazardous Waste Sites and Industrial Facilities and Risk of Neural Tube Defects in Offspring.
Suarez L, Brender JD, Langlois PH, Zhan FB, Moody K.
Ann Epidemiol. 2007 Oct;17(10):772-7.
PURPOSE: We examined the relationship between maternal proximity to hazardous waste sites and industrial facilities and neural tube defect (NTD) risk. METHODS: Texas Birth Defects Registry cases were linked with their birth or fetal death certificates; controls (without defects) were randomly selected from birth certificates. Distances from maternal addresses at delivery to National Priority List (NPL) and state superfund sites and Toxic Release Inventory (TRI) facilities were determined for 655 cases and 4368 controls. RESULTS: Living within 1 mile of an NPL or state superfund site was not related to NTD risk (adjusted odds ratio [OR] = 1.0; 95% confidence intervals [CI] = 0.6, 1.7). Living within 1 mile of a TRI facility carried a slight risk (adjusted OR = 1.2; 95% CI = 1.0, 1.5). The effect was highest among mothers 35 years and older (OR = 2.7; 5% CI = 1.4, 5.0) and among non-Hispanic white mothers (OR = 1.8; 95% CI = 1.1, 2.8). CONCLUSIONS: Hazardous waste sites posed little risk for NTDs in offspring. Close proximity to industrial facilities with chemical air emissions was associated with NTD risk in some subgroups. Further investigation is needed to determine if the effects are real or due to unresolved confounding or bias.

West Nile Virus Infection among the Homeless, Houston, Texas.
Meyer TE, Bull LM, Holmes KC, Pascua RF, Da Rosa AT, Gutierrez CR, Corbin T, Woodward JL, Taylor JP, Tesh RB, Murray KO.
Emerg Infect Dis. 2007 Oct;13(10):1500-1503.
Among 397 homeless participants studied, the overall West Nile virus (WNV) seroprevalence was 6.8%. Risk factors for WNV infection included being homeless >1 year, spending >6 hours outside daily, regularly taking mosquito precautions, and current marijuana use. Public health interventions need to be directed toward this high-risk population.

Methicillin-resistant Staphylococcus Aureus Nasal Carriage Rate in Texas County Jail Inmates.
Felkner M, Rohde RE, Valle-Rivera AM, Baldwin T, Newsome LP.
Journal of Correctional Health Care. 2007;13:289-295.
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a health issue in corrections. The Texas Department of State Health Services (DSHS) partnered with an urban jail to investigate risk factors for MRSA carriage. This study assessed nasal carriage rate and strainrelatedness of MRSA among recently booked inmates. Of 403 inmates, 115 (28.5%) carried S. aureus; 18 were MRSA-positive (4.5%). Pulsed field gel electrophoresis identified 10 MRSA strains. Previous health care exposures and history of skin infection were more strongly associated with carriage risk than previous correctional facility exposure, although none of these exposures was statistically significant after adjustment. Our data suggest that MRSA is endemic in persons coming into correctional facilities. Correctional health care workers should be prepared to treat MRSA infections that arise from exposures before incarceration.

Gemfibrozil Ingestions Reported to Texas Poison Control Centers, 2000-2005.
Forrester MB.
J Toxicol Environ Health A 2007;70:2027-2032.
Review of the literature failed to identify any information on potentially adverse ingestions of the cholesterol lowering drug gemfibrozil (gem) reported to poison control centers. Data from Texas poison control centers were used to describe the pattern of isolated gem ingestions reported during 2000-2005. A total of 118 cases were identified. The mean maximum dose ingested was 2,407 mg (range 300-18,000 mg) or 3.3 tablets/capsules (range 1-30 tablets/capsules). The patient was male in 55% of the cases. The most common circumstances of the exposure were unintentional therapeutic error (49%), general unintentional (34%), and suspected attempted suicide (11%). The management site was on site (84%), already at/en route to a health care facility (10%), referred to a health care facility (5%), and other (2%). The ingestion considered potentially toxic in 3% of the cases and no deaths were reported. A specific adverse clinical effect was listed for 9% of the cases, being gastrointestinal (5%), neurological (3%), or cardiovascular (1%). A specific treatment was listed for 54% of the cases, most frequently decontamination by dilution (39%) or food (15%). Potentially adverse isolated gem ingestions reported to poison control centers generally do not involve serious medical outcomes and are successfully managed at home with a favorable outcome.

Eszopiclone Ingestions Reported to Texas Poison Control Centers, 2005 2006.
Forrester MB.
Hum Exp Toxicol 2007;26:795-800.
Eszopiclone is a nonbenzodiazepine hypnotic for the treatment of insomnia and classified as schedule IV controlled substance. Limited information exists on eszopiclone ingestions reported to poison control centers. The distribution of eszopiclone ingestions reported to Texas poison control centers during 2005-2006 was determined for various factors. In addition, triage guidelines for the management of such ingestions were drafted. Of 525 total eszopiclone ingestions, 259 involved coingestants. Of coingestant cases, 78.8% involved suspected attempted suicide and 90.7% were managed at a healthcare facility. Of 266 ingestions of eszopiclone alone, 40.2% were suspected attempted suicide and 62.0% were managed at a healthcare facility. A final medical outcome and dose ingested were known for 60 ingestions of eszopiclone alone. The mean dose was 28.3 mg (range 0.3-210 mg). Ingestions of eszopiclone alone of </=6 and >6 mg differed with respect to the proportion involving suspected attempted suicide (0.0% versus 64.7%), final medical outcome of minor or moderate effect (38.5% versus 67.6%) and management at a healthcare facility (34.6% versus 91.2%). Using 6 mg as a threshold dose for referral to a healthcare facility, 78% of cases not already at/en route to a healthcare facility were managed according drafted triage guidelines.

Pediatric Montelukast Ingestions Reported to Texas Poison Control Centers, 2000-2005.
Forrester MB.
J Toxicol Environ Health A 2007;70:1792-1797.
Limited information exists on the toxicity of pediatric ingestions of the drug montelukast used in the treatment of chronic asthma. All ingestions of montelukast involving children age 0-5 years reported to Texas poison control centers during 2000-2005 were retrieved. For a subset of cases where the final medical outcome and dose in mg or mg/kg were known, the pattern of exposures by final medical outcome and management site was evaluated. There were a total of 3,698 cases. Of those cases with a known final medical outcome and dose, the mean dose in mg was 42.5 mg (range 0.4-536 mg) and the mean dose in mg/kg was 3.36 mg/kg (range 0.18-33.71 mg/kg). The final medical outcome was no observed effect in 95% of the cases and minor effect in remainder of cases. The patient was managed on site in 80% of the cases. The proportion of cases with a minor effect increased from 5% for ingested dose of <=100 mg to 10% for >100 mg but was 5% for dose <=5 mg/kg and >5 mg/kg. The proportion of cases managed with healthcare facility involvement increased from 15% for ingested dose of <=100 mg to 56% for >100 mg and rose from 10% for dose <=5 mg/kg to 47% for dose >5 mg/kg. Pediatric montelukast ingestions of doses up to 536 mg or 33.71 mg/kg do not appear likely to result in serious adverse effects and usually can be managed at home.

