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DSHS Authors: 2010 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-diamond2010 Articles (in date order with most recent first)

State policy and research initiatives focused on improving nursing workforce: an integrative literature review.
Green A, Kishi A, Esperat MC.
Annu Rev Nurs Res. 2010;28:63-112.
The purpose of this chapter is to examine to and synthesize nursing workforce research and policy initiatives at the state level. An integrative literature review was systematically conducted using Ganong's Stages of an Integrative Research Review (1987). Searches were limited to English-language publications in the years from 2000 to 2010 which focused on workforce issues in the United States. A total of 155 published articles were included in this review. Overall, the literature indicated that significant research is examining nursing workforce issues and that states are actively engaged in policy initiatives to address nursing workforce issues, particularly those related to a shortage of nurses and faculty. The findings also indicated a major disconnect between nursing workforce research and patient outcomes research. Recommendations include connecting research and policy links between nursing workforce research and patient outcomes research and creating clear correlations to system-level determinants of quality Additional implications for further research are provided which include the important role of nurse researchers in connecting nursing care and nurse staffing to processes and outcome measures, which demonstrate the financial impact upon health care.

Transmission of Multidrug-Resistant Escherichia Coli through Kidney Transplantation --- California and Texas, 2009.
Centers for Disease Control and Prevention (CDC). DSHS employees:  Pascoe N, Heseltine G.
MMWR Morb Mortal Wkly Rep. 2010 Dec 24;59(50):1642-6.
On July 6, 2009, the Organ Procurement and Transplantation Network received notification of possible disease transmission. A transplant center in California (TCA) reported a kidney transplant recipient with Escherichia coli urinary tract infection and sepsis suspected to have been contracted from the donated kidney. Upon further investigation, a transplant center in Texas (TCB) reported that the recipient of the other kidney from the same donor developed a perinephric abscess caused by E. coli. The kidney grafts failed in both recipients; however, both recipients survived. E. coli isolates from both recipients demonstrated similar antimicrobial susceptibility profiles. Molecular typing studies conducted at CDC showed that the E. coli isolates from both kidney recipients were identical to an isolate from the donor's urine. On October 30, 2009, the Texas Department of State Health Services requested assistance from CDC to investigate this transplant-associated E. coli transmission and make recommendations to prevent future transmissions. The investigation identified gaps in communicating important donor information that might have adversely affected transplant outcomes. Each organ procurement organization (OPO) should establish protocols that clearly assign responsibilities for receiving, reviewing, and conveying any relevant donor information that becomes available subsequent to organ procurement.

Community Assessment for Public Health Emergency Response following Hurricane Ike--Texas, 25-30 September 2008.
Zane DF, Bayleyegn TM, Haywood TL, Wiltz-Beckham D, Guidry HM, Sanchez C, Wolkin AF.
Prehosp Disaster Med. 2010 Nov-Dec;25(6):503-10.
Introduction: On 13 September 2008, Hurricane Ike made landfall near Galveston, Texas, resulting in an estimated 74 deaths statewide and extensive damage in many counties. The Texas Department of State Health Services, US Public Health Service, and the Centers for Disease Control and Prevention conducted assessments beginning 12 days following hurricane landfall to identify the public health needs of three affected communities. The results of the assessment are presented, and an example of a type of public health epidemiological response to a disaster due to a natural hazard is provided. Methods: A one-page questionnaire that focused on household public health characteristics was developed. Using a two-stage cluster sampling methodology, 30 census blocks were selected randomly in three communities (Galveston, Liberty, and Manvel, Texas). Seven households were selected randomly from each block to interview. Results: The assessments were conducted on 25, 26, and 30 September 2008. At the time of the interview, 45% percent of the households in Galveston had no electricity, and 26% had no regular garbage collection. Forty-six percent reported feeling that their residence was unsafe to inhabit due to mold, roof, and/or structural damage, and lack of electricity. Sixteen percent of households reported at least one member of the household had an injury since the hurricane. In Liberty, only 7% of the household members interviewed had no access to food, 4% had no working toilet, 2% had no running water, and 2% had no electricity. In Manvel, only 5% of the households did not have access to food, 3% had no running water, 2% had no regular garbage collection, and 3% had no electricity. Conclusions: Post-Ike household-level surveys conducted identified the immediate needs and associated risks of the affected communities. Despite the response efforts, a high proportion of households in Galveston still were reportedly lacking electricity and regular garbage pickup 17 days post-storm. The proportion of households with self-reported injury in Galveston suggested the need to enhance public education on how to prevent injuries during hurricane cleanup. Galveston public health officials used the assessment to educate local emergency and elected officials of the health hazards related to lack of basic utilities and medical care in the community. This resulted in the provision of an extensive public health outreach education program throughout the island. The Liberty and Manvel assessment findings suggest that most households in both communities were receiving the basic utilities and that the residents felt "safe". The assessments reassured local health officials that there were no substantial acute public health needs and provided objective information that services were being restored.

Evaluation of a Postexposure Rabies Prophylaxis Protocol for Domestic Animals in Texas: 2000-2009.
Wilson PJ, Oertli EH, Hunt PR, Sidwa TJ.
J Am Vet Med Assoc. 2010 Dec 15;237(12):1395-401.
Objective: To determine whether postexposure rabies prophylaxis (PEP) in domestic animals, as mandated in Texas, has continued to be effective and to evaluate preexposure or postexposure vaccination failures from 2000 through 2009. Design: Retrospective case series. Animals: 1,014 unvaccinated domestic animals (769 dogs, 126 cats, 72 horses, 39 cattle, 3 sheep, 4 goats, and 1 llama) that received PEP and 12 vaccinated domestic animals (7 dogs and 5 cats) with possible failure of protection. Procedures: Zoonotic incident reports from 2000 through 2009 were reviewed for information regarding unvaccinated domestic animals that received PEP in accordance with the state protocol after exposure to a laboratory-confirmed rabid animal; reports also were reviewed for any preexposure or postexposure vaccination failures. The state-required PEP protocol was as follows: immediately vaccinate the animal against rabies, isolate the animal for 90 days, and administer booster vaccinations during the third and eighth weeks of the isolation period. Results: From 2000 through 2009, 1,014 animals received PEP; no failures were recorded. One preexposure vaccination failure was recorded. Conclusions and Clinical Relevance: The Texas PEP protocol was used during the 10-year period. Results indicated that an effective PEP protocol for unvaccinated domestic animals exposed to rabies was immediate vaccination against rabies, a strict isolation period of 90 days, and administration of booster vaccinations during the third and eighth weeks of the isolation period.

Improving Ascertainment of Risk Factors for HIV Infection: Results of a Group-Randomized Evaluation.
McDavid Harrison K, Pals SL, Sajak T, Chase J, Kajese T.
Eval Rev. 2010 Dec;34(6):439-54.
To allow appropriate allocation of prevention and care funding, HIV/AIDS surveillance data must include risk factor information, currently available for less than 70% of cases reported in the United States. The authors evaluated an intervention consisting of provider training and materials to improve risk factor reporting. Facilities were matched prior to randomization to intervention or control, and generalized linear mixed models were used to test for an intervention effect. Twenty-one percent of cases from intervention facilities and 33.4% from control facilities (p = .09) were reported without any risk factor information. The pre—post difference (20.7% for intervention and 36.0% for control) was not significant among HIV cases (p = .11) nor among AIDS cases (p = .12; 21.3% for intervention and 31.1% for control). The methods the authors’ evaluated may need to be combined with other approaches and/or alternative classification schemes to significantly reduce the percentage of cases reported to surveillance without risk factor information.

Maternal and Congenital Brucellosis in Texas: Changing Travel Patterns and Laboratory Implications.
Glocwicz J, Stonecipher S, Schulte J.
J Immigr Minor Health. 2010 Dec;12(6):952-5.
Brucellosis is an uncommon disease in the US, but Texas reports approximately a third of cases. We review the investigation of a pair of mother-infant cases that were unique in the demographics, the nature of travel exposure and the resulting brucellosis exposure in a hospital's delivery suite and laboratory. These cases illustrate the changing nature of travel and the need to obtain a relevant travel history and adequate laboratory procedures. Clinicians and laboratory workers in Texas need to understand that brucellosis remains an endemic disease, but that its epidemiology is changing.

 Motor Vehicle-Related Flood Fatalities in Texas, 1959-2008.
Sharif HO, Jackson T, Hossain M, Bin-Shafique S, Zane D.
Journal of Transportation Safety & Security. Dec2010; 2(4):325-335.
The number of related fatalities is one of the most essential socioeconomic characteristics of a natural disaster as death is the most serious and irreversible consequence of a disaster. Texas leads the nation in flash flood fatalities. From 1959 through 2008 the flood fatalities in Texas (839) were more than three times the fatalities in the next leading state, Pennsylvania (265). Flood fatalities in Texas represent a serious public health problem. Flood fatality statistics were extracted from National Climatic Data Center Storm Data publications. Review of the flood fatalities, where the death circumstances are provided, reveals that most fatalities are motor vehicle related (77%). Data analysis indicates that, in Texas, males are much more likely to be the victims of motor vehicle related flood accidents than are females. Most motor vehicle related fatalities happened at night (56%). Most fatalities resulted from flash floods. Spatial analysis indicates that the highest numbers of fatalities occur in counties having major urban areas. Flood fatalities in Texas can be reduced through a combination of improved hydrometeorological forecasting, educational programs aimed at enhancing the public awareness of flood risk and the seriousness of flood warnings, and timely and appropriate action by local emergency and safety authorities.

Reductions in Cigarette Smoking and Acute Myocardial Infarction Mortality in Jefferson County, Texas.
McAlister AL, Huang P, Ramirez AG, Harrist RB, Fonseca VP.
Am J Public Health. 2010 Dec;100(12):2391-2.
After litigation against the tobacco industry ended in a settlement, the Texas legislature funded pilot projects to reduce tobacco use in selected areas of the state. Subsequent telephone surveys showed that well-funded activities were successful in reducing population rates of self-reported cigarette smoking. We present evidence that the reduction in smoking promptly led to lower rates of death from acute myocardial infarctions.

