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DSHS Authors: 2011 Research Articles by DSHS Staff


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-diamond2011 Articles (in date order with most recent first)

Surveillance of Bleeding Disorders, Texas, 2007.
Mirchandani GG, Drake JH, Cook SL, Castrucci BC, Brown HS, Labaj CP.
Am J Prev Med. 2011 Dec;41(6 Suppl 4):S354-9.
Background: In 2007, some 1261 patients with hemophilia or other bleeding disorders were seen at federally funded hemophilia treatment centers (HTCs) in Texas. Although HTCs function as sites for passive surveillance of bleeding disorders, annual HTC visit data likely underestimate true prevalence of the disease due to the infrequent nature of healthcare utilization for this population. Purpose: The main aim of this study was to compare two alternative methods for estimating prevalence of hemophilia and to describe the challenges associated with making valid prevalence estimates. Each method utilized a separate data source, with the goal of validating one or both of the methods, compared to the gold standard of active case finding. Methods: Two data sets, one describing treatment of hemophilia in an outpatient setting at HTCs and one describing treatment and care of patients in a hospital inpatient setting, were used to calculate annual prevalence estimates of hemophilia among men in Texas in 2007. The prevalence estimates resulting from each of the two methods were compared to each other and to past estimates based on active surveillance. Results: Calculations based on HTC data resulted in estimated prevalence rates of 8.9 and 2.1/100,000 male population for hemophilia A and B, respectively. Prevalence estimates based on hospital discharge data yielded rates of 12.3 and 2.9/100,000 males for hemophilia A and B, respectively. Conclusions: Hemophilia is a rare, chronic disease with high treatment costs. Prevalence estimates based on HTC and hospital discharge data were similar to each other as well as to active surveillance prevalence estimates in published literature.

Descriptive Epidemiology of Selected Heritable Birth Defects in Texas.
Moffitt KB, Abiri OO, Scheuerle AE, Langlois PH.
Birth Defects Res A Clin Mol Teratol. 2011 Dec;91(12):990-4.
Background: Few population-based studies exist on descriptive epidemiologic characteristics of rare heritable birth defects. The number of birth defect cases in the Texas Birth Defects Registry (one of the largest active birth defects surveillance systems in the world) enabled us to examine six different heritable disorders (aqueductal stenosis, infantile polycystic kidney disease, achondroplasia, thanatophoric dwarfism, chondrodysplasia/dwarfism not otherwise specified (NOS), and osteogenesis imperfecta) for a variety of descriptive demographic variables. Methods: The Texas Birth Defects Registry was used to identify infants or fetuses with heritable birth defects. Crude prevalence rates were calculated and Poisson regression was used to test the association of each demographic variable (e.g., maternal age) with each of the selected genetic birth defects. Results: White non-Hispanics exhibited higher rates of achondroplasia and osteogenesis imperfecta than other race/ethnic groups. Lower maternal education level and to a lesser extent, paternal education level, was associated with higher rates of several disorders. The birth prevalence rate for achondroplasia decreased from 1999 through 2006. Conclusion: The use of a large birth defects registry provides a sufficient count of cases to perform some basic epidemiologic analysis on selected rare heritable birth defects.

Building Academic Capacity through Statewide Partnerships.
Green A, Mancini ME, Flemming S, Bingle C, Jordan C, Kishi A, Fowler C, Thomas K, Sjoberg E, Walker S.
J Prof Nurs. 2011 Nov;27(6):e51-7.
In 2008, Texas was challenged by the Center to Champion Nursing in America, an initiative of the Robert Wood Johnson Foundation and AARP, to join a nationwide campaign for action to increase nursing education capacity. This article describes how one state created academic partnerships to achieve capacity building and strengthened relationships and commitments to invest in nursing education. Three year outcomes include a) the creation of a statewide team to address nursing education capacity, b) progress toward doubling the number of nursing graduates from the state's schools of nursing, c) strengthening and emphasizing retention efforts across the state, d) regionalization, including implementation of a $1 million grant and e) transitioning the statewide team to a broader focus and commitment to the Initiative on the Future of Nursing via the formation of a Regional Action Coalition.