Using Geographic Information Systems and Spatial and Space-Time Scan Statistics for a Population-Based Risk Analysis of the 2002 Equine West Nile Epidemic in Six Contiguous Regions of Texas.
Warner LM, Alexander JL, Dixon KR.
Int J Health Geogr. 2007 Sep 21;6(1):42.
BACKGROUND: In 2002, West Nile virus (WNV) first appeared in Texas. Surveillance data were retrospectively examined to explore the temporal and spatial characteristics of Texas equine WNV epidemic in 2002. Using Geographic Information Systems (GIS) and the Spatial and Space-Time Scan statistics (SaTScan), we analyzed 1421 of the reported equine WNV cases from six contiguous state Health Service Regions (HSRs), comprising 158 counties, in western, northern, central and eastern Texas. RESULTS: Two primary epidemic peaks occurred in Epidemiological (Epi) week 35 (August 25 to 31) and Epi week 42 (October 13 to 19) of 2002 that took place in west and east part of the study area, respectively. The SaTScan statistics detected nine non-random spatio-temporal equine case aggregations (mini-outbreaks) and five unique high-risk areas imbedded within the overall epidemic. CONCLUSIONS: The 2002 Texas equine WNV epidemic occurred in a bi-modal pattern. Some "local hot spots" of WNV epidemic developed in Texas. The use of GIS and SaTScan can serve as valuable tools in analyzing on-going surveillance data to identify high-risk areas and shifts in disease clustering within a large geographic area. Such techniques should become increasingly useful and important in future epidemics, as decisions must be made to effectively allocate limited resources.

Voluntary Readmission among Schizophrenic Patients in the Texas State Psychiatric Hospital System.
Becker EA, Shafer A.
Texas Medicine. 2007 Sep;103(9):54-59.
This study examined risk factors for hospital recidivism within the Texas state psychiatric hospital system. Voluntary admissions of 5212 schizophrenic patients were followed for five years after discharge. First, the study examined differences between patients who were not readmitted and those who were. Second, readmissions were examined in relation to demographics, diagnostic information, posthospital discharge community aftercare, and other hospitalization information, such as length of stay. Readmission predictors were being male, single, and Hispanic; having an aftercare appointment; living in a county with a mental hospital; and having comorbid personality disorder and alcohol and drug abuse diagnoses. Longer index hospitalizations led to slightly few readmissions, but the total length of stay of subsequent readmissions was longer. While our predictors of readmission are mostly immutable, they can still be used to flag those at risk for lengthy hospital reentry.

Adult Glyburide Ingestions Reported to Texas Poison Control Centers, 1998-2005.
Forrester MB.
Hum Exp Toxicol 2007;26:563-571.
Limited information exists on potentially adverse adult glyburide ingestions reported to poison control centers. Using adult glyburide ingestions reported to Texas poison control centers during 1998-2005, 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). Of 126 cases identified, 49 (39%) involved serious outcomes. Serious outcomes were significantly more likely to occur with a maximum dose >24 mg (RR 4.74, 95% CI 1.74-14.90) or >4 tablets (RR 3.27, CI 1.57-7.31), where the circumstances of the exposures involved self-harm or malicious intent (RR 2.44, CI 1.33-4.46), or the patient was already at or en route to a health care facility when the poison control center was contacted (RR 12.89, CI 4.00-66.12) or referred to a health care facility by the poison control center (RR 12.21, CI 3.53-65.01). The severity of the outcome associated with adult glyburide ingestions depended on the dose and the circumstances of the ingestion. The management of patients with severe outcomes was more likely to involve health care facilities. Such information is useful for creating triage guidelines for the management of adult glyburide ingestions.

Paradox Found (Again): Infant Mortality among the Mexican-Origin Population in the United States.
Hummer RA, Powers DA, Pullum SG, Gossman GL, Frisbie WP.
Demography. 2007 Aug;44(3):441-57.
Recent research suggests that the favorable mortality outcomes for the Mexican immigrant population in the United States may largely be attributable to selective out-migration among Mexican immigrants, resulting in artificially low recorded death rates for the Mexican-origin population. In this paper we calculate detailed age-specific infant mortality rates by maternal race/ethnicity and nativity for two important reasons: (1) it is extremely unlikely that women of Mexican origin would migrate to Mexico with newborn babies, especially if the infants were only afew hours or afew days old; and (2) more than 50% of all infant deaths in the United States occur during the first week of life, when the chances of out-migration are very small. We use concatenated data from the U.S. linked birth and infant death cohort files from 1995 to 2000, which provides us with over 20 million births and more than 150,000 infant deaths to analyze. Our results clearly show that first-hour, first-day, and first-week mortality rates among infants born in the United States to Mexican immigrant women are about 10% lower than those experienced by infants of non-Hispanic, white U.S.-born women. It is extremely unlikely that such favorable rates are artificially caused by the out-migration of Mexican-origin women and infants, as we demonstrate with a simulation exercise. Further, infants born to U.S.-born Mexican American women exhibit rates of mortality that are statistically equal to those of non-Hispanic white women during the first weeks of life and fare considerably better than infants born to non-Hispanic black women, with whom they share similar socioeconomic profiles. These patterns are all consistent with the definition of the epidemiologic paradox as originally proposed by Markides and Coreil (1986).

Mutations in the Regulatory Domain of Phenylalanine Hydroxylase and Response to Tetrahydrobiopterin.
Wang L, Surendran S, Michals-Matalon K, Bhatia G, Tanskley S, Koch R, Grady J, Tyring SK, Stevens RC, Guttler F, Matalon R.
Genet Test. 2007 Summer;11(2):174-8.
Tetrahydrobiopterin (BH4) is a co-factor that enhances the activity of other enzymes, and this co-factor level is found to be affected in phenylketonuria (PKU), an amino acid metabolism disorder. The present study was aimed at understanding the effect of BH4 on mutations in the regulatory domain of phenylalanine hydroxylase (PAH). Among 14 patients, 5 patients were classical PKU, 3 were atypical PKU, and 6 were mild PKU. All of these patients had at least one mutation in the regulatory domain. Patients were given 10 mg/kg BH4, and the response of blood phenylalanine (Phe) levels was monitored following treatment. The level of blood Phe decreased after BH4 treatment in all of the patients. These studies suggest that mutations in the regulatory domain also responded to BH4 even if the patient had classical PKU.

Public-Academic Collaboration in the Application of Evidence-Based Practice in Texas Mental Health System Redesign.
Cook JA, Ruggiero K, Shore S, Daggett P, Butler SB.
Int J Ment Health. 2007;36(2):36-49.
This article describes a public -- academic collaboration between a state university research center and the Texas state mental health authority to design and evaluate a service package of psychosocial rehabilitation interventions. The project used a combination of evidence-based practice and community consensus as a tool for system change. The story of this effort and the new system that resulted is told through interviews with consumers, family members, and other advocates involved in the process, along with data from the state's management information system and reports prepared for the federal Mental Health Block Grant's Uniform Reporting System. Lessons learned about university -- community partnerships are discussed in light of the current emphasis on public mental health system transformation.

The Complete Genome Sequence For An American Isolate Of Enterovirus 77.
Oberste MS, Maher K, Patterson MA, Pallansch MA.
Arch Virol. 2007;152(8):1587-91.
The article presents a study on the complete genome sequence for an American isolate of enterovirus 77 (EV77). The study revealed that enteroviruses are the most common viral cause of meningitis and encephalitis, acute flaccid paralysis, myocarditis, and other serious illnesses. Furthermore, the study also presented the complete genome sequence for an EV77 strain isolated from a child with encephalitis in Texas.