Updated National Birth Prevalence Estimates for Selected Birth Defects in the United States, 2004-2006.
Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, Anderson P, Mason CA, Collins JS, Kirby RS, Correa A; for the National Birth Defects Prevention Network.
Birth Defects Res A Clin Mol Teratol. 2010 Dec;88(12):1008-16.
Background: The National Birth Defects Prevention Network collects state-specific birth defects surveillance data for annual publication of prevalence estimates and collaborative research projects. In 2006, data for 21 birth defects from 1999 through 2001 were presented as national birth prevalence estimates. The purpose of this report was to update these estimates using data from 2004 through 2006. Methods: Population-based data from 11 active case-finding programs, 6 passive case-finding programs with case confirmation, and 7 passive programs without case confirmation were used in this analysis. Pooled birth prevalence estimates for 21 birth defects, stratified by case ascertainment approach, were calculated. National prevalence estimates, adjusted for maternal race/ethnicity and maternal age (trisomy 13, trisomy 18, and Down syndrome only) were determined using data from 14 programs. The impact of pregnancy outcomes on prevalence estimates was also assessed for five specific defects. Results: National birth defects prevalence estimates ranged from 0.72 per 10,000 live births for common truncus to 14.47 per 10,000 live births for Down syndrome. Stratification by type of surveillance system showed that active programs had a higher prevalence of anencephaly, anophthalmia/microphthalmia, cleft lip with or without cleft palate, reduction defect of upper limbs, and trisomy 18. The birth prevalence of anencephaly, trisomy 13, and trisomy 18 also varied substantially with inclusion of elective terminations. Conclusion: Accurate and timely national estimates of the prevalence of birth defects are needed for monitoring trends, assessing prevention efforts, determining service planning, and understanding the burden of disease due to birth defects in the United States.

Universal MRSA Nasal Surveillance: Characterization of Outcomes at a Tertiary Care Center and Implications for Infection Control.
Parvez N, Jinadatha C, Fader R, Huber TW, Robertson A, Kjar D, Cornelius LK.
South Med J. 2010 Nov;103(11):1084-91.
Background:: Recognition of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage by active surveillance cultures has been widely debated. Our institution implemented universal nasal screening by polymerase chain reaction (PCR) for MRSA and isolation of screen positive patients in December 2007. Here we present data about the correlation between screen positivity and subsequent development of infection and the impact of isolation on surgical site infection rates. Methods:: This was a retrospective, observational study from January 1, 2008, through June 30, 2008, on all inpatient admissions with a nasal MRSA PCR screen. Genotype of 15 MRSA blood isolates was determined utilizing the Diversilab® (bioMérieux, Hazelwood, MO) system. A phenotypic rule was deduced and utilized for analyzing all MRSA clinical isolates. Results:: 5375 patients were screened at ≤48 hours following admission. 581 MRSA positive nasal carriers (10.80%) were identified. 496 (85.3%) were asymptomatic MRSA nasal carriers. There were a total of 158 MRSA clinical infections. 85 (14.6%) MRSA nasal carriers had clinical infection. Of the 4794 (89.1%) non-nasally colonized patients, 73 (1.5%) had MRSA clinical infection. MRSA surgical site infection rate remained unchanged during the intervention period. Phenotypic predictive rule inferred 59.8% community-acquired MRSA (CA-MRSA) infections and 40% hospital-acquired MRSA (HA-MRSA) infections. Conclusions: Our study showed a positive correlation between having a nasal screen positivity and subsequent development of infection. Isolation of MRSA screen positive patients alone as an intervention did not reduce the surgical site infection rates. Since most of our isolates are CA-MRSA, our institution is implementing several new interventions to further reduce the incidence of HA-MRSA conditions.

Prevalence and Risk Factors for Adult Paternity among Adolescent Females Ages 14 through 16 Years.
Castrucci BC, Clark J, Lewis K, Samsel R, Mirchandani G.
Matern Child Health J. 2010 Nov;14(6):895-900.
To investigate sociodemographic factors associated with adolescent females ages 14-16 years having children fathered by males age 20 years or older and identify differences in correlates across rural, urban, and border areas. The method section was a cross-sectional study using Texas birth record data. From 2000 through 2004, there were 29,186 births to adolescent females aged 14-16 years with valid paternal age. Prevalence of and adjusted odds of paternal age of 20 years or older were identified by paternal and maternal factors. The Results section Having both parents born outside of the U.S. was associated with a 5.29 (95% CI: 4.82, 5.80) times increase in the odds of paternal age of 20 years or older as compared to having both parents born in the U.S. Parental place of birth was associated with greater odds of paternal age of 20 years or older in urban areas compared to rural or border areas. Compared to those with average or high educational attainment relative to age, low educational attainment relative to age was associated with an increase in the odds of paternal age of 20 years or older. This association was present whether maternal or paternal educational attainment was low relative to age. Messages are needed to help adolescent females avoid pregnancy with adult males. In addressing this specific prevention challenge, it is important to consider maternal/paternal place of birth and its association with adolescent births with adult males.

Prevalence and Risk Factors for Adult Paternity among Adolescent Females Ages 14 through 16 Years.
Castrucci BC, Clark J, Lewis K, Samsel R, Mirchandani G.
Matern Child Health J. 2010 Nov;14(6):895-900.
To investigate sociodemographic factors associated with adolescent females ages 14-16 years having children fathered by males age 20 years or older and identify differences in correlates across rural, urban, and border areas. The method section was a cross-sectional study using Texas birth record data. From 2000 through 2004, there were 29,186 births to adolescent females aged 14-16 years with valid paternal age. Prevalence of and adjusted odds of paternal age of 20 years or older were identified by paternal and maternal factors. The Results section: Having both parents born outside of the U.S. was associated with a 5.29 (95% CI: 4.82, 5.80) times increase in the odds of paternal age of 20 years or older as compared to having both parents born in the U.S. Parental place of birth was associated with greater odds of paternal age of 20 years or older in urban areas compared to rural or border areas. Compared to those with average or high educational attainment relative to age, low educational attainment relative to age was associated with an increase in the odds of paternal age of 20 years or older. This association was present whether maternal or paternal educational attainment was low relative to age. Messages are needed to help adolescent females avoid pregnancy with adult males. In addressing this specific prevention challenge, it is important to consider maternal/paternal place of birth and its association with adolescent births with adult males.

Change in Glow Product Exposures Reported to Poison Control Centers on Halloween.
Forrester M, Jaramillo J.
Texas Public Health Journal. Fall2010 2010;62(4):43-46.
The article presents a study on the number of glow product exposures reported to poison control centers during Halloween. It states that the intent of the investigation is to determine whether Texas poison control centers observed an increase in glow product exposure calls during Halloween 2007 and Halloween 2008. It notes that the study is conducted to educate the public prior to Halloween about the products to emphasize the utilization of poison control centers for the triage of exposures.

County-Level Socioeconomic Status and Cancer Rates in Texas, 2001-2005.
Risser DR, Miller EA, Williams MA, Foxhall LE.
Tex Med 2010, 106(10):53-56. (No abstract available.)

Use of Interactive Voice Response Technology by Poison Centers during the H1N1 Outbreak.
Forrester MB, Villanacci JF, Valle N.
Prehosp Disaster Med. 2010;25:415-418.
Introduction: Interactive voice response (IVR) technology may facilitate poison centers to handle increased call volumes that may occur during public health emergencies. On 28 April 2009, the Texas Poison Center Network (TPCN) added a H1N1 message in English and Spanish to its IVR system. This study tested whether IVR technology could be used to assist Texas poison centers during the H1N1 outbreak. Methods: The distribution of callers who accessed the H1N1 message during 29 April-31 May 2009 was determined with respect to message language, subsequent caller action, and date of the call. Results: The H1N1 message was accessed by 1,142 callers, of whom, 92.9% listened to the message in English, and 7.1% listened to the message in Spanish. After listening to the message, 33.3% hung up while 66.7% spoke to a poison center agent. The number of callers who accessed the message was highest on 29 April 2009 and then declined. Conclusions: Interactive voice response technology can be used to assist poison centers to provide information and handle calls from the public during a public health emergency.

Ciguatera Poisoning in Texas.
Forrester MB.
Texas Public Health Journal 2010;62(4):47. (No abstract available.)

Functional Needs Support Services: A New Paradigm in Emergency Shelter Operations.
Clements B.
Domestic Preparedness Journal. 2010;6(10):5-7. (No abstract available.)

Physical Activity Participation by Parental Language Use in 4th, 8th, and 11th Grade Students in Texas, USA.
Springer AE, Lewis K, Kelder SH, Fernandez ME, Barroso CS, Hoelscher DM.
J Immigr Minor Health. 2010 Oct;12(5):769-80.
Research on physical activity (PA) by level of acculturation in Hispanic children is limited and findings have been mixed. We examined PA participation by primary language used with parents in a representative sample of 4th, 8th, and 11th grade Texas public school students. Mixed-effects regression models were conducted using cross-sectional data from the 2004-2005 School Physical Activity and Nutrition Study (n = 22,049). Self-reported PA was compared among three language-ethnic groups: Spanish-Hispanic (SH) (referent); English-Hispanic (EH); and English-Other (EO). EH and/or EO girls were generally between 1.25 and 2.58 [OR] times more likely to participate in PA across grade levels, with the largest differences found for school sports in 8th grade girls. EH and EO 8th grade boys were 1.71 (CI: 1.40, 2.10) and 2.06 (CI: 1.68, 2.51) times, respectively, more likely to participate in school sports. Findings indicate important disparities in Spanish-speaking Hispanic children's PA participation.

Pediatric Carvedilol Ingestions Reported to Texas Poison Centers, 2000 to 2008.
Forrester MB.
Pediatr Emerg Care 2010 Oct;26(10):730-2.
Objectives: The objective of this study was to describe the pattern of pediatric carvedilol ingestions reported to poison centers. Methods: Cases were all carvedilol ingestions by patients aged 0 to 5 years reported to Texas poison centers during 2000 to 2008. Multiple substance ingestions and patients not followed up to a final medical outcome were excluded. The distribution of cases by selected demographic and clinical factors was determined, and the mean dose (MD) in milligrams and milligrams per kilogram calculated for those cases where the dose ingested was reported. Results: Of a total 111 cases, the dose in mg was reported in 67 (mean, 18.2 mg; range, 0.3-200 mg) and in mg/kg was reported in 41 (mean, 1.5 mg/kg; range, 0.1-14.8 mg/kg). Of total cases, 63.1% were males and 36.9% females. The management site was as follows: 23.4% on site (MD, 7.8 mg and 0.6 mg/kg), 37.8% already at or en route to health care facility (MD, 22.7 mg and 2.6 mg/kg), and 38.7% referred to health care facility (MD, 22.1 mg and 1.6 mg/kg). The medical outcome as follows: 97.3% no effect (MD, 18.7 mg and 1.5 mg/kg), 1.8% minor effect (MD, 3.4 mg and 0.5 mg/kg), and 0.9% moderate effect. Adverse clinical effects were reported in 4 cases (3 drowsiness and 1 hypotension). Conclusions: Pediatric ingestions of as much as 200 mg (14.8 mg/kg) reported to Texas poison centers might be expected to result in at most minor effects, although ingestions involving higher doses might be referred to health care facilities.