Cholera in United States Associated with Epidemic in Hispaniola.
Newton AE, Heiman KE, Schmitz A, Török T, Apostolou A, Hanson H, Gounder P, Bohm S, Kurkjian K, Parsons M, Talkington D, Stroika S, Madoff LC, Elson F, Sweat D, Cantu V, Akwari O, Mahon BE, Mintz ED.
Emerg Infect Dis. 2011 Nov;17(11):2166-8.
Cholera is rare in the United States (annual average 6 cases). Since epidemic cholera began in Hispaniola in 2010, a total of 23 cholera cases caused by toxigenic Vibrio cholerae O1 have been confirmed in the United States. Twenty-two case-patients reported travel to Hispaniola and 1 reported consumption of seafood from Haiti.

Educational pipelines of nurses in Texas: promoting academic mobility through partnerships.
Darnall ED, Kishi A, Wiebusch P.
J Prof Nurs. 2011 Nov;27(6):e46-50.
Texas, like many states across the nation, is struggling to position itself to achieve the Institute of Medicine (IOM) recommendations on the future of nursing. This article provides insights into the hurdles faced by Texas in achieving some of the IOM goals, particularly those related to a better educated nursing workforce. Only 9% of actively licensed nurses have pursued higher degrees, putting Texas below the national average. Currently, there is a gap between actual academic mobility and national recommendations to increase the numbers of baccalaureate- and doctorate-prepared nurses by 2020. The purpose of this study was to evaluate the educational pipeline in the state of Texas while suggesting partnerships as a solution to promote academic mobility. This cross-sectional study evaluated the academic mobility of four selected cohorts of nurses who have been in practice for 5 to 20 years. The findings revealed limited academic mobility compared with national benchmarks among all cohorts, regardless of basic degree and length in the profession. Educational pipelines for nurses need to be more dynamic in Texas than current trends reflect. Collaboration and partnerships between academics, clinicians, administrators, employers, and policy makers should be developed to address barriers that are deterring nurses from continuing their education.

Acute Hepatitis Associated with Autochthonous Hepatitis E Virus Infection -- San Antonio, Texas, 2009.
Tohme RA, Drobeniuc J, Sanchez R, Heseltine G, Alsip B, Kamili S, Hu DJ, Guerra F, Teshale EH.
Clin Infect Dis. 2011 Oct;53(8):793-6.
Locally acquired hepatitis E infection is increasingly being observed in industrialized countries. We report 2 cases of autochthonous acute hepatitis E in the United States. Hepatitis E virus genotype 3a related to US-2 and swine hepatitis E virus strains was isolated from one of the patients, indicating potential food-borne or zoonotic transmission.

Performance of Premarket Rapid Hepatitis C Virus Antibody Assays in 4 National Human Immunodeficiency Virus Behavioral Surveillance System Sites.
Smith BD, Teshale E, Jewett A, Weinbaum CM, Neaigus A, Hagan H, Jenness SM, Melville SK, Burt R, Thiede H, Al-Tayyib A, Pannala PR, Miles IW, Oster AM, Smith A, Finlayson T, Bowles KE, Dinenno EA.
Clin Infect Dis. 2011 Oct;53(8):780-6.
Background: The Centers for Disease Control and Prevention (CDC) estimates that 4.1 million Americans have been infected with hepatitis C virus (HCV) and 75%-80% of them are living with chronic HCV infection, many unaware of their infection. Persons who inject drugs (PWID) account for 57.5% of all persons with HCV antibody (anti-HCV) in the United States. Currently no point-of-care tests for HCV infection are approved for use in the United States. Methods: Surveys and testing for human immunodeficiency virus (HIV) and anti-HCV were conducted among persons who reported injection drug use in the past 12 months as part of the National HIV Behavioral Surveillance System in 2009. The sensitivity and specificity of point-of-care tests (finger-stick and 2 oral fluid rapid assays) from 3 manufacturers (Chembio, MedMira, and OraSure) were evaluated in field settings in 4 US cities. Results: Sensitivity (78.9%-97.4%) and specificity (80.0%-100.0%) were variable across assays and sites. The highest assay-specific sensitivities achieved for the Chembio, MedMira, and OraSure tests were 94.0%, 78.9% and 97.4%, respectively; the highest specificities were 97.7%, 83.3%, and 100%, respectively. In multivariate analysis, false-negative anti-HCV results were associated with HIV positivity for the Chembio oral assay (adjusted odds ratio, 8.4-9.1; P < .01) in 1 site (New York City). Conclusions: Sensitive rapid anti-HCV assays are appropriate and feasible for high-prevalence, high-risk populations such as PWID, who can be reached through social service settings such as syringe exchange programs and methadone maintenance treatment programs.