Dengue Hemorrhagic Fever--U.S.-Mexico Border, 2005.
Centers for Disease Control and Prevention (CDC). DSHS contributors: Abell A, Smith B, Fournier M, Betz T, Gaul L, Taylor R.
MMWR Morb Mortal Wkly Rep. 2007 Aug 10;56(31):785-9. 
Dengue fever is a mosquito-transmitted disease caused by any of four closely related virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) of the genus Flavivirus. Infection with one of these serotypes provides lifelong immunity to the infecting serotype only. Therefore, persons can acquire a second dengue infection from a different serotype, and second infections place them at greater risk for dengue hemorrhagic fever (DHF), the more severe form of the disease. DHF is characterized by bleeding manifestations, thrombocytopenia, and increased vascular permeability that can lead to life-threatening shock. In south Texas, near the border with Mexico, sporadic, locally acquired outbreaks of dengue fever have been reported previously; however, on the Texas side of the border, these outbreaks have not included recognized cases of locally acquired DHF in persons native to the area. In July 2005, a case of DHF was reported in a resident of Brownsville, Texas. In August 2005, health authorities in the neighboring state of Tamaulipas, Mexico, reported an ongoing dengue outbreak with 1,251 cases of dengue fever, including 223 cases (17.8%) of DHF. To characterize this dengue outbreak, the Texas Department of State Health Services (TDSHS), Mexican health authorities, and CDC conducted a clinical and epidemiologic investigation. This report summarizes the results of that investigation, which determined that the percentage of DHF cases associated with dengue fever outbreaks at the Texas-Tamaulipas border has increased. Health-care providers along the U.S. border with Mexico should be vigilant for DHF and familiar with its diagnosis and management to reduce the number of severe illnesses and deaths associated with outbreaks of dengue fever.

Assuring Clinical Genetic Services for Newborns Identified through U.S. Newborn Screening Programs.
Kaye CI, Livingston J, Canfield MA, Mann MY, Lloyd-Puryear MA, Therrell BL Jr.
Genet Med. 2007 Aug;9(8):518-27.
PURPOSE: The study purpose was to determine whether U.S. newborn screening and/or genetics programs systematically document whether newborns and their families, identified with genetic disorders through newborn dried blood spot screening, receive clinical genetic services. METHODS: Nineteen state genetic plans were reviewed and a 30-question survey was administered to 53 respondents, including state newborn screening program coordinators and state genetics program coordinators in 36 states and principal investigators of 5 Health Resources and Services Administration-designated regional genetic and newborn screening collaboratives. RESULTS: Survey findings indicate that none of the state newborn screening and/or state genetics programs routinely tracked patient-level data on clinical genetic services for newborns identified with all of the genetic and congenital conditions for which their programs screened. Few programs could provide information systematically on whether patients were referred for, or received, genetic counseling. CONCLUSIONS: Systematic tracking of clinical genetic services for newborns identified by newborn screening programs is desirable and manageable. Recent national guidelines recommend tracking genetic counseling in newborn screening follow-up. The communications processes that state programs currently use to obtain follow-up reports from subspecialists could be augmented with clinical genetic service questions. Programs should be encouraged and supported in the efforts to track genetic services for the benefit of newborns and their families.

Wildfire-related Deaths--Texas, March 12-20, 2006.
Centers for Disease Control and Prevention (CDC). DSHS contributors: D Zane, J Henry, C Lindley, P Pendergrass, L Mansolo. Also acknowledged: J Alexander, B Hernandez, T Haywood, P Raimondo, J Walker, T Sidwa, S Elkins, D Johnson, A Whitley, P Tabor, C Tuttle, D McLellan, R Apodaca, M Widtfeldt, S Prosperie, B Ray, D Powell.
MMWR Morb Mortal Wkly Rep. 2007 Aug 3;56(30):757-60.
During March 12-20, 2006, wildfires burned approximately 1 million acres in the Panhandle region of Texas, advancing 45 miles in 9 hours, with dense smoke and flames up to 11 feet. The two largest fires, which together extended into nine counties, resulted from power lines downed by sustained winds of 46 mph and gusts up to 53 mph. The wildfires destroyed more than 89 structures, with losses estimated at $16 million. The fires caused evacuations in eight communities with a total population of 4,072. This report summarizes the circumstances of 12 deaths and describes the five separate incidents caused by the two wildfires that resulted in those deaths.

Pattern of Statin Exposures Reported to Texas Poison Centers, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2007;70:1424-1432.
Information on the management of potentially adverse exposures to statins is limited. This study examined the pattern of 2331 statin exposures reported to Texas poison control centers during 1998-2004. In particular comparisons were made between exposures among pediatric (age 5 yr) and adult (age 20 yr) patients. The number of exposures increased from 134 in 1998 to 516 in 2004. Of the total exposures, 55% were to statins alone. Of the exposures to statins alone, 57% of the patients were 5 yr of age and 22% were 60 yr of age. The majority of exposures to statins alone (a) involved female patients (53%), (b) were unintentional (94%), (c) occurred at home (91%), (d) were managed on-site/at home (89%), and (e) had a final medical outcome classified as no effect (94%). Pediatric and adult patients differed with respect to patient gender (45 versus 66% female), exposure reason (100 versus 88% unintentional, 1 versus 75% therapeutic error), exposure site (14 versus 2% at other residence), final medical outcome (4 versus 11% minor effect, none versus 4% moderate effects), report of specific adverse clinical exposures (0.2 versus 5% neurological effects, none versus 1% cardiovascular effects), and listed treatments (60 versus 24% decontamination by dilution, 13 versus 6% decontamination by food). In conclusion, reported statin exposures are increasing. The majority of potentially adverse statin exposures reported to poison control centers may be successfully managed at home with favorable outcomes. The pattern of exposures differs with age.

Review of Sole Lamotrigine Exposures Reported to Texas Poison Centers during a Seven-Year Period.
Baeza SH, Cleary JL, Forrester MB, Snodgrass W.
Clin Toxicol 2007;45:642.
Background: There is limited data reported on patients’ clinical effects with adverse exposures of the anticonvulsant lamotrigine. The objective of this study is to categorize these effects to enable poison center specialists to better manage these ingestions. Methods: We performed a retrospective chart review of all cases involving only lamotrigine with known outcomes that were reported to a state-wide poison center network during 2000 through 2006. Results: A total of 269 cases with known outcomes were identified, of which 151 (56%) had known doses. For cases with a known dose, the mean dose was 980 mg (range 2.5 to 10,000 mg). Suspected suicides accounted for 38% of cases, while general unintentional and unintentional therapeutic errors represented 33.1% and 22% respectively. Only 32% were managed on site as 55% were already in/enroute to a health care facility when the poison center was contacted and 12% were referred to a health care facility by the poison center. Half of all identified cases had no effects reported, 32% had only minor effects, 14% had moderate effects, and only 4% had major effects. There were no deaths reported from isolated lamotrigine ingestions during this seven-year time frame. The most common clinical effects reported include drowsiness/letharginess (23%), vomiting (10%), tachycardia (9%), nausea (7%), dizziness/lightheadedness (6%), ataxia (6%) and agitation/irritability (4%). Discussion: CNS effects are most prevalent with lamotrigine ingestions followed by nausea/vomiting and tachycardia. A limitation of this study is that it excluded cases with mixed ingestions. The potential for drug-drug interactions and increased severity or duration of clinical effects with other CNS depressant agents is possible. Conclusion: Although we were able to identify the most likely clinical effects noted with lamotrigine exposures, further research is required in order to determine if it is possible to predict risk of toxicity based on a mg/kg dosage or other dosing parameter.