Iguana Bites Reported to Texas Poison Centers.
Forrester MB.
Am J Emerg Med 2010;28:817-819.
Although thousands of iguanas are kept as pets in the United States, information on their bites is limited. The intent of this investigation was to describe the pattern of iguana bites reported to Texas poison centers. Iguana bites reported during 1998-2008 were identified. The distribution of cases by various factors was determined. Of 59 total bites, 71% were managed on-site, 17% of the patients were at or en route to a health care facility when the poison center was contacted, and 10% were referred to a health care facility. The medical outcome was no effect in 9% of the cases, minor effect in 24%, moderate effect in 2%, not followed but minimal effects possible in 64%, and unable to follow but potentially toxic in 2%. Most iguana bites reported to Texas poison centers did not result in serious effects and were managed on-site

Potential Toxicity of Hand Sanitizers.
Forrester MB.
Texas Public Health Journal 2010;62(3):27. (No abstract available.)

Pythons: An Unusual Cause of Snake Bites in Texas.
Forrester MB.
Texas Public Health Journal 2010;62(3):27-28. (No abstract available.)

Redotex Ingestions Reported to Texas Poison Centers.
Forrester MB.
Hum Exp Toxicol. 2010 Sep;29(9):789-91.
Although the multi-component weight loss supplement Redotex is banned in the United States, the supplement can be obtained in Mexico. The intent of this report was to describe the pattern of Redotex calls received by a statewide poison center system. Cases were all Redotex calls received by Texas poison centers during 2000-2008. The distribution of total calls and those involving ingestion of the supplement were determined for selected demographic and clinical factors. Of 34 total Redotex calls received, 55.9% came from the 14 Texas counties that border Mexico. Of the 22 reported Redotex ingestions, 77.3% of the patients were female and 45.5% 20 years or more. Of the 17 ingestions involving no coingestants, 52.9% were already at or en route to a health care facility, 41.2% were managed on site, and 5.9% was referred to a health care facility. The final medical outcome was no effect in 23.5% cases, minor effect in 5.9%, moderate effect in 11.8%, not followed but minimal clinical effects possible in 47.1%, and unable to follow but judged to be potentially toxic in 11.8%. Most Redotex calls to the Texas poison center system originated from counties bordering Mexico

Mortality among Infants with Birth Defects: Joint Effects of Size at Birth, Gestational Age, and Maternal Race/Ethnicity.
Nembhard WN, Salemi JL, Ethen MK, Fixler DE, Canfield MA.
Birth Defects Res A Clin Mol Teratol. 2010 Sep;88(9):728-36.
Background: We examined the separate and joint effects of gestational age, size at birth and maternal race/ethnicity on early childhood survival among 48,391 singleton infants with major birth defects. Methods: Texas Birth Defects Registry data were linked to death records and the National Death Index to ascertain deaths. Gestational age categories were preterm or term birth; size at birth included small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA). Kaplan-Meier survival estimates were calculated, and Cox-proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) to determine risk of death after adjusting for covariates. Results: Overall, relative to non-Hispanic (NH) -whites, NH-blacks, and Hispanics had a 51 and 10% greater risk of death during early childhood, respectively. Compared to NH-whites born term and AGA (survival = 97%), Hispanic children born  SGA and preterm had the greatest risk of death (HR(a) = 6.1; 95% CI, 5.2, 7.2) and the lowest early childhood survival (76%), followed by SGA preterm NH-blacks (HR(a) = 4.8; 95% CI, 3.6, 6.5; survival = 81%) and SGA preterm NH-whites (HR(a) = 4.5; 95% CI, 3.7, 5.6; survival = 83%). Children born LGA at term had no increased risk of mortality regardless of maternal race/ethnicity. Conclusions: The joint effect of gestational age and size at birth had greatest impact on childhood mortality. Additional population based studies are needed to  better understand causes of racial/ethnic disparities in mortality among children with birth defects.

Impact of Asthma 101 Training on Level of Nursing Students’ Knowledge.
Zuniga GC, Seol YH, Kirk S, Hernandez T, Nadeau N, Zuniga MA.
Journal of Asthma & Allergy Educators. 2010 Aug 13;1(4):138-43.
The Asthma 101 training, developed by the American Lung Association, was offered in 2009 to 93 senior bachelor of science in nursing (BSN) students. It was offered again in 2010 to 65 senior BSN students enrolled at the University of Texas Pan American in Edinburg, Texas. The training included both a pretest and posttest to evaluate changes in level of knowledge. Nursing students who were trained in 2009 participated in an asthma study offering asthma education to local elementary and middle schools students and their parents. The goal of Asthma 101 training was to educate nursing students so that they could provide general information about asthma to elementary school children and their parents, which could be done in a variety of settings such as health fairs and in classrooms. Test results for those who received the 2009 training showed an improvement in their knowledge about asthma. More than 95% of participants were very or somewhat satisfied with the Asthma 101 training. Test results in 2010 showed a significant improvement in participants’ knowledge in 2 areas: taking asthma medications to prevent an asthma episode (P = .001) and occurrence of asthma symptoms (P = .016). Two questions of statistical significance related to the use of medications and asthma episode demonstrated that nursing students had increased their knowledge in these areas. These findings suggest that health professionals can acquire additional knowledge from a brief yet focused training, such as the Asthma 101 training outlined in this article.

Evaluation of Completeness of Selected Poison Control Center Data Fields.
Jaramillo JE, Marchbanks B, Willis B, Forrester MB.
J Med Syst
2010 Aug;34(4):499-507.
Poison control center data are used in research and surveillance. Due to the large volume of information, these efforts are dependent on data being recorded in machine readable format. However, poison center records include non-machine readable text fields and machine readable coded fields, some of which are duplicative. Duplicating this data increases the chance of inaccurate/incomplete coding. For surveillance efforts to be effective, coding should be complete and accurate. Investigators identified a convenience sample of 964 records and reviewed the substance code determining if it matched its text field. They also reviewed the coded clinical effects and treatments determining if they matched the notes text field. The substance code matched its text field for 91.4% of the substances. The clinical effects and treatments codes matched their text field for 72.6% and 82.4% of occurrences respectively. This under-reporting of clinical effects and treatments has surveillance and public health implications.

Polytomous Logistic Regression as a Tool for Exploring Heterogeneity across Birth Defect Subtypes: An Example Using Anencephaly and Spina Bifida.
Lupo PJ, Symanski E, Waller DK, Chan W, Canfield MA, Langlois PH, Mitchell LE; National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2010 Aug;88(8):701-5.
Background: In birth defect epidemiology, phenotypic subgroups are often combined into a composite phenotype in an effort to increase statistical power. Although the validity of using composite phenotypes has been questioned, formal evaluations of the underlying assumption of effect homogeneity across component phenotypes have not been conducted. Methods: Polytomous logistic regression was used to assess effect heterogeneity of several generally accepted neural tube defect (NTD) risk factors across the component phenotypes of anencephaly and spina bifida. Data for these analyses were obtained from the National Birth Defects Prevention Study. Results: The use of a composite phenotype has the potential to mask associations specific to a component phenotype and in some cases the effect of a variable may be misattributed to the composite phenotype. For example, an association between infant sex and anencephaly (adjusted odds ratio [AOR], 1.5; 95% CI, 1.1-1.9) was masked when data from all NTDs were analyzed (AOR, 1.1; 95% CI, 0.9-1.3), whereas an association with maternal body mass index that was specific to spina bifida (AOR, 1.9; 95% CI, 1.6-2.4) was attributed to all NTDs (AOR, 1.6; 95% CI, 1.4-2.0). Furthermore, conclusions regarding effect heterogeneity based on ad hoc comparisons, rather than some formal assessment, may be vulnerable to considerable subjectivity, as was the case for the association of maternal Hispanic ethnicity with spina bifida (AOR, 1.4; 95% CI, 1.2-1.8) and anencephaly (AOR, 2.0; 95% CI, 1.5-2.8). Conclusions: Polytomous logistic regression provides a useful tool for evaluating putative risk factors for which there is no a priori basis for assuming effect homogeneity across component phenotypes.

Integrated Preparedness for Continuity of Tuberculosis Care after Hurricanes Gustav and Ike: Louisiana and Texas, 2008.
Miner MC, Burns-Grant G, DeGraw C, Wallace C, Pozsik C, Jereb J.
Public Health Rep. 2010 Jul-Aug;125(4):518-9. (No abstract available.)

Selective Isolation of Yersinia Pestis from Plague-Infected Fleas.
Sarovich DS, Colman RE, Price EP, Chung WK, Lee J, Schupp JM, Cobble KR, Busch JD, Alexander J, Keim P, Wagner DM.
J Microbiol Methods. 2010 Jul;82(1):95-7. Epub 2010 Apr 10.
We evaluated Yersinia CIN agar for the isolation of Yersinia pestis from infected fleas. CIN media is effective for the differentiation of Y. pestis from flea commensal flora and is sufficiently inhibitory to other bacteria that typically outcompete Y. pestis after 48 h of growth using less selective media.

A Physician Survey Regarding Diagnostic Variability among Birth Defects.
Langlois PH, Sheu SU, Scheuerle AE.
Am J Med Genet A. 2010 Jun;152A(6):1594-8.
Research Letter to the Editor.