Sporadic Fatal Insomnia in a Young Woman: A Diagnostic Challenge: Case Report.
Moody KM, Schonberger LB, Maddox RA, Zou WQ, Cracco L, Cali I.
BMC Neurol. 2011 Oct 31;11:136.
Background: Sporadic fatal insomnia (sFI) and fatal familial insomnia (FFI) are rare human prion diseases. Case Presentation: We report a case of a 33-year-old female who died of a prion disease for whom the diagnosis of sFI or FFI was not considered clinically. Following death of this patient, an interview with a close family member indicated the patient's illness included a major change in her sleep pattern, corroborating the reported autopsy diagnosis of sFI. Genetic tests identified no prion protein (PrP) gene mutation, but neuropathological examination and molecular study showed protease-resistant PrP (PrPres) in several brain regions and severe atrophy of the anterior-ventral and medial-dorsal thalamic nuclei similar to that described in FFI. Conclusions: In patients with suspected prion disease, a characteristic change in sleep pattern can be an important clinical clue for identifying sFI or FFI; polysomnography (PSG), genetic analysis, and nuclear imaging may aid in diagnosis.

Retrospective Evaluation of an Inpatient Psychiatric Pharmacist Consultation Service.
Suehs BT, Mican LM, Campbell AH.
J Am Pharm Assoc. 2011 Sep-Oct;51(5):599-604.
Objective: To describe and evaluate clinical outcomes of pharmacist consult service recommendations in an inpatient psychiatric setting. Design: Retrospective study. Setting: Austin, TX, between September 1, 2005, and May 31, 2006. Patients: 105 patients receiving a pharmacy consult while admitted to the Austin State Hospital. Intervention: Completion of consultation pursuant to provider referral. Main Outcome Measures: Clinical Global Impression (CGI)-Severity (CGI-S) and CGI-Improvement (CGI-I) scores were retrospectively determined by blinded psychiatric pharmacy specialists upon review of physician progress notes. Results: A total of 105 pharmacy consultations and associated physician progress notes were reviewed. Overall, 73% of the primary consultation recommendations were implemented. The most common reasons for referral to the psychopharmacology service were nonresponse to treatment and aggression. Patients with high implementation of consultation recommendations displayed more favorable endpoint CGI-S scores and displayed a greater CGI-I response rate compared with patients with low implementation of consult recommendations. Conclusion: Implementing clinical pharmacists' consult recommendations was associated with significantly greater improvement in overall severity of illness and global improvement. This study supports the positive role that pharmacists have in optimizing patient care and clinical outcomes.