Escitalopram Ingestions Reported to Texas Poison Control Centers, 2002-2005.
Forrester MB.
Hum Exp Toxicol 2007;26:473-482.
Limited information exists on potentially adverse escitalopram ingestions reported to poison control centers. Using isolated escitalopram ingestions reported to Texas poison control centers during 2002-2005, the proportion of cases involving serious medical outcomes was determined for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Of 1179 cases identified, 234 (20%) involved serious outcomes. Serious outcomes were significantly more likely to occur with a maximum dose of >100 mg (RR 4.69, CI 2.52-9.29) or >5 tablets (RR 4.96, CI 2.94-8.93), where the circumstances of the exposures involved self-harm or malicious intent (RR 3.21, CI 2.42-4.29), or when the patient was already at or en route to a health care facility when the poison control center was contacted (RR 7.88, CI 4.31-15.79) or referred to a health care facility by the poison control center (RR 15.91, CI 8.78-31.64). The severity of the outcome associated with isolated escitalopram ingestions depended on the dose and the circumstances of the ingestion. The management of patients with serious outcomes were more likely to involve health care facilities. Such information is useful for creating triage guidelines for the management of escitalopram ingestions.

Adult Lisinopril Ingestions Reported to Texas Poison Control Centers, 1998-2005.
Forrester MB.
Hum Exp Toxicol 2007;26:483-489.
There is limited information on potentially adverse lisinopril ingestions reported to poison control centers. Using adult lisinopril ingestions reported to Texas poison control centers during 1998-2005, 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). Of 468 cases identified, 43 (9%) involved serious outcomes. The severity of the outcome associated with adult lisinopril ingestions depended on the dose and the circumstances of the ingestion. Thus, serious outcomes were significantly more likely to occur with a maximum dose >80 mg (RR 5.69, CI 2.43-13.33) or, if the dose was unknown, >3 tablets (RR 9.57, CI 2.39-54.97), where the circumstances of the exposures involved self-harm or malicious intent (RR 6.96, CI 3.65-13.31), or the patient was already at or en route to a health care facility when the poison control center was contacted (RR 7.33, CI 3.09-17.85) or referred to a health care facility by the poison control center (RR 23.76, CI 10.62-55.67). The management of patients with severe outcomes was more likely to involve health care facilities. Such information is useful for creating of triage guidelines for the management of adult lisinopril ingestions.

Maternal Thyroid Disease as a Risk Factor for Craniosynostosis.
Rasmussen SA, Yazdy MM, Carmichael SL, Jamieson DJ, Canfield MA, Honein MA; for the National Birth Defects Prevention Study.
Obstet Gynecol. 2007 Aug;110(2):369-377.
OBJECTIVE: To study the relationship between maternal thyroid disease and craniosynostosis using data from the National Birth Defects Prevention Study, a multisite, case-control study. METHODS: Case infants (n=431) were identified through population-based birth defects surveillance systems at eight sites and had craniosynostosis verified by radiographic imaging. Control infants (n=4,094) consisted of a random sample of live births with no major birth defects from the same population as the case infants. Information on thyroid disease was based on self-report: mothers who reported either a thyroid disorder or use of a medication to treat a thyroid disorder during pregnancy were considered to have thyroid disease. Using an unconditional logistic regression model, we considered potential confounding factors (maternal age, race or ethnicity, smoking, body mass index, preexisting diabetes, plurality, gravidity, family history, infant sex). RESULTS: Among case mothers, 19 (4.4%) were classified as having thyroid disease, compared with 65 (1.6%) of control mothers. Maternal thyroid disease was associated with craniosynostosis after controlling for maternal age (adjusted odds ratio 2.47, 95% confidence interval 1.46-4.18), the only factor that remained significant in the final model. CONCLUSION: These data provide additional evidence that maternal thyroid disease (most likely Graves' disease) or its treatment is associated with craniosynostosis. Given the frequency of maternal thyroid disease, this association warrants further investigation. LEVEL OF EVIDENCE: II.

Prepregnancy Obesity as a Risk Factor for Structural Birth Defects.
Waller DK, Shaw GM, Rasmussen SA, Hobbs CA, Canfield MA, Siega-Riz AM et al.
Arch Pediatr Adolesc Med 2007;161(8):745-50.
OBJECTIVE: To describe the relation between maternal obesity, overweight and underweight status, and 16 categories of structural birth defects. DESIGN: An ongoing multisite, case-control study. Clinical geneticists reviewed all of the cases, excluding those that had or were strongly suspected to have a single-gene disorder or chromosomal abnormality. Mothers with preexisting diabetes were also excluded. Body mass index was based on maternal report of height and weight prior to pregnancy. SETTING: Eight participating states in the United States. PARTICIPANTS: Mothers enrolled in the National Birth Defects Prevention Study who had index pregnancies between October 1, 1997, and December 31, 2002. MAIN EXPOSURE: Maternal obesity. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios. RESULTS: Mothers of offspring with spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele were significantly more likely to be obese than mothers of controls, with odds ratios ranging between 1.33 and 2.10. Mothers of offspring with gastroschisis were significantly less likely to be obese than mothers of controls. CONCLUSIONS: To our knowledge, this is the first population-based study of its scale to examine prepregnancy obesity and a range of structural birth defects. These results suggest a weak to moderate positive association of maternal obesity with 7 of 16 categories of birth defects and a strong inverse association with gastroschisis. The mechanisms underlying these associations are not yet understood but may be related to undiagnosed diabetes.

Neural Tube Defects, Micronutrient Deficiencies, and Helicobacter pylori: A New Hypothesis.
Felkner M, Suarez L, Liszka B, Brender JD, Canfield M.
Birth Defects Res A Clin Mol Teratol. 2007 Aug;79(8):617-21.
BACKGROUND: Previous findings for the Texas Neural Tube Defects Project suggested that while maternal access to nutrients is adequate, bioavailability of nutrients to the fetus is compromised in NTD-affected pregnancies. Helicobacter pylori could cause nutrient loss to the fetus. Folate, B(12,) and ferritin are depleted in H. pylori infection; these same deficiencies are related to NTD risk. METHODS: Using H. pylori IgG ELISA Test System, we tested for H. pylori serum antibodies in participants in the population-based case-control study component of the Texas Neural Tube Defect Project conducted along the Texas-Mexico border. Case-women had pregnancies affected by NTD (anencephalus, spina bifida, encephalocele) and resided and delivered in one of the 14 Texas-Mexico border counties from 1995 through 2000. Control-women were study area residents delivering normal live births during the same period. RESULTS: Of 225 case- and 378 control-women, 103 cases and 156 controls provided questionnaire and H. pylori antibody data. H. pylori seropositivity was modestly associated with NTD-affected pregnancies (OR 1.4; 95% CI: 0.8-2.4). ORs of 2.0 or greater were seen in women younger than age 25 and with less than 7 years education. CONCLUSIONS: Our findings intimate that H. pylori could play a role in NTD causation in certain populations. While results did not provide compelling support for this proposal, subgroup findings prompt us to advocate an evaluation of this hypothesis in developing nations among populations with higher prevalence of H. pylori, marginal nutrient intake, and young childbearing age.

Using Social Network Analysis to Understand Missouri's System of Public Health Emergency Planners.
Harris JK, Clements B.
Public Health Rep. 2007 Jul-Aug;122(4):488-98.
OBJECTIVES: Effective response to large-scale public health threats requires well-coordinated efforts among individuals and agencies. While guidance is available to help states put emergency planning programs into place, little has been done to evaluate the human infrastructure that facilitates successful implementation of these programs. This study examined the human infrastructure of the Missouri public health emergency planning system in 2006. METHODS: The Center for Emergency Response and Terrorism (CERT) at the Missouri Department of Health and Senior Services has responsibility for planning, guiding, and funding statewide emergency response activities. Thirty-two public health emergency planners working primarily in county health departments contract with CERT to support statewide preparedness. We surveyed the planners to determine whom they communicate with, work with, seek expertise from, and exchange guidance with regarding emergency preparedness in Missouri. RESULTS: Most planners communicated regularly with planners in their region but seldom with planners outside their region. Planners also reported working with an average of 12 local entities (e.g., emergency management, hospitals/ clinics). Planners identified the following leaders in Missouri's public health emergency preparedness system: local public health emergency planners, state epidemiologists, the state vaccine and grant coordinator, regional public health emergency planners, State Emergency Management Agency area coordinators, the state Strategic National Stockpile coordinator, and Federal Bureau of Investigation Weapons of Mass Destruction coordinators. Generally, planners listed few federal-level or private-sector individuals in their emergency preparedness networks. CONCLUSIONS: While Missouri public health emergency planners maintain large and varied emergency preparedness networks, there are opportunities for strengthening existing ties and seeking additional connections.