Childhood Cancer in Relation to Parental Race and Ethnicity: A 5-State Pooled Analysis.
Chow EJ, Puumala SE, Mueller BA, Carozza SE, Fox EE, Horel S, Johnson KJ, McLaughlin CC, Reynolds P, Von Behren J, Spector LG.
Cancer. 2010 Jun 15;116(12):3045-53.
Background: Children of different racial/ethnic backgrounds have varying risks of cancer. However, to the authors' knowledge, few studies to date have examined cancer occurrence in children of mixed ancestry. Methods: This population-based case-control study examined cancer among children aged <15 years using linked cancer and birth registry data from 5 US states from 1978 through 2004. Data were available for 13,249 cancer cases and 36,996 controls selected from birth records. Parental race/ethnicity was determined from birth records. Logistic regression analysis was used to examine the association of cancer with different racial/ethnic groups. Results: Compared with whites, blacks had a 28% decreased risk of cancer (odds ratio [OR], 0.72; 95% confidence interval [95% CI], 0.65-0.80), whereas both Asians and Hispanics had an approximate 15% decrease. Children of mixed white/black ancestry also were found to be at decreased risk (OR, 0.71; 95% CI, 0.56-0.90), but estimates for mixed white/Asian and white/Hispanic children did not differ from those of whites. Compared with whites: 1) black and mixed white/black children had decreased ORs for acute lymphoblastic leukemia (OR, 0.39 [95% CI, 0.31-0.49] and OR, 0.58 [95% CI, 0.37-0.91], respectively); 2) Asian and mixed white/Asian children had decreased ORs for brain tumors (OR, 0.51 [95% CI, 0.39-0.68] and OR, 0.79 [95% CI, 0.54-1.16], respectively); and 3) Hispanic and mixed white/Hispanic children had decreased ORs for neuroblastoma (OR, 0.51 [95% CI, 0.42-0.61] and OR, 0.67 [95% CI, 0.50-0.90], respectively). Conclusions: Children of mixed ancestry tend to have disease risks that are more similar to those of racial/ethnic minority children than the white majority group. This tendency may help formulate etiologic studies designed to study possible genetic and environmental differences more directly.

Pulsed-Field Gel Electrophoresis for Salmonella Infection Surveillance, Texas, USA, 2007.
Long SG, DuPont HL, Gaul L, Arafat RR, Selwyn BJ, Rogers J, Casey E.
Emerg Infect Dis. 2010 Jun;16(6):983-5.
To identify sources of transmission for area clusters, in 2007 the Houston Department of Health and Human Services conducted an 8-month study of enhanced surveillance of Salmonella infection. Protocol included patient interviews and linking the results of interviews to clusters of pulsed-field gel electrophoresis patterns detected by the local PulseNet laboratory.

Dietary Methionine Intake and Neural Tube Defects in Mexican-American Women.
Graham A, Brender JD, Sharkey JR, Zhu L, Felkner M, Suarez L, Canfield MA.
Birth Defects Res A Clin Mol Teratol. 2010 Jun;88(6):451-7.
Background: Nutrients other than maternal folic acid are also thought to play a role in preventing neural tube defects (NTDs). Evidence suggests that methionine interacts with folic acid and vitamin B(12) in the methylation of contractile proteins involved in closing the neural folds. The role of dietary intake of methionine in NTD risk has not been specifically studied among Mexican Americans, a population with one of the highest prevalences of NTDs in the United States. Methods: We conducted a case-control study of 184 Mexican American women with NTD-affected pregnancies (case women) and 225 women with normal offspring (control women) who resided along the Texas-Mexico border. The average daily intakes of methionine were calculated from periconceptional food frequency questionnaire data. Women were categorized according to quartiles of daily methionine intake, based on the control mothers' distribution, and the risk for an NTD-affected pregnancy was calculated using the lowest quartile of intake as the referent. Results: With adjustment for income, body mass index, hyperinsulinemia, and diarrhea, the odds ratios for increasing quartile of methionine intake were: 0.95 (95% confidence interval [CI], 0.48,1.90), 0.92 (95% CI, 0.46,1.84), and 0.66 (95% CI, 0.30,1.45). Some evidence of interaction between dietary methionine and serum vitamin B(12) was noted particularly at higher levels of both components. Conclusions: This study was limited by a small sample size but examined this association in an exclusively Hispanic population. Results were suggestive of a potential protective effect for NTDs with increasing maternal dietary methionine intake. 2010 Wiley-Liss, Inc.

Pulsed-Field Gel Electrophoresis for Salmonella Infection Surveillance, Texas, USA, 2007.
Long SG, DuPont HL, Gaul L, Arafat RR, Selwyn BJ, Rogers J, Casey E.
Emerg Infect Dis. 2010 Jun;16(6):983-5.
To identify sources of transmission for area clusters, in 2007 the Houston Department of Health and Human Services conducted an 8-month study of enhanced surveillance of Salmonella infection. Protocol included patient interviews and linking the results of interviews to clusters of pulsed-field gel electrophoresis patterns detected by the local PulseNet laboratory.

First U.S. Report of Shellfish Harvesting Closures Due to Confirmed Okadaic Acid in Texas Gulf Coast Oysters.
Deeds JR, Wiles K, Heideman GB 6th, White KD, Abraham A.
Toxicon. 2010 Jun 1;55(6):1138-46.
Between March 7 and April 12, 2008, several bay systems on the east (Gulf of Mexico) coast of Texas, USA were closed to the harvesting of oysters (Crassostrea virginica) due to the presence of the DSP (Diarrheic Shellfish Poisoning) toxin okadaic acid in excess of the 20 microg/100 g tissue FDA regulatory guidance level. This was the first shellfish harvesting closure due to the confirmed presence of DSP toxins in US history. Light microscopic cell counts were performed on water samples collected from numerous sampling sites along the Texas Gulf coast where shellfish harvesting occurs. Ultra performance liquid chromatography, electrospray ionization, selected reaction monitoring, mass spectrometry (UPLC/ESI/SRM/MS) was used to detect DSP toxins in oysters. The closures were associated with an extensive bloom of the dinoflagellate Dinophysis cf. ovum. Only okadaic acid (OA) and OA acyl esters were found in shellfish tissues (max. OA eq. levels 47 microg/100 g tissue). OA was also confirmed in a bloom water sample. No illnesses were reported associated with this event. DSP toxins now add to a growing list of phycotoxins, which include those responsible for PSP (paralytic shellfish poisoning), NSP (neurotoxic shellfish poisoning), and ASP (amnesic shellfish poisoning) which must now be monitored for in US coastal waters where shellfish are harvested.

Human Ingestions of Veterinary Cyclooxygenase-2 Inhibitors.
Forrester MB.
J Pharm Technol 2010;26:107-110.
Background: Deracoxib and firocoxib are cyclooxygenase-2 inhibitors approved for veterinary use, but not for use in humans. Information on the outcome of human ingestions of these drugs is not readily available. Objective: To describe human ingestions of cyclooxygenase-2 inhibitors reported to poison centers. Methods: All human ingestions of deracoxib and firocoxib reported to Texas poison centers during 2003–2009 were identified, and the distribution of ingestions by demographic and clinical factors was determined. Final medical outcome was determined by poison center staff, based on adverse clinical effects that are observed or expected. Results: Of 72 total ingestions, 56.9% involved deracoxib and 43.1% involved firocoxib. One tablet or less was ingested in 87.7% of cases in which the number of tablets was known. The patients were 62.5% female, 51.4% aged 0–5 years, 6.9% aged 6–19 years, and 41.7% aged 20 years or more. The patient was managed on site in 94.4% of the cases. The distribution of cases by final medical outcome was 44.4% no effect, 18.1% not followed but judged nontoxic, 34.7% not followed but minimal effects possible, and 2.8% effects probably not related to the ingestion. Conclusions: Human ingestions of deracoxib and firocoxib reported to Texas poison centers were relatively uncommon. Such ingestions usually involved 1 tablet or less. Cases followed to known outcome did not result in serious outcomes and were frequently managed on site.

Coding of Influenza A H1N1 Virus Calls Received by Texas Poison Centers.
Forrester MB, Jaramillo JE.
Clin Toxicol (Phila) 2010;48:359-364.
Context. The utilization of poison center data for research and surveillance depends on the complete and accurate coding of the data. Objective. The intent of this study was to describe the coding that Texas poison centers used to identify calls relating to the recent H1N1 outbreak and the extent to which the coding accurately identified the calls. Methods. Cases were all H1N1 calls added to the six Texas poison centers' common database during April 28-September 30, 2009. Cases were selected by identifying all records that had the required H1N1 code or text in the FreeArea1, Substance Verbatim, or PoisIndex code fields or had the terms "swine" or "H1N1" anywhere within the Notes field. The proportion of fields that were coded correctly was determined for each field alone and all three combined and for each of the six poison centers and by 2-month period. Results. Of the 222 H1N1 calls identified, the FreeArea1 field was coded correctly in 67.1% cases, Substance Verbatim field in 73.9%, PoisIndex code field in 73.9%, all three fields together in 45.9%, and none of the three fields in 9.0%. Correct coding of all three fields ranged from 29.7 to 65.5% between the poison centers. All three fields were coded correctly in 49.7% of the April-May calls, 38.5% of June-July calls, and 29.6% of the August-September calls. Discussion. All three of the fields were coded correctly in less than half of the H1N1 calls; however, at least one of the fields was useful in identifying 91% of the calls. Correct coding rates varied widely between the poison centers and declined over time. Conclusions. Use of three different fields to code H1N1 calls identified the majority of such calls received. However, dependence on a single field would have missed a number of calls.

Overweight among Low-Income Texas Preschoolers Aged 2 to 4 Years.
Lewis KL, Castrucci BC, Gossman G, Mirchandani G, Sayegh MA, Moehlman C, Van Eck M, Petrilli K.
J Nutr Educ Behav. 2010 May-Jun;42(3):178-84.
Objective: Determine child/maternal factors associated with overweight among 2- to 4-year-olds enrolled in the Texas Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Design: Matched child and maternal data collected by self-report of the mother during WIC certification. These data were extracted from existing statewide WIC databases and merged. Setting: Texas WIC children aged 2 to 4 years in April 2006. Participants: Final sample was 22,837 mother-child dyads. Main Outcome Measure: Dependent variable--child overweight; independent variables: Child-related--gender, age, race/ethnicity, Medicaid status, living area, and dental problems; Maternal-related--certification status, age, times certified, overweight, high maternal weight gain, and gestational diabetes. Analysis: Bivariate relationships at P < .05 were included in the logistic regression. Results: Living in a nonborder urban area associated with greater odds of overweight compared to living in a border area. Mother's overweight, high gestational weight gain, and gestational diabetes associated with greater odds of child overweight. Conclusions and Implications: Several child- and maternal-related factors were found to be associated with overweight in Texas WIC preschoolers. Health interventions should target 4-year-old Hispanic children living in nonborder urban areas and mothers who are overweight, have high gestational weight gain, or have gestational diabetes.