Retrospective Evaluation Of An Inpatient Psychiatric Pharmacist Consultation Service.
Suehs BT, Mican LM, Campbell AH.J Am Pharm Assoc. 2011 Sep-Oct;51(5):599-604.Objective: To describe and evaluate clinical outcomes of pharmacist consult service recommendations in an inpatient psychiatric setting. Design: Retrospective study. Setting: Austin, TX, between September 1, 2005, and May 31, 2006. Patients: 105 patients receiving a pharmacy consult while admitted to the Austin State Hospital. Intervention: Completion of consultation pursuant to provider referral. Main Outcome Measures: Clinical Global Impression (CGI)-Severity (CGI-S) and CGI-Improvement (CGI-I) scores were retrospectively determined by blinded psychiatric pharmacy specialists upon review of physician progress notes. Results: A total of 105 pharmacy consultations and associated physician progress notes were reviewed. Overall, 73% of the primary consultation recommendations were implemented. The most common reasons for referral to the psychopharmacology service were nonresponse to treatment and aggression. Patients with high implementation of consultation recommendations displayed more favorable endpoint CGI-S scores and displayed a greater CGI-I response rate compared with patients with low implementation of consult recommendations. Conclusion: Implementing clinical pharmacists' consult recommendations was associated with significantly greater improvement in overall severity of illness and global improvement. This study supports the positive role that pharmacists have in optimizing patient care and clinical outcomes.

Synthetic Cannabinoid Exposures Reported to Texas Poison Centers.
Forrester MB, Kleinschmidt K, Schwarz E, Young A.
J Addict Dis 2011;30:351-8.
Synthetic cannabinoid abuse is increasing in the United States. Synthetic cannabinoid exposures reported to Texas poison centers in 2010 were identified, and the distribution of exposures by selected factors was determined. There were 464 total cases. The number of exposures increased each month during January-July, then remained relatively constant for the next 5 months. The patients were 73.9% male and 57.3% were 20 years or older. Moderate or major effects or potentially toxic outcome occurred in 59.9% of the exposures. The most frequently reported clinical effects were tachycardia (37.3%), agitation (18.5%), drowsiness (18.5%), vomiting (15.7%), hallucinations (10.8%), and nausea (9.9%).

Time Trends in the Prevalence of Birth Defects in Texas 1999-2007: Real or Artifactual?
Langlois PH, Marengo LK, Canfield MA.
Birth Defects Res A Clin Mol Teratol. 2011 Oct;91(10):902-17
Background: Few studies have reported time trends for total birth defects or for a comprehensive range of phenotypes. Methods: We examined data from the Texas Birth Defects Registry (TBDR) from 1999 through 2007. Poisson regression was used to fit trend lines to birth prevalence over time for total birth defects (each infant/fetus counted once), for every birth defect collected by the TBDR, and for subsets of cases or defects grouped various ways. Results: From 1999 through 2007, birth prevalence of total birth defects in Texas increased 3.6% per year. Increases were observed in all population groups, persisted after adjustment for demographic characteristics, and were strongest in regions of Texas that were more urban. There was a wide variety of different defects showing significant increases. The trends of several defects were driven by their mild cases. Perhaps the most compelling finding was that larger upward trends were observed in defects that had been rated as more susceptible to diagnostic variation. One notable exception to that was gastroschisis, which showed an average increase of over 5% per year, the total birth defects rate in TBDR increased at 3.6% per year, similar to 3.7% per year in birth certificate check boxes. Conclusions: In our opinion, the weight of evidence in our study suggests that the observed increase over time in total birth defects and in many specific birth defects is artifactual. This likely reflects increased awareness, referral, detection, or documentation in health care facilities visited by TBDR staff, resulting in more complete ascertainment by the registry, rather than a true change over time in the occurrence of most birth defects.

The Public Health Ethics of Contagion.
Clements B.
Domestic Preparedness Journal. 2011;7(10):5-8. (No abstract available.)