Folic Acid Supplementation among Diabetic, Overweight, or Obese Women of Childbearing Age.
Case AP, Ramadhani TA, Canfield MA, Beverly L, Wood R.
J Obstet Gynecol Neonatal Nurs. 2007 Jul-Aug;36(4):335-41.
OBJECTIVE: To examine whether obese, overweight, or diabetic women were equally likely to supplement with folic acid as normal-weight or nondiabetic women. DESIGN: Texas Behavioral Risk Factor Surveillance System was used to compare folic acid supplementation rates among obese, overweight, or diabetic women to those of normal-weight or nondiabetic women. PARTICIPANTS: Responses from nonpregnant Texas women of ages 18 to 44 were analyzed. MAIN OUTCOME MEASURES: Odds ratios were calculated for association between diabetes, body mass index, and folic acid supplementation. RESULTS: Of 6,835 participants, 35% reported daily folic acid supplementation. Obese women were less likely to supplement, even after adjustment for other factors. CONCLUSIONS: All women of childbearing age, but especially those who are obese or diabetic, should be encouraged to take folic acid daily to reduce the risk of neural tube defects.

Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2007
National Association of State Public Health Veterinarians, Inc. (NASPHV) and Centers for Disease Control and Prevention. DSHS member of NASPHV: James H. Wright.
MMWR Recomm Rep. 2007 Jul 6;56(RR-5):1-13.
Certain venues encourage or permit the public to contact animals, resulting in millions of human-animal interactions each year. These settings include county or state fairs, petting zoos, animal swap meets, pet stores, zoologic institutions, circuses, carnivals, farm tours, livestock-birthing exhibits, educational exhibits at schools, and wildlife photo opportunities. Although multiple benefits of human-animal contact exist, infectious diseases, rabies exposures, injuries, and other human health problems associated with these settings are possible. Infectious disease outbreaks reported during the previous decade have been caused by Escherichia coli O157:H7, Salmonella, Cryptosporidium, Coxiella burnetii, Mycobacterium tuberculosis, ringworm, and other pathogens. Such incidents have substantial medical, public health, legal, and economic effects. This report provides recommendations for public health officials, veterinarians, animal venue staff, animal exhibitors, visitors to animal venues, physicians, and others concerned with minimizing risks associated with animals in public settings. The recommendation to wash hands is the single most important prevention step for reducing the risk for disease transmission. Other critical recommendations are that venues not allow food in animal areas, venues include transition areas between animal areas and nonanimal areas, visitors be educated about disease risk and prevention procedures, and animals be properly cared for and managed.

Speech Delay and Autism Spectrum Behaviors Are Frequently Associated with Duplication of the 7q11.23 Williams-Beuren Syndrome Region.
Berg JS, Brunetti-Pierri N, Peters SU, Kang SH, Fong CT, Salamone J, Freedenberg D, Hannig VL, Prock LA, Miller DT, Raffalli P, Harris DJ, Erickson RP, Cunniff C, Clark GD, Blazo MA, Peiffer DA, Gunderson KL, Sahoo T, Patel A, Lupski JR, Beaudet AL, Cheung SW.
Genet Med. 2007 Jul;9(7):427-41.
PurposeE: Williams-Beuren syndrome is among the most well-characterized microdeletion syndromes, caused by recurrent de novo microdeletions at 7q11.23 mediated by nonallelic homologous recombination between low copy repeats flanking this critical region. However, the clinical phenotype associated with reciprocal microduplication of this genomic region is less well described. We investigated the molecular, clinical, neurodevelopmental, and behavioral features of seven patients with dup(7)(q11.23), including two children who inherited the microduplication from one of their parents, to more fully characterize this emerging microduplication syndrome. Methods: Patients were identified by array-based comparative genomic hybridization. Clinical examinations were performed on seven affected probands, and detailed cognitive and behavioral evaluations were carried out on four of the affected probands. Results: Our findings confirm initial reports of speech delay seen in patients with dup(7)(q11.23) and further delineate and expand the phenotypic spectrum of this condition to include communication, social interactions, and repetitive interests that are often observed in individuals diagnosed with autism spectrum disorders. Conclusions: Array-based comparative genomic hybridization is a powerful means of detecting genomic imbalances and identifying molecular etiologies in the clinic setting, including genomic disorders such as Williams-Beuren syndrome and dup(7)(q11.23). We propose that dup(7)(q11.23) syndrome may be as frequent as Williams-Beuren syndrome and a previously unrecognized cause of language delay and behavioral abnormalities. Indeed, these individuals may first be referred for evaluation of autism, even if they do not ultimately meet diagnostic criteria for an autism spectrum disorder.

Gastroschisis and Associated Defects: An International Study.
Mastroiacovo P, Lisi A, Castilla EE, Martinez-Frias ML, Bermejo E, Marengo L et al.
Am J Med Genet A 2007;143(7):660-671.
Our objective was to evaluate the frequency and type of malformations associated with gastroschisis in a large pool of international data, to identify malformation patterns, and to evaluate the role of maternal age in non-isolated cases. Case-by-case information from 24 registries, all members of the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR), were evaluated. After the exclusion of other abdominal wall defects cases were classified as: (a) isolated; (b) recognizable syndrome, chromosomal or not; (c) multiple congenital anomalies (MCA). Our results showed that out of 3,322 total cases 469 non-isolated cases were registered (14.1%): 41 chromosomal syndromes, 24 other syndromes, and 404 MCA. Among MCA four groups of anomalies were most frequent: CNS (4.5%), cardio-vascular (2.5%), limb (2.2%), and kidney anomalies (1.9%). No similar patterns emerged except two patterns resembling limb-body wall complex and OEIS. In both of them the gastroschisis could be however misclassified. Chromosomal trisomies and possibly non-syndromic MCA are associated with an older maternal age more than isolated cases. On consideration of our data and the most valid studies published in the literature, the best estimate of the proportion of gastroschisis associated with major unrelated defects is about 10%, with a few cases associated to recognizable syndromes. Recognized syndromes with gastroschisis seem to be so exceptional that the well documented and validated cases are worth being published as interesting case report. An appropriate case definition in etiological studies should include only isolated gastroschisis after an appropriate definition of isolated and non-isolated cases and a thorough case-by-case review.