La Crosse Virus in Aedes Albopictus Mosquitoes, Texas, USA, 2009.
Lambert AJ, Blair CD, D'Anton M, Ewing W, Harborth M, Seiferth R, Xiang J, Lanciotti RS.
Emerg Infect Dis. 2010 May;16(5):856-8.
We report the arthropod-borne pediatric encephalitic agent La Crosse virus in Aedes albopictus mosquitoes collected in Dallas County, Texas, USA, in August 2009. The presence of this virus in an invasive vector species within a region that lies outside the virus' historically recognized geographic range is of public health concern.

Compliance with Atypical Antipsychotic Triage Guidelines by Texas Poison Centers.
Forrester MB
J Med Toxicol 2010;6:403-7.
Triage guidelines for poison center management of atypical antipsychotic ingestions were published in December 2007. This investigation determined whether Texas poison centers already complied with a simplified version of these guidelines. All acute aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone ingestions reported to Texas poison centers during 2000-2007 were identified. Exclusion criteria were the presence of coingestants, patient already at or en route to a health-care facility when the poison center was contacted, and chronic ingestion. Each case was evaluated whether it was managed in compliance with the simplified triage guidelines and the compliance rate calculated. For 2,611 total cases, the compliance rate was 64.1%. The rate was 71.7% for aripiprazole, 43.6% for clozapine, 71.6% for olanzapine, 60.8% for quetiapine, 65.5% for risperidone, and 59.0% for ziprasidone. The majority of acute atypical antipsychotic ingestions reported to Texas poison centers were managed according to a simplified version of recommended triage algorithm.

Pandemic 2009 Influenza A(H1N1) Virus Illness among Pregnant Women in the United States.
Siston AM, Rasmussen SA, Honein MA, Fry AM, Seib K, Callaghan WM, Louie J, Doyle TJ, Crockett M, Lynfield R, Moore Z, Wiedeman C, Anand M, Tabony L, Nielsen CF, Waller K, Page S, Thompson JM, Avery C, Springs CB, Jones T, Williams JL, Newsome K, Finelli L, Jamieson DJ; Pandemic H1N1 Influenza in Pregnancy Working Group.
JAMA. 2010 Apr 21;303(15):1517-25.
Context: Early data on pandemic 2009 influenza A(H1N1) suggest pregnant women are at increased risk of hospitalization and death. Objective: To describe the severity of 2009 influenza A(H1N1) illness and the association with early antiviral treatment among pregnant women in the United States. Design, Setting, and Patients: Surveillance of 2009 influenza A(H1N1) in pregnant women reported to the Centers for Disease Control and Prevention (CDC) with symptom onset from April through December 2009. Main Outcome Measures: Severity of illness (hospitalizations, intensive care unit [ICU] admissions, and deaths) due to 2009 influenza A(H1N1) among pregnant women, stratified by timing of antiviral treatment and pregnancy trimester at symptom onset. Results: We received reports on 788 pregnant women in the United States with 2009 influenza A(H1N1) with symptom onset from April through August 2009. Among those, 30 died (5% of all reported 2009 influenza A[H1N1] influenza deaths in this period). Among 509 hospitalized women, 115 (22.6%) were admitted to an ICU. Pregnant women with treatment more than 4 days after symptom onset were more likely to be admitted to an ICU (56.9% vs 9.4%; relative risk [RR], 6.0; 95% confidence interval [CI], 3.5-10.6) than those treated within 2 days after symptom onset. Only 1 death occurred in a patient who received treatment within 2 days of symptom onset. Updating these data with the CDC's continued surveillance of ICU admissions and deaths among pregnant women with symptom onset through December 31, 2009, identified an additional 165 women for a total of 280 women who were admitted to ICUs, 56 of whom died. Among the deaths, 4 occurred in the first trimester (7.1%), 15 in the second (26.8%), and 36 in the third (64.3%); Conclusions: Pregnant women had a disproportionately high risk of mortality due to 2009 influenza A(H1N1). Among pregnant women with 2009 influenza A(H1N1) influenza reported to the CDC, early antiviral treatment appeared to be associated with fewer admissions to an ICU and fewer deaths.

Obesity and Mortality in Persons with Obstructive Lung Disease Using Data from the NHANES III.
Jordan JG Jr, Mann JR.
South Med J. 2010 Apr;103(4):323-30.
Objectives: The objective of this study was to determine the relationship between obesity and all-cause mortality among participants with obstructive lung disease in the National Health and Nutrition Examination Survey (NHANES III). Methods: Public data from a retrospective cohort of the 33,994 participants in NHANES III was analyzed to determine the relationship between obesity and all-cause mortality among participants with obstructive lung disease. Results were analyzed using proportional hazard models and controlled for age, sex, race, smoking status, current oral corticosteroid use, and severity of airway obstruction. Secondary analysis considered time until death from respiratory disease or time until death from chronic lower respiratory disease (excluding asthma). Results: The subset used in the analysis consisted of 2439 persons with 844 documented deaths. Extreme obesity (body mass index [BMI] >40) was significantly associated with increased respiratory disease mortality (hazard ratio [HR] 5.78; 95% confidence interval {CI} [1.09 to 30.61]) and chronic lower respiratory disease mortality (HR 13.69; 95% CI [1.45 to 129.29]). In addition, underweight status (BMI <18.5) was significantly associated with increased all-cause mortality (HR 2.42; 95% CI [1.31 to 4.46]), respiratory disease mortality (HR 7.10; 95% CI [1.94 to 26.00]) and chronic lower respiratory disease mortality (HR 14.80; 95% CI [2.24 to 97.99]). Conclusion: Underweight adults had increased risk of death from all causes and respiratory conditions, compared to class I obese adults. Extreme obesity was associated with increased risk of death from respiratory conditions, but not all-cause mortality. Additional research is needed to explain the complex relationship between BMI and specific causes of mortality in the context of pulmonary disease.

Health-Related Outcomes of Adverse Childhood Experiences in Texas, 2002.
Dube SR, Cook ML, Edwards VJ.
Prev Chronic Dis 2010;7(3):A52.
Introduction: We assessed the prevalence of 7 childhood adversities (psychological, physical, and sexual abuse; household mental illness; household substance abuse; maternal battery; and incarceration of a household member) and the associations of those adversities with health outcomes. Methods: Using data from 5,378 people who responded to the 2002 Texas Behavioral Risk Factor Surveillance System survey (which included questions about childhood adversity), we created 4 groups: no childhood abuse or household dysfunction, childhood abuse only, household dysfunction only, and both childhood abuse and household dysfunction. We examined groups by sociodemographic variables and the association with current smoking, obesity, and self-rated health. Results: Among adult respondents, 46% reported at least 1 childhood adversity. Reports of both household dysfunction and abuse were significantly lower for college graduates than for people with less education. For those with both abuse and household dysfunction, the odds of current smoking were 1.9 and for obesity were 1.3. Compared to people without childhood adversities, people who experienced childhood adversities more frequently reported having fair or poor general health status. Conclusion: Childhood adversities are common among Texas adults. People with childhood adversities are more likely to be socioeconomically disadvantaged, less educated, and have difficulties maintaining employment in adulthood compared to people with no adversities. Moreover, childhood adversities appear to be associated with health problems such as current smoking, obesity, and poor or fair general health among Texas adults.

Breast-feeding Attitudes and Behavior among WIC Mothers in Texas.
Vaaler ML, Stagg J, Parks SE, Erickson T, Castrucci BC.
J Nutr Educ Behav. 2010;42:S30-S38.
Objective: This study explored the influence of demographic characteristics on attitudes toward the benefits of breast-feeding, approval of public breast-feeding, and the use of infant formula. Additionally, the study examined whether attitudes were related to infant feeding practices among mothers enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Texas. Design: This study used a cross-sectional design. Setting: Participants completed questionnaires at WIC clinic sites across Texas. Participants: Mothers of young children who were receiving WIC benefits. Main Outcome Measure(s): Attitudes toward the benefits of breast-feeding, attitudes toward public breast-feeding, attitudes toward infant formula, and the choice of infant feeding practice. Analysis: Descriptive statistics, multivariate ordinary least squares regression, and multinomial logistic regression. Results: A key finding was that many Hispanic mothers held favorable attitudes toward both breast milk and infant formula. Younger and less educated mothers were least likely to agree with the benefits of breast-feeding. Mothers with positive attitudes toward the benefits of breast-feeding were likely to exclusively breastfeed and use both formula and breast milk. Conclusions and Implications: Attitudes toward breast-feeding, public breast-feeding, and infant formula and their influence on breast-feeding behavior should inform the curriculum of breast-feeding promotion programs.

Borrelia, Ehrlichia, and Rickettsia spp. in Ticks Removed from Persons, Texas, USA.
Williamson PC, Billingsley PM, Teltow GJ, Seals JP, Turnbough MA, Atkinson SF.
Emerg Infect Dis. 2010 Mar;16(3):441-6.
Data regarding the type, frequency, and distribution of tick-borne pathogens and bacterial agents are not widely available for many tick species that parasitize persons in the southern United States. We therefore analyzed the frequency and identity of pathogens and bacterial agents in ticks removed from humans and subsequently submitted to the Texas Department of State Health Services, Zoonosis Control Program, from October 1, 2004, through September 30, 2008. The data showed associations of bacterial agents and potential vectors. Tick-related illnesses may pose unidentified health risks in areas such as Texas, where incidence of human disease related to tick bites is low but well above zero and where ticks are not routinely suspected as the cause of disease. Cause, treatment, and prevention strategies can be better addressed through collecting sufficient data to establish baseline assessments of risk.