Pilot of a Diabetes Primary Prevention Program in a Hard-to-Reach, Low-Income, Immigrant Hispanic Population.
Millard AV, Graham MA, Wang X, Mier N, Sánchez ER, Flores I, Elizondo-Fournier M.
J Immigr Minor Health. 2011 Oct;13(5):906-13.
An immigrant Hispanic population in the Texas-Mexico border region urgently requested assistance with diabetes. The project team implemented an exploratory pilot intervention to prevent type 2 diabetes in the general population through enhanced nutrition and physical activity. Social networks in low-income rural areas(colonias) participated in an adaptation of the Diabetes Empowerment Education Program. The program had a pre-post-test design with a comparison group. The intervention had a small but significant effect in lowering body mass index, the biological outcome variable. The process evaluation shows that the participants valued the pilot project and found it culturally and economically appropriate. This program was the first primary prevention program in diabetes to address a general population successfully. The study shows that low-income, rural Mexican American families will take ownership of a program that is participatory and tailored to their culture and economic situation.

Comparison of Pediatric Levalbuterol and Albuterol Exposures Reported to Texas Poison Centers.
Forrester MB.
J Pharm Technol 2011;27:216-221.
Background: Levalbuterol is R-albuterol, which is the active isomer and accounts for the therapeutic activity of albuterol. The effects of S-albuterol are often the opposite of those of levalbuterol, and the effects of levalbuterol may be diminished in the presence of S-albuterol. Objective: To compare exposures among young children to levalbuterol and albuterol that were reported to poison centers. Methods: Cases included levalbuterol and albuterol exposures among patients age 0-5 years reported to Texas poison centers during 2000-2009. The distribution of total cases for each medication was determined for selected characteristics. For cases not involving other substances and where a final medical outcome was known, the distribution of each medication was determined for outcome and management site of the exposure and most common clinical effects and treatments. Comparisons were made by calculating the rate ratio (RR) and 95% confidence interval. Results: There were a total of 1,012 levalbuterol and 4,338 albuterol exposures. Other substances were involved in 11.8% of levalbuterol and 6.6% of albuterol exposures (RR 1.77, 95% CI 1.42 to 2.20). No effect was reported in 84.0% of levalbuterol and 71.9% of albuterol exposures (RR 1.17, 95% CI 1.03 to 1.32), and 91.7% of levalbuterol and 73.1% of albuterol exposures were managed on site (RR 1.26, 95% CI 1.11 to 1.41). The most common adverse clinical effects were reported more frequently among albuterol exposures. The most frequent treatments of levalbuterol and albuterol exposures were, respectively, dilution 59.5% and 42.0% (RR 1.42, 95% CI 1.22 to 1.64), food 18.9% and 12.8% (RR 1.48, 95% CI 1.12 to 1.94), single-dose activated charcoal 0.3% and 10.1% (RR 0.03, 95% CI 0.00 to 0.15), and cathartic 0.0% and 4.6% (RR 0.00, 95% CI 0.00 to 0.22).  CONCLUSIONS: Among exposures involving children aged 0-5 years that were reported to Texas poison centers, levalbuterol was more likely to include other substances, have less serious outcomes, and be managed on site when compared to albuterol.

Parental Feeding Practices and Concerns Related to Child Underweight, Picky Eating, and Using Food to Calm Differ according to Ethnicity/Race, Acculturation, and Income.
Evans A, Seth JG, Smith S, Harris KK, Loyo J, Spaulding C, Van Eck M, Gottlieb N.
Matern Child Health J. 2011 Oct;15(7):899-909.
The purpose of this study was to examine differences in parental feeding practices according to ethnicity/race, household income, parent education level, acculturation (for Hispanic participants only), and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program among parents living in a southern state in the United States. For this cross-sectional study, parents of children ages 1-5 years living throughout Texas were recruited through random digit dialing with screening questions during Fall 2006. Eligible parents who agreed to participate completed the Preschooler Feeding Questionnaire (PFQ) and a demographic questionnaire over the phone in either English or Spanish. The PFQ included five subscales: child overeating concerns, child underweight concerns, difficulty with picky eating, using food to calm, and pushing child to eat. Demographic questions assessed ethnicity/race, household income, parent education level, acculturation, and WIC participation. Structural Equation Modeling (SEM), with the demographic variables as predictors, was used to predict the five PFQ subscales. Complete data were obtained from 721 parents, 50% of whom were Hispanic. Significant differences for the PFQ subscales were noted for ethnicity/race, acculturation, and income level. Spanish-speaking Hispanic participants were significantly more worried about their child being underweight than English-speaking Hispanic participants. High-income non-WIC respondents were more likely to report that they have difficulty with picky eaters compared to WIC respondents. Spanish-speaking Hispanics and Black respondents were more likely than English-speaking Hispanics to use food to calm the child. Health practitioners need to be aware of differences in parental feeding practices and concerns among parents of diverse demographic backgrounds. Results from this study can be used to tailor health programs that promote healthy feeding practices among parents.