The State Policy Context of Implementation Issues for Evidence-Based Practices in Mental Health.
Isett KR, Burnam MA, Coleman-Beattie B, Hyde PS, Morrissey JP, Magnabosco J, Rapp CA, Ganju V, Goldman HH.
Psychiatr Serv. 2007 Jul;58(7):914-21.
OBJECTIVES: This study analyzed implementation issues related to several evidence-based practices for adults with serious mental illness that were included in a national demonstration project. The five evidence-based practices included in this investigation are assertive community treatment, family psychoeducation, illness management and recovery, integrated dual diagnosis treatment, and supported employment. The objective of the study was to assess the role of state mental health authorities as agents of change. METHODS: Two-person teams conducted interviews with state mental health authorities, consumers, families, representatives of local mental health authorities, and representatives of other relevant state agencies-more than 30 individuals at each of the eight sites. Interviews took place at two time points at least one year apart and probed the facilitators and barriers to implementation at the state level. Data were assessed qualitatively to identify common trends and issues across states related to leadership, training, and regulatory issues for each evidence-based practice. RESULTS: Each of the five practices has different critical contingencies for statewide implementation and requires unique assets to address those contingencies by the state mental health authorities. The contingencies are related to these critical areas: financing and regulations, leadership, and training and quality. CONCLUSIONS: States are key to implementing evidence-based practices, but state mental health authorities should note that each of the practices requires different skill sets and involves different stakeholders. Thus implementing many evidence-based practices at once may not yield economies of scale.

Prevalence of Multiple Sclerosis in 19 Texas Counties, 1998-2000.
Williamson DM, Henry JP, Schiffer R, Wagner L.
J Environ Health. 2007 Jun;69(10):41-5.
The study reported here determined the prevalence of multiple sclerosis (MS) between January 1, 1998, and December 31, 2000, for a 19-county study area surrounding Lubbock, Texas. The primary data source for case ascertainment was medical records from the offices of neurologists practicing in the study area. The study found that the overall prevalence for the 19-county study area was 42.8 per 100,000 population (95 percent CI = 36.8-49.5). The prevalence estimate for females was 68.6 per 100,000 (95 percent CI = 58.0-80.6), and for males it was 16.6 per 100,000 (95 percent CI = 11.6-23.1). The prevalence estimate for non-Hispanic whites was 56.0 per 100,000 (95 percent CI = 47.1-66.1); the next highest prevalence was among non-Hispanic blacks at 22.1 per 100,000 (95 percent Cl = 8.1-48.1), and Hispanics at 11.2 per 100,000 (95 percent CI = 6.4-18.2). This project generated the first Texas-specific population-based MS prevalence estimates, including prevalence estimates specific to Hispanics and blacks in Texas. The results underscore the need for additional epidemiologic information on the distribution of MS in other areas of Texas and the United States, as well as information on the underlying etiology of the disease.

Investigation of a Cluster of Multiple Sclerosis in Two Elementary School Cohorts.
Henry JP, Williamson DM, Schiffer R, Wagner L, Shire J, Garabedian M.
J Environ Health. 2007 Jun;69(10):34-8.
The authors investigated a cluster of multiple sclerosis (MS) among people who had attended two elementary schools in El Paso, Texas, from 1948 through 1970. The community was concerned about the possibility of childhood exposure to heavy metals from a large nearby smelter because historical environmental and biological sampling data demonstrated the potential for study cohort members to have been exposed to heavy metals during their pre-adolescent years. One cohort had no reported cases of MS. In the second cohort, 22 members self-reported a diagnosis of MS, and 16 of these cases were confirmed as MS by an independent board-certified neurologist. The crude MS prevalence estimate was 411 per 100,000 (95 percent confidence interval [CI] = 197-603), Prevalence estimates from four different populations were used for calculation of standardized morbidity ratios (SMRs). At the extremes, the study cohort represents a deficit of cases (SMR= 0.9; 95 percent CI = 0.51-1.44) or a four-fold excess (SMR = 4.0; 95 percent Cl = 2.29-6.5).

Potential Effect of Over-the-Counter Sales on Omeprazole Calls to Texas Poison Centers.
Forrester MB.
Texas Medicine 2007 Jun;103(6):48-51.
Omeprazole exposures reported to Texas poison centers before over-the-counter (OTC) approval (January 1998 through June 2003) and after OTC approval (July 2003 through December 2005) were compared. The mean number of human exposures per month declined from 12 before OTC approval to 8 after OTC approval. For exposures involving omeprazole alone, the calls before and after OTC approval were similar with respect to the exposure being unintentional (93% vs 92%), management occurring outside of a health care facility (90% vs 86%), and final medical outcome classified as no effect (95% vs 95%). During both time frames, no specific category of adverse clinical effect was reported in more than 6% of the exposures. Decontamination was the most common method of treatment both before (54%) and after (42%) OTC approval. In conclusion, approval of omeprazole did not alter the pattern of the potentially adverse omeprazole exposures reported to Texas poison centers.

Pediatric Atomoxetine Ingestions Reported to Texas Poison Control Centers, 2003-2005.
Forrester MB.
J Toxicol Environ Health A 2007;70:1064-1070.
ABSTRACT: Limited information exists on potentially adverse consequences following pediatric atomoxetine ingestions reported to poison control centers. Using pediatric atomoxetine ingestions reported to Texas poison control centers during 2003-2005, the proportion of cases involving serious outcomes (medical outcomes classified as moderate effects, major effects, death, or judged as potentially toxic exposures) was determined for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Of 501 cases identified, 31 (6%) involved serious outcomes. Higher serious outcome rates were found with a maximum dose of >2.8 mg/kg or >200 mg or >4 tablets. Serious outcome rates were also higher if the exposure involved intentional self-harm or the patient was already at or en route to a health care facility when the poison control center was contacted or referred to a health care facility by the poison control center. The severity of the outcome associated with pediatric atomoxetine ingestions was dependent upon the dose and the circumstances of the ingestion (whether intentional self-harm was involved). The management of patients with serious outcomes was more likely to involve health care facilities. This information is useful for creating triage guidelines for the management of pediatric atomoxetine ingestions.

Availability of Lactation Counseling Services Influences Breastfeeding among Infants Admitted to Neonatal Intensive Care Units.
Castrucci BC, Hoover KL, Lim S, Maus KC.
Am J Health Promot. 2007 May-Jun;21(5):410-5.
PURPOSE: To assess the association between the presence of international board-certified lactation consultant (IBCLC) services at a delivery hospital and the breastfeeding practices of women whose infants required neonatal intensive care unit (NICU) admission. DESIGN: Cross-sectional study using population-level data. SETTING: Philadelphia, Pennsylvania. SUBJECTS: 2132 infants admitted to the NICU. MEASURES: Breastfeeding at hospital discharge was measured with the question, "Is the infant being breastfed?" Delivery hospitals were dichotomized as to the presence or absence of an IBCLC on staff ANALYSIS: Logistic regression was used to assess the relationship between breastfeeding at discharge and the presence of an IBCLC at the delivery facility while adjusting for maternal characteristics and birth outcomes. RESULTS: Among mothers of infants admitted to the NICU, breastfeeding rates among mothers who delivered at hospitals with an IBCLC were nearly 50% compared with 36.9% among mothers who delivered at hospitals without an IBCLC. The adjusted odds of breastfeeding initiation prior to hospital discharge were 1.34 (95% confidence interval = 1.03, 1.76) times higher for women who delivered at a facility with an IBCLC. CONCLUSIONS: To increase breastfeeding rates among the NICU population, these findings support the need for universal availability of IBCLCs at delivery facilities that have NICUs.

Texas Statewide Hepatitis C Counseling and Testing, 2000-2005.
Heseltine G, McFarlane J.
Public Health Reports; 2007 May/Jun;122(2 Suppl):6-11.
In 1999, the Texas legislature funded a statewide hepatitis C education and prevention program. Hepatitis training was incorporated into training for all human immunodeficiency virus (HIV), sexually transmitted disease (STD), and substance abuse counselors. Hepatitis C virus (HCV) counseling and HCV-antibody (anti-HCV) testing services were integrated into 20 HIV/STD service provider programs. Hepatitis C counseling and testing became available in 2000. Through 2005, 38,717 tests were administered, with 8,964 (23.2%) anti-HCV positive. Injection drug use was reported by 7,105 people (79.3%) who tested positive. In Texas, a state-initiated and almost entirely state-funded program supported statewide HCV counseling and anti-HCV testing among high-risk adults.