Association of Paternal Age and Risk for Major Congenital Anomalies From the National Birth Defects Prevention Study, 1997 to 2004.
Green RF, Devine O, Crider KS, Olney RS, Archer N, Olshan AF, Shapira SK; The National Birth Defects Prevention Study.
Ann Epidemiol. March;20(3):241-9.
Purpose: The objective of this study was to examine the associations between paternal age and birth defects of unknown etiologies while carefully controlling for maternal age. Methods: By using 1997 to 2004 data from the National Birth Defects Prevention Study, we fit logistic regression models with paternal and maternal age as continuous variables while adjusting for demographic and other factors. Results: Elevated odds ratios (ORs) for each year increase in paternal age were found for cleft palate (OR. 1.02, 95% confidence interval [95% CI], 1.00-1.04), diaphragmatic hernia (OR, 1.04; 95% CI, 1.02-1.06), right ventricular outflow tract obstruction (OR, 1.03; 95% CI, 1.01-1.04), and pulmonary valve stenosis (OR, 1.02, 95% CI, 1.01-1.04). At younger paternal ages, each year increase in paternal age correlated with increased odds of having offspring with encephalocele, cataract, esophageal atresia, anomalous pulmonary venous return, and coarctation of the aorta, but these increased odds were not observed at older paternal ages. The effect of paternal age was modified by maternal age for gastroschisis, omphalocele, spina bifida, all orofacial clefts, and septal heart defects. Conclusions: Our findings suggest that paternal age may be a risk factor for some multifactorial birth defects.

Differences in Exposure Assignment between Conception and Delivery: The Impact of Maternal Mobility.
Lupo PJ, Symanski E, Chan W, Mitchell LE, Waller DK, Canfield MA, Langlois PH.
Paediatr Perinat Epidemiol. 2010 Mar;24(2):200-8.
In studies of reproductive outcomes, maternal residence at delivery is often the only information available to characterise environmental exposures during pregnancy. The goal of this investigation was to describe residential mobility during pregnancy and to assess the extent to which change of residence may result in exposure misclassification when exposure is based on the address at delivery. Maternal residential mobility was compared between neural tube defect cases and unaffected controls from Texas participants in the National Birth Defects Prevention Study (NBDPS). Maternal residential information was obtained from the NBDPS interview. Data from the U.S. EPA National Air Toxics Assessment [Assessment System for Population Exposure Nationwide (ASPEN)], modelled at the census tract level, were used to estimate benzene exposure based on address at conception and address at delivery. Quartiles of exposure were assigned based on these estimates and the quartile assignments based on address at conception and address at delivery were compared using traditional methods (kappa statistics) and a novel application of mixed-effects ordinal logistic regression. Overall, 30% of case mothers and 24% of control mothers moved during pregnancy. Differences in maternal residential mobility were not significant between cases and controls, other than case mothers who moved did so earlier during pregnancy than control mothers (P = 0.01). There was good agreement between quartiles of estimated benzene exposure at both addresses (kappa = 0.78, P < 0.0001). Based on the mixed-effects regression model, address at delivery was not significantly different from using address at conception when assigning quartile of benzene exposure based on estimates from ASPEN (odds ratio 1.03, 95% confidence interval 0.85, 1.25). Our results indicate that, in this Texas population, maternal residential movement is generally within short distances, is typically not different between cases and controls, and does not significantly influence benzene exposure assessment.

Gastroschisis Prevalence in Texas 1999-2003.
Benjamin BG, Ethen MK, Van Hook CL, Myers CA, Canfield MA.
Birth Defects Res A Clin Mol Teratol.
2010 Mar;88(3):178-85
Background: The worldwide prevalence of gastroschisis is increasing. Maternal age, race/ethnicity, and place of residence have been associated with increased risk. Methods: We obtained descriptive characteristics of mothers of infants with gastroschisis and mothers of all live births from the Texas Birth Defects Registry and Texas vital records for 1999-2003. We calculated prevalence, crude prevalence ratios, and prevalence ratios adjusted for maternal age, parity, education, race/ethnicity, and geographic entity (Mexican border proximity, urban/rural residence, health service region, and county). Results: We observed 764 cases of gastroschisis among 1,827,317 live births, for a prevalence of 4.18 per 10,000 births (95% confidence interval 3.88-4.48). Prevalence increased during 1999-2003 (p for trend <0.02). Infants of young and nulliparous mothers were at greatest risk in crude analyses. Other characteristics associated with increased risk were 12 or fewer years of education, border residence, and Hispanic ethnicity. Black mothers were at lower risk. When adjusted for maternal age, race/ethnicity, education, parity, and residence, we found that border residence, educational level, and Hispanic race/ethnicity were no longer significant, but young mothers and nulliparous mothers remained at higher risk, and blacks at reduced risk. Differences in prevalence observed between regions and counties largely disappeared when adjusted for maternal factors. No significant difference between urban and rural residence was found. Conclusion: The prevalence of gastroschisis increased in Texas during 1999-2003. Black mothers were at lower risk, and Hispanic mothers were at no greater risk than whites. No differences were found between urban/rural or border/nonborder residents.

Maternal Fever during Early Pregnancy and the Risk of Oral Clefts.
Hashmi SS. Gallaway MS, Waller DK, Langlois PH, Hecht JT, The National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2010 Mar;88(3):186-94.
An increased risk of birth defects after hyperthermic exposures has been confirmed in animal studies, but population studies have yielded inconsistent results. Oral clefts are a common birth defect and have been associated with these exposures in some of these studies. In this study, data from the National Birth Defects Prevention Study was used to evaluate the association of maternal report of febrile illness in early pregnancy and the risk of oral clefts. All oral cleft cases born between 1997 and 2004 were compared with nonmalformed controls born in the same geographical region during the same time period. Mothers reporting febrile illness during pregnancy were stratified by fever grade and antipyretic use. Logistic regression models were used to generate crude and adjusted odds ratios for exposure to fever and association with each oral cleft phenotype. The dataset included 5821 controls, 1567 cases of cleft lip with or without cleft palate (CL+/-P) and 835 cases of cleft palate only. A modestly increased risk was observed for isolated CL+/-P (odds ratio, 1.28; 95% confidence interval, 1.01-1.63). Stratification by fever grade (body temperature <101.5° or 101.5°F) did not yield significant differences in risk. Risk estimates were higher among women who reported a fever, but did not take antipyretics to control their fever, particularly for nonisolated compared with isolated oral clefts. This finding suggests that adequate control of fever may diminish the deleterious effects of fever in cases of oral cleft.

Murine Typhus in Austin, Texas, USA, 2008.
Adjemian J, Parks S, McElroy K, Campbell J, Eremeeva ME, Nicholson WL, McQuiston J, Taylor J.
Emerg Infect Dis. 2010 Mar;16(3):412-7.
In August 2008, Texas authorities and the Centers for Disease Control and Prevention investigated reports of increased numbers of febrile rash illnesses in Austin to confirm the causative agent as Rickettsia typhi, to assess the outbreak magnitude and illness severity, and to identify potential animal reservoirs and peridomestic factors that may have contributed to disease emergence. Thirty-three human cases of confirmed murine typhus were identified. Illness onset was reported from March to October. No patients died, but 23 (70%) were hospitalized. The case-patients clustered geographically in central Austin; 12 (36%) resided in a single ZIP code area. Specimens from wildlife and domestic animals near case-patient homes were assessed; 18% of cats, 44% of dogs, and 71% of opossums had antibodies reactive to R. typhi. No evidence of R. typhi was detected in the whole blood, tissue, or arthropod specimens tested. These findings suggest that an R. typhi cycle involving opossums and domestic animals may be present in Austin.

Borrelia, Ehrlichia, and Rickettsia spp. in Ticks Removed from Persons, Texas, USA.
Williamson PC, Billingsley PM, Teltow GJ, Seals JP, Turnbough MA, Atkinson SF.
Emerg Infect Dis. 2010 Mar;16(3):441-6.
Data regarding the type, frequency, and distribution of tick-borne pathogens and bacterial agents are not widely available for many tick species that parasitize persons in the southern United States. We therefore analyzed the frequency and identity of pathogens and bacterial agents in ticks removed from humans and subsequently submitted to the Texas Department of State Health Services, Zoonosis Control Program, from October 1, 2004, through September 30, 2008. The data showed associations of bacterial agents and potential vectors. Tick-related illnesses may pose unidentified health risks in areas such as Texas, where incidence of human disease related to tick bites is low but well above zero and where ticks are not routinely suspected as the cause of disease. Cause, treatment, and prevention strategies can be better addressed through collecting sufficient data to establish baseline assessments of risk.

Occurrence of Conotruncal Heart Birth Defects in Texas: A Comparison of Urban/Rural Classifications.
Langlois PH, Jandle L, Scheuerle A, Horel SA, Carozza SE.
J Rural Health. 2010 Mar;26(2):164-74.
Purpose: (1) Determine if there is an association between 3 conotruncal heart birth defects and urban/rural residence of mother. (2) Compare results using different methods of measuring urban/rural status. Methods: Data were taken from the Texas Birth Defects Registry, 1999-2003. Poisson regression was used to compare crude and adjusted birth prevalence. Findings: Based on residences of births in Texas, the values for urban influence code (UIC), rural urban continuum code (RUCC), and rural urban commuting area (RUCA) were highly correlated with each other and, less highly, to percentage of land in crops. For tetralogy of Fallot, the most rural category consistently showed the highest prevalence ratio for all measures. The adjusted prevalence ratio for highest percentage cropland was 1.73 [95% CI, 1.14-2.51] using natural breaks and 1.42 [95% CI, 1.07-1.86] using quartiles. The trend with cropland percentage was significant (P < .03), whether crude or adjusted. The crude trend was also significant using RUCC. Neither truncus arteriosus nor transposition of the great arteries exhibited consistent associations with urban or rural residence. Conclusions: The urban/rural measures were generally correlated with each other; as a broad measure, RUCA has advantages for many health studies. Tetralogy of Fallot was most prevalent in rural areas; that pattern was strongest using percentage of land in crops.

Use of Oral Contraceptives in Pregnancy and Major Structural Birth Defects in Offspring.
Waller DK, Gallaway MS, Taylor LG, Ramadhani TA, Canfield MA, Scheuerle A, Hernández-Diaz S, Louik C, Correa A; the National Birth Defects Prevention Study.
Epidemiology. 2010 Mar;21(2):232-9
Background: Oral contraceptives (OCs) are the most commonly used reversible contraceptive method among US women. Although the majority of previous studies have reported no association between OC use during pregnancy and birth defects, some studies have reported increased occurrence of neural tube defects, limb reduction defects, and urinary tract anomalies. Methods: We assessed OC use among mothers who participated in the multisite, case-control, National Birth Defects Prevention Study. Mothers of 9986 infants with 32 types of birth defects and 4000 infants without birth defects were included. Results: Maternal OC use during the first 3 months of pregnancy was associated with an increased odds ratio for 2 of 32 birth defects: hypoplastic left heart syndrome (adjusted odds ratio = 2.3 [95% confidence interval = 1.3-4.3) and gastroschisis (1.8 [1.3-2.7]). Conclusion: Previous reports of associations between OC use and specific types of anomalies were not corroborated. Given that associations were assessed for 32 types of birth defects, our findings of 2 increased associations between OC use and gastroschisis and hypoplastic left heart syndrome should be interpreted as hypotheses until they can be evaluated further. Overall, our findings are consistent with the majority of previous studies that found women who use OCs during early pregnancy have no increased risk for most types of major congenital malformations.