Do Foreign- and U.S.-Born Mothers across Racial/Ethnic Groups Have a Similar Risk Profile for Selected Sociodemographic and Periconceptional Factors?
Ramadhani TA, Canfield MA, Farag NH, Royle M, Correa A, Waller DK, Scheuerle A; the National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2011 Sep;91(9):823-830.
Background: We examined differences in selected pregnancy-related risk factors, including maternal sociodemographic characteristics, health-related conditions, and periconceptional behavioral factors, among foreign-born versus U.S.-born control mothers across race/ethnic groups. Methods: We used data from the National Birth Defects Prevention Study, and calculated odds ratios (ORs) and 95% confidence intervals (CIs) of the risk factors, for foreign-born Hispanic, non-Hispanic white, non-Hispanic black, and Asian/Pacific Islander (API) mothers, compared to their U.S.-born counterparts. Results: Across all race/ethnic groups, foreign-born mothers were older and had lower odds of obesity compared to their U.S.-born counterparts. With the exception of foreign-born black mothers, foreign-born mothers from other race/ethnic groups had significantly lower odds of binge drinking during the periconceptional period. Compared to U.S.-born, foreign-born Hispanic mothers had twice the odds of gestational diabetes (OR = 2.23; 95% CI = 1.36-3.66). Certain health behaviors were less prevalent in foreign-born black mothers (e.g., folic acid use; OR = 0.54; 95% CI = 0.31-0.96) and foreign-born API mothers (e.g., cigarette smoking; OR = 0.10; 95% CI = 0.02-0.48). Conclusions: Significant differences in pregnancy related risk factors during the periconceptional period and throughout pregnancy were observed between maternal nativity groups and across race/ethnicity. Prevention efforts for both prepregnancy and after conception should be designed and delivered according to maternal nativity for each racial/ethnic group.

Acute Pesticide Illnesses Associated with Off-Target Pesticide Drift from Agricultural Applications: 11 States, 1998-2006.
Lee SJ, Mehler L, Beckman J, Diebolt-Brown B, Prado J, Lackovic M, Waltz J, Mulay P, Schwartz A, Mitchell Y, Moraga-McHaley S, Gergely R, Calvert GM.
Environ Health Perspect. 2011 Aug;119(8):1162-9.
Background: Pesticides are widely used in agriculture, and off-target pesticide drift exposes workers and the public to harmful chemicals. Objective: We estimated the incidence of acute illnesses from pesticide drift from outdoor agricultural applications and characterized drift exposure and illnesses. Methods: Data were obtained from the National Institute for Occupational Safety and Health's Sentinel Event Notification System for Occupational Risks-Pesticides program and the California Department of Pesticide Regulation. Drift included off-target movement of pesticide spray, volatiles, and contaminated dust. Acute illness cases were characterized by demographics, pesticide and application variables, health effects, and contributing factors. Results: From 1998 through 2006, we identified 2,945 cases associated with agricultural pesticide drift from 11 states. Our findings indicate that 47% were exposed at work, 92% experienced low-severity illness, and 14% were children (< 15 years). The annual incidence ranged from 1.39 to 5.32 per million persons over the 9-year period. The overall incidence (in million person-years) was 114.3 for agricultural workers, 0.79 for other workers, 1.56 for nonoccupational cases, and 42.2 for residents in five agriculture-intensive counties in California. Soil applications with fumigants were responsible for the largest percentage (45%) of cases. Aerial applications accounted for 24% of cases. Common factors contributing to drift cases included weather conditions, improper seal of the fumigation site, and applicator carelessness near nontarget areas. Conclusions: Agricultural workers and residents in agricultural regions had the highest rate of pesticide poisoning from drift exposure, and soil fumigations were a major hazard, causing large drift incidents. Our findings highlight areas where interventions to reduce off-target drift could be focused.