Financing Newborn Screening: Sources, Issues, and Future Considerations.
Therrell BL, Williams D, Johnson K, Lloyd-Puryear MA, Mann MY, Ramos LR.
J Public Health Manag Pract. 2007 March/April;13(2):207-213.
Newborn screening (NBS) programs are population-based public health programs and are uniquely financed footline compared with many other public health programs. Since they began more than 45 years ago, the financing issues have become more complex for NBS programs. Today, almost all programs have a portion of their costs paid by fees. The fee amounts vary from program to program, with little standardization in the way they are formulated, collected, or used. We previously surveyed 37 of the 51 dried blood spot screening programs throughout the United States, and confirmed an increasing dependence on NBS fees. In this study, we have collected responses from all 51 programs (100%), including updated responses from the original 37, and updated our fee listings. Comments from those surveyed indicated that the lack of a national standardized procedural coding system for NBS contributes to billing complexities. We suggest one coding possibility for discussion and debate for such a system. Differences in Medicaid interpretations may also contribute to financing inequities across NBS programs and there may be benefit from certain clarifications at the national level. Completed survey responses accounted for few changes in the conclusions of our original survey. We confirmed that 90 percent of all NBS programs have a fee paid by parents or a third party payer. Sixty-one percent reported receiving some funds from the Maternal and Child Health Services Title V block grant, 33 percent reported some funding from state general revenue/general public health appropriations; and 24 percent reported obtaining direct reimbursement from Medicaid (without passing through a third party). A majority of programs (63%) reported budget increases between 2002 and 2005, with increases primarily from fees (72%) and to a lesser extent from Medicaid, the Title V block grant, and state general revenues.

Acute Pesticide Poisoning in the U.S. Retail Industry, 1998–2004.
Calvert GM, Petersen AM, Sievert J, Mehler LN, Das R, Harter LC, Romoli C, Becker A, Ball, C, Male D, Schwartz A, Lackovic M.
Public Health Rep. 2007 March-April;122:232-44.
Objective. This study was conducted to describe the national magnitude and characteristics of acute pesticide poisoning among workers and customers in retail establishments. Methods. Analyses included retail employees 15–64 years of age and customers with acute pesticide poisoning identified from the Sentinel Event Notification System for Occupational Risks-Pesticides (SENSOR-Pesticides) and California Department of Pesticide Regulation from 1998 to 2004. Pesticide poisoning incidence rates and incidence rate ratios (IRR) were calculated. Results. A total of 325 cases of acute pesticide poisoning were identified. Of these cases, 287 (88%) were retail employees and 38 (12%) were customers. Overall, retail employees had a significantly lower acute pesticide poisoning incidence rate compared with non-agricultural, non-retail employees (IRR50.53; 95% confidence interval 0.47, 0.59). However, significantly elevated pesticide poisoning incidence rates were observed for four retail occupations (janitors, stock handlers/baggers, bakery/deli clerks, and shipping/receiving handlers). In addition, workers employed in two retail industry sectors (farm supply stores and hardware stores) had significantly elevated acute pesticide poisoning incidence rates. Incidence rates among the retail employees demonstrated a quadratic trend, monotonically decreasing from 1998 to 2000 and monotonically increasing from 2000 to 2003. The rates appear to have leveled off in 2003 and 2004. Conclusions. Preventive measures to decrease acute pesticide poisoning incidence in the retail sector include adoption of unbreakable and tear-resistant container requirements, increased utilization of integrated pest management strategies, and advisement to store managers, employees, and customers about poisoning prevention.

Geographic Disparities in Diabetes-Related Amputations - Texas-Mexico Border 2003.
Huang P, Bensyl D, Miller EA.
JAMA. 2007 Mar 14;297(10):1051-2.
The article discusses the greater occurrence of diabetes-related amputations of the lower extremities in patients in Texas along the Texas-Mexico border than the rest of the state. The number of lower extremity amputations in people with diabetes was calculated using the 2003 Texas Inpatient Hospital Discharge Data. There are barriers to health care among people living along the Texas-Mexico border, including lower levels of education, lower incomes, and no health insurance. The authors state that measures to prevent diabetes and improve education about diabetes are needed to reduce diabetes-related lower extremity amputations.

Effectiveness and Tolerability of Aripiprazole in Child and Adolescent Inpatients: A Retrospective Evaluation.
Gibson AP, Lynn Crismon M, Mican LM, Fischer C.
Int Clin Psychopharmacol. 2007 Mar;22(2):101-105.
The objective of this study was to evaluate the effectiveness and tolerability of aripiprazole use in child and adolescent psychiatric inpatients. This was a naturalistic, retrospective evaluation of the discharged patients treated with aripiprazole on the child and adolescent unit at the Austin State Hospital. To be included, patients had to be <18 years of age and treated with aripiprazole for at least two consecutive weeks during their hospital stay. We used a chart extracted Clinical Global Impression of Improvement, and a chart extracted Clinical Global Impression of Severity of Illness score to determine their effectiveness. Adverse events and side effects recorded in the physician or nursing notes were collected to establish tolerability. Forty-five patients met the criteria and were included in this analysis. Average clinical global impression of severity of illness scores at baseline and endpoint were 5.04+/-0.91 and 3.33+/-1.24 respectively. This difference was statistically significant (Wilcoxon's signed-rank test: Z=-5.179, P<0.001). Fifty-one percent of the youth had a clinical global impression of severity of illness score that was much improved or very much improved (clinical global impression of improvement score of 1 or 2). Significant reduction in clinical global impression of severity of illness scores suggests a decline in the symptom severity for patients treated with aripiprazole. On the basis of the reported adverse events and side effects, aripiprazole was generally well tolerated. Randomized controlled trials of aripiprazole in childhood mental disorders are warranted.

A Pilot Program Using “Promotoras De Salud” to Educate Farmworker Families about the Risk from Pesticide Exposure.
Liebman A K, Juarez PM, Leyva C, Corona, A
Journal of Agromedicine; 2007; 12(2):33-43.
This paper reviews a successful community-based education effort to minimize pesticide exposure to migrant and seasonal farmworkers and their families through innovative training curricula, informal participatory educational techniques and culturally sensitive outreach methods. In 2004, Migrant Clinicians Network, Inc., trained lay health educators, or “promotoras de salud,” from local agencies in southern New Mexico in pesticide safety and in ways to successfully promote safety information in the farmworker community. Through home visits and small group workshops, the “promotoras” trained 273 farmworkers and farmworker family members on ways to reduce exposures to pesticides in their homes and at work, with an emphasis on protecting children. The families received a Spanish language comic book that reinforced the pesticide safety information, emphasizing the health effects of acute and chronic pesticide exposure and steps to protect farmworker children from pesticide exposure. The project resulted in a significant increase in knowledge regarding the routes of exposure, the vulnerability of children, the signs and symptoms of pesticide poisonings and the ways to minimize pesticide exposures. Additionally, the project showed improved behaviors aimed at minimizing pesticide exposure through accidental poisonings in the home. This pilot project proved the efficacy of an in-home, one-on-one approach with a culturally appropriate educational comic book as an instrument to help transfer education to the community. Moreover, the educational method involving promotoras offers a training-of- trainer approach that is easy to implement and potentially replicate.