Shortage of Child and Adolescent Psychiatrists in Texas.
Becker EA, King B, Shafer A, Thomas CR.
Texas Medicine. 2010 March;106(3).
This study was conducted to determine how the current shortage of Texas child and adolescent psychiatrists (CAPs) impacts the delivery of mental health care services to indigent Texas youth. First, Texas Medical Board data detailed how many counties had CAPs and how many did not. Second, statewide Medicaid data revealed the number of prescriptions for psychotropics written for Medicaid youth by CAPs and non-CAPS. Third, Local Mental Health Authority (LMHA) encounter data of youth seen by a CAP were analyzed. Fourth, state census data gave the location and characteristics of youth by county. Eighty percent of counties in Texas, predominantly rural, do not have a CAP. Non-CAPs wrote 66% of psychotropic medication prescriptions written for Medicaid youth. Those in nonmetropolitan areas were more likely to see a non-CAP than were Medicaid youth in metropolitan areas. For youth seen by an LMHA, those in rural poor counties were less likely to see a CAP than were those in urban counties. The shortage of CAPs in Texas results in an unequal distribution of psychiatric care for those receiving Medicaid prescriptions or services through LMHAs, especially in rural areas. Suggestions to correct this shortage are made.

Falls among Older Adults in Texas : Profile from 2007 Hospital Discharge Data.
Smith ML, Ory MG, Beasley C, Johnson KN, Wernicke MM, Parrish R.
Texas Public Health Journal. 2010 Winter;62(1):7-13.
In 2006, approximately 1.8 million American seniors sustained a non-fatal injury fall and over 16,600 died from fall-related trauma. The purposes of this study are to utilize the most currently available Texas data to: (1) document the prevalence of fall-related hospitalizations and event characteristics and (2) examine differences based on geographic dispersion and age. Population estimates and hospital discharge data from the year 2007 were obtained and analyzed for all counties and places in Texas to generate counts and prevalence rates of fall-related hospitalizations, associated injuries, and causes of fall-related events. Statewide, results showed high fall-related hospitalization prevalence rates among females (313 per 100,000), non-Hispanic Whites (369 per 100,000), and those age 85 years and older (5,937 per 100,000). Slips, trips, and stumbles were the most common specified cause of falls resulting in hospitalization (33%). Among those admitted to the hospital, the oldest old sustained more fractures from fall-related events (49%) of which 66% were hip fractures. Fall-related hospital charges exceeded $1.8 billion statewide for adults age 50 and older with an average hospitalization lasting approximately 6 days. Falls among the senior population in Texas are a large and important public health issue and require constant surveillance from state and local health authorities. To combat fall events and offset the associated health sequelae, there is a need to build the capacity to create and deliver evidence-based fall prevention programs statewide.

Risk Factors for Non-Syndromic Holoprosencephaly in the National Birth Defects Prevention Study.
Miller EA, Rasmussen SA, Siega-Riz AM, Frías JL, Honein MA; National Birth Defects Prevention Study.
Am J Med Genet C Semin Med Genet. 2010 Feb 15;154C(1):62-72.
Holoprosencephaly (HPE) is a complex structural brain anomaly that results from incomplete cleavage of the forebrain. The prevalence of HPE at birth is low, and risk factors have been difficult to identify. Using data from a large multi-state population-based case-control study, we examined risk factors for non-syndromic HPE. Data from maternal telephone interviews were available for 74 infants with HPE and 5871 controls born between 1997 and 2004. Several characteristics and exposures were examined, including pregnancy history, medical history, maternal diet and use of nutritional supplements, medications, tobacco, alcohol, and illegal substances. We used chi(2)-tests and logistic regression (excluding women with pre-existing diabetes) to examine associations with HPE. Except for diet (year before pregnancy) and sexually transmitted infections (STIs) (throughout pregnancy), most exposures were examined for the time period from the month before to the third month of pregnancy. HPE was found to be associated with pre-existing diabetes (chi(2) = 6.0; P = 0.01), aspirin use [adjusted odds ratio (aOR) = 3.4; 95% confidence interval (CI) 1.6-6.9], lower education level (aOR = 2.5; 95%CI 1.1-5.6), and use of assisted reproductive technologies (ART) (crude OR = 4.2; 95%CI 1.3-13.7). Consistent maternal folic acid use appeared to be protective (aOR = 0.4; 95%CI 0.2-1.0), but the association was of borderline statistical significance. While some of these findings support previous observations, other potential risk factors identified warrant further study.

A Focus on Asthma and Individual Health Plans: A Survey of Texas Schools.
Zuniga GC, Kirk S, Hernandez T.
Journal of Asthma & Allergy Educators. 2010;1(1):23-7.
A survey was conducted to assess asthma and the implementation of individual health plans for asthma (IHPA), also known as asthma action plans, in Texas schools. Most of the respondents (91.7%) were school nurses. Forty-four percent of respondents indicated that their school district maintained a written policy requiring implementation of IHPA for students with asthma, while 61.5% implemented IHPA for students with asthma. More than 93% of respondents from school districts with written policies indicated that IHPA were implemented for students with asthma. However, only 36.6% of respondents from school districts without written policies indicated that IHPA were implemented. More than 38% of respondents indicated that asthma education was not provided at their school. Texas schools should be encouraged to adopt written policies requiring implementation of IHPA for all students with asthma, and school nurses should be encouraged to implement asthma education in their schools.

Maternal Characteristics Associated with the Dietary Intake of Nitrates, Nitrites, and Nitrosamines in Women of Child-Bearing Age: A Cross-Sectional Study.
Griesenbeck JS, Brender JD, Sharkey JR, Steck MD, Huber JC Jr, Rene AA, McDonald TJ, Romitti PA, Canfield MA, Langlois PH, Suarez L; National Birth Defects Prevention Study.
Environ Health. 2010 Feb 19;9:10-26.
Background: Multiple N-nitroso compounds have been observed in animal studies to be both mutagenic and teratogenic. Human exposure to N-nitroso compounds and their precursors, nitrates and nitrites, can occur through exogenous sources, such as diet, drinking water, occupation, or environmental exposures, and through endogenous exposures resulting from the formation of N-nitroso compounds in the body. Very little information is available on intake of nitrates, nitrites, and nitrosamines and factors related to increased consumption of these compounds. Methods: Using survey and dietary intake information from control women (with deliveries of live births without major congenital malformations during 1997-2004) who participated in the National Birth Defects Prevention Study (NBDPS), we examined the relation between various maternal characteristics and intake of nitrates, nitrites, and nitrosamines from dietary sources. Estimated intake of these compounds was obtained from the Willet Food Frequency Questionnaire as adapted for the NBDPS. Multinomial logistic regression models were used to estimate odds ratios and 95% confidence intervals for the consumption of these compounds by self-reported race/ethnicity and other maternal characteristics. Results: Median intake per day for nitrates, nitrites, total nitrites (nitrites + 5% nitrates), and nitrosamines was estimated at 40.48 mg, 1.53 mg, 3.69 mg, and 0.472 μg respectively. With the lowest quartile of intake as the referent category and controlling for daily caloric intake, factors predicting intake of these compounds included maternal race/ethnicity, education, body mass index, household income, area of residence, folate intake, and percent of daily calories from dietary fat. Non-Hispanic White participants were less likely to consume nitrates, nitrites, and total nitrites per day, but more likely to consume dietary nitrosamines than other participants that participated in the NBDPS. Primary food sources of these compounds also varied by maternal race/ethnicity. Conclusions: Results of this study indicate that intake of nitrates, nitrites, and nitrosamines vary considerably by race/ethnicity, education, body mass index, and other characteristics. Further research is needed regarding how consumption of foods high in nitrosamines and N-nitroso precursors might relate to risk of adverse pregnancy outcomes and chronic diseases.

Mortality in First 5 Years in Infants with Functional Single Ventricle Born in Texas, 1996 to 2003.
Fixler DE, Nembhard WN, Salemi JL, Ethen MK, Canfield MA.
Circulation. 2010 Feb 9;121(5):644-50.
Background: Infants with functional single ventricle have a high risk of death during the early years of life. Studies have reported improvement in postoperative survival, but they do not include preoperative deaths or those occurring before transfer. The purpose of this population-based study was to estimate 5-year survival in infants with functional single ventricle, to define factors associated with survival, and to estimate improvement in outcome. Methods and Results: Patients with hypoplastic left heart syndrome, pulmonary atresia intact ventricular septum, single ventricle, and tricuspid atresia born in 1996 to 2003 were identified from the Texas Birth Defects Registry and linked to state and national birth and death vital records. We examined the effects of defect type, birth era, birth weight, gestational age, maternal race/ethnicity, extracardiac anomalies, sex, and maternal age and education on survival. Five-year survival varied by defect type: hypoplastic left heart syndrome, 38.0% (95% confidence interval, 32.6 to 43.5); single ventricle, 56.1% (95% confidence interval, 49.9 to 61.7); pulmonary atresia intact ventricular septum, 55.7% (95% confidence interval, 45.8 to 64.4); and tricuspid atresia, 74.6% (95% confidence interval, 62.4 to 83.4). The presence of extracardiac defects increased the adjusted risk of death by 84%. Non-Hispanic blacks had an adjusted risk of death that was 41% higher than that for non-Hispanic whites, and Hispanics had a 26% higher risk. Patients born in 2001 to 2003 had a 47% lower risk than those born in 1996 to 2000. Conclusions: This population-based study demonstrates significant improvement in overall 5-year survival, particularly in cases of hypoplastic left heart syndrome and single ventricle. Additional studies are needed to determine the factors causing racial/ethnic and regional differences in outcome.

Public Health Security for Mass Gatherings.
Clements B.
DomPrep Journal. 2010 Jan;6(1):24,26.