Increasing Use of Rapid HIV Testing in Labor and Delivery among Women with No Prenatal Care: A Local Initiative.
Levison J, Williams LT, Moore A, McFarlane J, Davila JA.
Matern Child Health J. 2011 Aug;15(6):822-6.
Pregnant women who do not receive prenatal care and may not be aware of their HIV status are at greatest risk of transmitting HIV to their newborn. A multi-component intervention was designed and implemented to increase the use of rapid HIV testing among pregnant women with no prenatal care at labor and delivery in two county hospitals in Houston/Harris County, Texas. The intervention involved establishing a local task force including representatives from each hospital, assessing each hospital's readiness to implement rapid testing, providing educational presentations and materials, and offering individualized follow-up. Outcomes data were obtained and included the number of patients presenting with no prenatal care who received rapid HIV testing on admission. Before the intervention, both hospitals had rapid test kits available but were not using them consistently. Following the intervention, we observed a significant increase in the use of rapid HIV testing at both institutions (P < 0.001). In the 3 months immediately following the intervention, use of rapid testing at Hospital 1 increased from 7.4 to 35.3% and at Hospital 2 from 27.4 to 41.5%. At 1 year, almost 100% of women with no prenatal care at both hospitals received rapid testing. Educating staff and clinicians and implementing system-wide changes may facilitate behavior change regarding prenatal HIV testing.

Incidence of Moxifloxacin Resistance in Clinical Mycobacterium tuberculosis Isolates in Houston, Texas.
El Sahly H, Teeter LD, Jost KC Jr, Dunbar D, Lew J, Graviss EA.
J Clin Microbiol. 2011 Aug;49(8):2942-5.
Comprehensive data on the prevalence of quinolone resistance in Mycobacterium tuberculosis (MTB) clinical isolates in the US are scarce. Using a systematic population-based approach, MTB strains from tuberculosis (TB) cases were collected in Harris County, Texas, 2007-2008. MTB isolates' susceptibility to moxifloxacin and ofloxacin was determined with the agar proportion indirect susceptibility method. Spoligotype and MIRU12-based genotyping of MTB isolates and sequencing of the gyrA, gyr B, Rv2686c, Rv2687c and Rv2688c gene in quinolone-resistant and year-of-diagnosis-matched MTB isolates were performed. Susceptibility testing on 557 MTB isolates was performed, of which 10 (1.8%) were resistant to moxifloxacin. There was a 100% concordance between ofloxacin and moxifloxacin susceptibility. A quinolone was prescribed to at least 5 (50%) patients in the period preceding TB diagnosis. Multidrug resistant tuberculosis was significantly associated with quinolone resistance (P=0.01). Mutations in the quinolone resistance determining region of gyrA were found in 50% of the resistant isolates. No other presumptive quinolone-resistance-associated mutations were identified. We conclude that the incidence of moxifloxacin-resistant TB is low in Harris County and is associated with MDR-TB.  Previous exposure to quinolones is common among patients with moxifloxacin resistance and warrants more careful evaluation.