Fatal Pneumonia among Metalworkers Due to Inhalation Exposure to Bacillus cereus Containing Bacillus anthracis Toxin Genes.
Avashia S, Riggins WS, Lindley C, Hoffmaster A, Drumgoole R, Nekomoto T, Jackson PJ, Hill KK, Williams K, Lehman L, Libal MC, Wilkins PP, Alexander J, Tvaryanas A, Betz T.
Clin Infect Dis. 2007 Feb 1;44(3):414-6.
Bacillus cereus pneumonia is unusual in nonimmunocompromised hosts. We describe fatal cases in 2 metalworkers and the associated investigation. Anthrax toxin genes were identified in B. cereus isolates from both patients using polymerase chain reaction. Finding anthrax toxin genes in non-Bacillus anthracis isolates has, to our knowledge, only been reported once previously.

Pediatric Lisinopril Ingestions Reported to Texas Poison Control Centers.
Forrester MB.
Hum Exp Toxicol. 2007 Feb;26(2):83-9.
Lisinopril is not recommended for use by young children. This study attempted to identify factors associated with serious outcomes in pediatric lisinopril ingestions. Cases for this study were lisinopril ingestions by children age < or =5 years reported to Texas poison control centers during 1998-2005. The percentage of cases involving serious medical outcomes was identified for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Of 691 total cases, 26 (3.8%) involved a serious outcome. Higher serious outcome rates were found with a maximum dose of >4 mg/kg (RR: 2.54, CI: 0.05-25.62), or >80 mg (RR: 7.85; CI: 1.73-29.29), or five or more tablets (RR: 8.18; CI: 2.73-22.54), or the patient was already at or en route to a health care facility when the poison control center was contacted (RR: 13.93; CI: 3.68-77.78), or referred to a health care facility by the poison control center (RR: 33.49; CI: 9.04-194.94). The management of patients with severe outcomes was more likely to involve health care facilities. This information is useful for drafting triage guidelines for the management of pediatric lisinopril ingestions.

Pattern of Proton Pump Inhibitor Calls to Texas Poison Centers, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2007;70:705-714.
There is little information on the management of potentially adverse exposures to proton pump inhibitors. This study examined the distribution of 2943 proton pump inhibitor exposures reported to Texas poison control centers during 1998-2004. In particular comparisons were made between exposures among pediatric (age 5 yr) and adult (age 20 yr) patients. Of the total exposures, 1813 (62%) were to the proton pump inhibitor alone. Of exposures to proton pump inhibitors alone, 66% were age 5 yr, 7% 6-19 yr, and 27% 20 yr. Pediatric and adult patients differed with respect to patient gender, exposure reason, exposure site, management site, final medical outcome, report of specific adverse clinical exposures, and listed treatments. Proton pump inhibitor exposures differed with patient age. In the majority of instances, potentially adverse proton pump inhibitor exposures reported to poison control centers may be successfully managed at home with favorable outcome.

Adderall Abuse in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2007;70:658-664.
Adderall is used in the treatment of attention deficit hyperactivity disorder (ADHD) in children and is subject to abuse. This study describes the patterns of Adderall abuse calls received by several poison control centers in Texas during 1998-2004. 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 all Adderall exposure calls, 12% involved abuse. The number of drug abuse calls received per year increased during the first part of 7-yr period but then declined. Male patients accounted for almost 60% of both drug abuse and nonabuse calls. Adolescent patients comprised 69% of drug abuse calls and children less than 13 yr old comprised 66% 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 nonabuse calls to involve exposures at another residence (6% vs. 3%), school (22% vs. 5%) and public areas (2% vs. 0.4%). Drug abuse calls were less likely than nonabuse calls to be managed outside of a health care facility (18% vs. 51%) and to be classified as no adverse effect (23% vs. 48%). Adderall abusers are more likely to be adolescents. Adderall abuse as compared to other exposures is more likely to occur outside of the person's home and involve more serious medical outcomes.

Oxycodone Abuse in Texas, 1998-2004.
Forrester MB.
J Toxicol Environ Health A 2007;70:534-538.
Oxycodone is frequently abused, and this abuse appears to be increasing. The purpose of this study was to describe the patterns of oxycodone abuse identified by Texas poison control centers. All oxycodone calls received by Texas poison control centers during 1998-2004 were identified. Annual trends and geographic distributions were determined for drug identification (ID) calls and abuse calls. The distribution of abuse calls was then compared to the distribution of all other types of human exposure calls for a variety of factors. Both drug ID and abuse calls involving oxycodone increased over the 7-yr period. The numbers of abuse calls were higher than expected in the central part of Texas, while drug ID calls were higher than expected in eastern and central Texas. A higher proportion of oxycodone abuse than other types of oxycodone exposures involved males, adolescents, exposures at other residences and public areas, referral by the poison control center to a health care facility, and some sort of clinical effect. Oxycodone abuse calls in Texas are increasing. The proportion of calls varies by geographic region. Oxycodone abuse calls differ from other types of exposures with respect to both demographic factors and clinical management and outcome.

A Large, Travel-Associated Outbreak of Legionellosis among Hotel Guests: Utility of the Urine Antigen Assay in Confirming Pontiac Fever.
Burnsed LJ, Hicks LA, Smithee LM, Fields BS, Bradley KK, Pascoe N, Richards SM,
Mallonee S, Littrell L, Benson RF, Moore MR
Clin Infect Dis. 2007 Jan 15;44(2):222-8.
Background. During March 2004, a large outbreak of legionnaires disease and Pontiac fever occurred among hotel guests in Oklahoma. An investigation was conducted to identify the source and evaluate the utility of the Legionella urine antigen assay and serologic testing for the identification of Pontiac fever Methods. A retrospective cohort investigation of hotel guests and employees and an environmental evaluation were performed. Participants were interviewed, and clinical specimens were collected from consenting individuals. Results. Six cases of legionnaires disease and 101 cases of Pontiac fever were identified. Exposure to the indoor pool and hot tub area was associated with legionellosis (relative risk, 4.4; 95% confidence interval, 2.8–6.9). Specimens from the pool and hot tub tested positive for Legionella pneumophila serogroup 1 by polymerase chain reaction. For Pontiac fever, the sensitivity and positive predictive value were 35.7% and 100%, respectively, for the urine antigen assay, and 46.4% and 90%, respectively, for serologic testing. The specificity and negative predictive value were 100% and 47.8%, respectively, for the urine antigen assay, and 89.3% and 45.5%, respectively, for serologic testing.Conclusions. Urine antigen testing, with or without serologic testing, can be used to confirm outbreak-associated cases of Pontiac fever caused by L. pneumophila serogroup 1.

Association of Paternal Age with Prevalence of Selected Birth Defects.
Archer NP, Langlois PH, Suarez L, Brender J, Shanmugam R.
Birth Defects Res A Clin Mol Teratol. 2007 Jan;79(1):27-34.
BACKGROUND: Unlike maternal age, the effect of paternal age on birth defect prevalence has not been well examined. We used cases from the Texas birth defect registry, born during 1996-2002, to evaluate the association of paternal age with the prevalence of selected structural birth defects. METHODS: Poisson regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) associated with paternal age for each birth defect, adjusting for maternal age, race/ethnicity, and parity. RESULTS: Relative to fathers ages 25-29 years, fathers 20-24 years of age were more likely to have offspring with gastroschisis (PR 1.47, 95% CI: 1.12-1.94), and fathers 40+ years old were less likely to have offspring with trisomy 13 (PR 0.40, 95% CI: 0.16-0.96). No association was seen between paternal age and prevalence of anencephaly and encephalocele. A selection bias was observed for the other birth defects in which cases of younger fathers were more often excluded from study. CONCLUSIONS: In studies of birth defect risk and paternal age, the source of information may affect the validity of findings.

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Last updated July 16, 2014