Impact of ENHANCE Study on Lipid-Lowering Agent Exposures Reported to Texas Poison Centers.
Forrester MB.
Texas Public Health Journal. 2010;62(2):19-21.
In January 2008, the early release of the results of the ENHANCE study indicated that ezetimibe in combination with simvastatin was comparable to simvastatin alone in the reduction of atherosclerosis. The objective of this study was to determine whether the ENHANCE study affected the reporting of lipid-lowering agent exposures to poison centers. Exposures to lipid-lowering agents (bile acid sequestrants, ezetimibe, fibrates, and statins) reported to Texas poison centers during 2007-2008 were identified. The number of exposures for various groups of lipid-lowering agents was determined for six-month periods and the relative change between different time periods compared. The number of exposures during July-December 2007 and July-December 2008, respectively, were 447 and 482 (+8%) for total lipid-lowering agents, 223 and 235 (+5%) for statins excluding simvastatin, and 161 and 179 (+11%) for simvastatin, and 83 and 48 (-42%) for ezetimibe. The release of the ENHANCE study results appears to have affected the reporting of ezetimibe, but not statins and lipid-lowering agents in general, to Texas poison centers. Thus, poison centers may be useful for evaluating the utility of public health recommendations in changing healthcare practices.

Poisoning among the Elderly.
Forrester MB.
Texas Public Health Journal. 2010;62(2):42-43.
[No abstract available.]

Adult Metaxalone Ingestions Reported to Texas Poison Control Centers, 2000-2006.
Forrester MB.
Hum Exp Toxicol 2010;29:55-62.
Few data exist on potentially adverse metaxalone (Skelaxin(R)) ingestions in adults. All metaxalone ingestions involving patients aged >/=20 years during 2000-2006 were retrieved from Texas poison control centers. Exclusion criteria were lack of follow-up or multiple substance ingestion. Cases were analyzed for selected demographic and clinical factors. Of the 142 patients, 66.2% were female. Dose ingested was reported for 61 patients. Of those cases with a reported dose, distribution by management site was 29.5% on-site, 59.0% already at/en route to health care facility, and 11.5% referred to health care facility. Final medical outcome was 'no effect' for 50.8% cases, 'minor effect' for 31.1%, and 'moderate effect' for 18.0%. The more common adverse clinical effects reported were drowsiness (27.9%), tachycardia (6.6%), agitation (6.6%), nausea (4.9%), dizziness (4.9%), slurred speech (4.9%), and tremor (4.9%). A moderate medical outcome occurred in 13.6% of ingestions of </=2400 mg and 20.5% of ingestions of >2400 mg. Management involved a health care facility in 18.2% of ingestions of </=2400 mg and 100.0% of ingestions of >2400 mg. This study found that adult ingestions of higher doses of metaxalone, particularly >2400 mg, were associated with more serious medical outcomes and were managed at health care facilities. This study also proposes triage guidelines for when ingestions can be safely managed at home.

Pattern of Oseltamivir Ingestions Reported to Texas Poison Centers.
Forrester MB.
Hum Exp Toxicol 2010;29:137-140.
Abstract: During serious influenza outbreaks, the number of oseltamivir exposures reported to poison centers might be expected to increase. This investigation describes the pattern of oseltamivir ingestions reported to Texas poison centers during 2000–2008. Of 298 total ingestions, 91.9% occurred in December–March, 76.8% involved patients aged 0–19 years, 72.5% resulted from therapeutic error, 90.0% were managed on-site, and 80.0% had no effect. The most frequently reported adverse clinical effects were vomiting (7.5%), nausea (3.8%), and abdominal pain (3.8%). Oseltamivir ingestions were reported to Texas poison centers primarily during periods of influenza outbreak. Most involved children, resulted from therapeutic error, and were managed on-site without serious outcome.

Pediatric Metaxalone Ingestions Reported to Texas Poison Control Centers, 2000-2007.
Forrester MB.
Pediatr Emerg Care 2010;26:15-18.
Objectives: The purpose of this study was to describe the pattern of metaxalone ingestions by young children reported to poison control centers. Methods: Cases were all metaxalone ingestions by patients aged 0 to 5 years reported to Texas poison control centers during 2000 to 2007. Cases with multiple substance ingestions and lack of follow-up were excluded. Cases were analyzed for selected demographic and clinical factors. Results: Of 148 total cases, 56.8% were boys. The distributions by management site were 56.1% on-site, 22.3% already at/en route to a health care facility, and 21.6% referred to a health care facility. Final medical outcomes were no effect for 90.5% cases, minor effect for 8.1%, moderate effect for 0.7%, and major effect for 0.7%. Specific clinical effects reported were drowsiness (11), vomiting (3), agitation (2), rash (1%), tachycardia (1), and ataxia (1). Conclusions: Pediatric metaxalone ingestions reported to Texas poison control centers usually resulted in minor or no effect. Most ingestions did not require hospitalization.

Teen Pregnancy in Texas: 2005 to 2015.
Sayegh MA, Castrucci BC, Lewis K, Hobbs-Lopez A.
Matern Child Health J.2010 Jan;14(1):94-101.
Objectives: Texas birth records and population projections were used to simulate pregnancy rates among women ages 15-19 years from 2005 to 2015. Methods: Monte Carlo simulation based on historical rates of natural increase, contraceptive failure and sexual experience among racial/ethnic groups of teenaged women was used for numerical projections. These projections were used in a systems dynamics model which posits teen pregnancy risk as a stochastic process of contraceptive failure and sexual activity. The PRI was constructed as a logistic function of sexual experience, the weighted average contraceptive failure rates and time-varying probabilities of natural increase among racial/ethnic sub-groups of adolescent women. Results: From 2005 to 2015, the number of adolescent, Hispanic females in Texas is expected to increase by 45%. During this same period, the expected pregnancy risk for 15 to 19 year old females is expected to increase to 13% or 127 per 1,000 women. This increase is due largely to the rise in the pregnancy risk among the growing population of Hispanic adolescents. Conclusions: Changing population characteristics in Texas and differences in sexual activity and contraceptive failure among racial/ethnic groups indicate that teenage pregnancy will not continue to decline in the coming decade. The adolescents most at risk for pregnancy are expected to increase significantly. Pregnancy prevention programs need to be intensified and adapted to the changing Texas social climate in order to preempt dramatic increases in teenage pregnancy.

Fetal Trisomy 21 and the Risk of Preeclampsia.
Defant J, Gambello MJ, Monga M, Langlois PH, Noblin SJ, Vidaeff AC.
J Matern Fetal Neonatal Med. 2010 Jan;23(1):55-9.
Objective. Microchimerism has been investigated as a possible contributor to the pathophysiology of preeclampsia. Although trisomy 21 is associated with pronounced microchimerism, it has not been connected with an increased risk of preeclampsia. Our objective was to readdress the relationship between preeclampsia and trisomy 21 in a large population. Methods. Using the Texas Birth Defects Registry for 1999-2003, a cohort of 2995 pregnancies with a trisomy 21 fetus was identified and compared with a control cohort of 1959 pregnancies with fetal isolated oral clefts. Chi-square test was used to estimate the significance of observed difference in the proportion of preeclampsia between groups. The interactive and confounding effects of covariates were examined by stratified analysis and the Mantel-Haenszel method. Results. We observed 84 cases of preeclampsia in the trisomy 21 cohort (3.7%) and 111 cases in the oral cleft cohort (5.7%). The crude OR for having preeclampsia in relation to trisomy 21 was 0.63 (95% CI 0.47-0.85). The OR estimates remained the same after adjustment for confounders. Conclusion. Pregnancies carrying a trisomy 21 fetus do not have an increased risk of preeclampsia. Besides epidemiologic significance, our data also have relevance for genetic counseling.

Urban-Rural Residence and the Occurrence of Cleft Lip and Cleft Palate in Texas, 1999-2003.
Messer LC, Luben TJ, Mendola P, Carozza SE, Horel SA, Langlois PH.
Ann Epidemiol. 2010 Jan;20(1):32-9
Purpose: The etiology of orofacial clefts is complex and relatively unknown. Variation in cleft lip with or without palate (CLP) and cleft palate alone (CP) was examined in Texas across urban-rural residence (1999 to 2003). Methods: Cases came from the Texas Birth Defects Registry (1,949 CLP and 1,054 CP) and denominator data came from vital records (254 counties; 1,827,317 live births). Variation in maternal residence was measured using four classification schemes: Rural Urban Continuum Codes, Urban Influence Codes, percentage of county in cropland, and Rural Urban Commuting Areas. Poisson regression was used to calculate rate ratios, adjusted for infant sex, plurality, gestational age, maternal parity, age, race/ethnicity, and education. Results: Compared to the most urban referent category, living in more rural areas was associated with an increased adjusted risk of CLP. For example, the Rural-Urban Continuum Codes demonstrated elevated risks for CLP in “thinly populated areas” compared to “metropolitan-urban areas” (adjusted prevalence ratio = 1.9; 95% confidence intervals (CI) 1.2–2.8); CP was not similarly associated. Percentage of county cropland was not consistently associated with any outcome. Conclusion: The association patterns between non-urban residence and risk of CLP, except for percentage of cropland, suggests a constellation of exposures that may differ across urban-rural residence.

Maternal Pesticide Exposure and Neural Tube Defects in Mexican Americans.
Brender JD, Felkner M, Suarez L, Canfield MA, Henry JP.
Ann Epidemiol. 2010 Jan;20(1):16-22.
Purpose: The relation between maternal pesticide exposures and neural tube defects (NTDs) in offspring was evaluated in 184 Mexican American case-women and 225 comparison women. Methods: In-person interviews solicited information about environmental and occupational exposures to pesticides during the periconceptional period. Results: With adjustment for maternal education, smoking, and folate intake, women who reported using pesticides in their homes or yards were two times more likely (95% confidence interval [CI], 1.2–3.1) to have NTD-affected pregnancies than women without these reported exposures. Case-women were also more likely to report living within 0.25 mile of cultivated fields than control-women (odds ratio [OR] 3.6; 95% CI, 1.7–7.6). As sources of pesticide exposure opportunities increased, risk of NTDs also increased. The adjusted ORs and 95% CIs for one, two, and three or more exposure sources were 1.2 (0.69–1.9), 2.3 (1.3–4.1) and 2.8 (1.2–6.3) respectively, and this positive trend was stronger for risk of anencephaly than for spina bifida. Conclusions: Self-reported pesticide exposures were associated with NTD risk in this study population, especially use of pesticides within the home and a periconceptional residence within 0.25 mile of cultivated fields.

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Last updated February 28, 2014