Investigation into an Increase in Plagiocephaly in Texas from 1999 to 2007.
Sheu SU, Ethen MK, Scheuerle AE, Langlois PH.
Arch Pediatr Adolesc Med. 2011 Aug;165(8):708-13.
Objective: To examine factors that may explain a 9-fold increase in plagiocephaly in Texas from 1999 to 2007. Design: Descriptive epidemiologic study of time trends and a nested case-control study. Setting: Texas. Participants: Cases in the Texas Birth Defects Registry. Outcome Measures: Time trends in the birth prevalence of plagiocephaly overall and by region, demographic group, and clinical subgroup. Trends in percentage of cases using specific facilities or procedures. Results: From 1999 to 2007, the prevalence of plagiocephaly in Texas increased from 3.0 cases per 10 000 live births to 28.8, an average increase of 21.2% per year. This was highly statistically significant. The time trend was most pronounced in the Dallas/Fort Worth region and in certain health care facilities. It was observed in all demographic and clinical subgroups. Cases born in 2004 and 2005 were not more likely to be postnatally acquired when compared with cases born in 1999 and 2000. There was no commensurate decrease in other birth defects of the face or skull. Conclusions: A small part of the trend might have been due to delayed compliance with the infant supine sleeping recommendation and a slight increase in preterm births. It was not due to changes in birth defect coding practice or trends in multiple births, torticollis, or oligohydramnios. Because the plagiocephaly trend was observed mainly in patients visiting certain health care facilities, among mild cases, and among cases with minimally invasive procedures, we suspect it may be due mainly to changes in available therapies and insurance reimbursement practices.

Dextromethorphan abuse in Texas, 2000-2009.
Forrester MB.
J Addict Dis 2011;30:243-247.
Dextromethorphan abuse is increasing in United States. Intentional misuse or abuse ingestions of dextromethorphan-containing products reported to Texas poison centers during 2000–2009 were identified and the distribution of ingestions by selected factors was determined. There were 3,421 total cases; Coricidin® (Schering-Plough Health Care Products, Inc., Memphis, TN) products were involved in 53.6% of cases. The number of cases increased during 2000–2002 and then declined during 2003–2005 before increasing again in 2006 and remaining relatively constant afterward. The majority of patients were male (60.4%) and between 13 and 19 years of age (69.0%). A potentially serious outcome was assigned in 46.2% of the cases and 83.1% were managed at a health care facility.

Peanut butter recall calls received by Texas poison centers.
Forrester MB.
TPHJ 2011;63(3):7-11.
Background: On February 14, 2007, the Food and Drug Administration issued an alert warning to consumers to not to eat certain jars of peanut butter because of possible Salmonella contamination, and the peanut butter was recalled. This investigation tested whether the Texas poison center system call volume was affected by this recall. Methods: Cases were all peanut butter recall calls received by Texas poison centers from February 14 through June 30, 2007. The pattern of calls was examined with respect to the date of the calls and location from which the calls originated. Results: A total of 988 such calls were received. Twelve calls were received the day of the recall.  Most calls (499) were received on February 15, accounting for 50.5% of all peanut butter recall calls. The next highest number of calls was received on February 16 (179), followed by February 17 (65). Calls continued to be received through April (12), May (5), and June (3). Most of the calls came from counties in the eastern part of Texas. Conclusion: Texas poison centers began to receive calls relating to the peanut butter recall shortly after the recall was announced. Most of the calls were received on the day after the announcement and declined over following days but continued for a relatively long period of time.

Secondary effects of public health emergencies: Example of West Nile virus and DEET.
Forrester MB.
TPHJ 2011;63(3):16-17. [No abstract available]

Potential impact of coral snake antivenin shortage.
Forrester MB.
TPHJ 2011;63(3):17-18. [No abstract available]

Public Health and Medical Interoperability Challenges.
Clements B.
Domestic Preparedness Journal. 2011;7(6):14-16. (No abstract available.)

Total Release Fogger Exposures Reported to Texas Poison Centers, 2000-2009.
Forrester MB, Diebolt-Brown B.
Toxicol Environ Chem 2011;93:1089-1097.
Total release foggers or “bug bombs” are products designed to fill an area such as a home or workplace with insecticide. Because of their method of action, unintentional exposures may occur. Cases for this retrospective study were all fogger exposures reported to Texas poison centers during 2000-2009. The distribution of cases was identified for various demographic and clinical factors. There were 2855 fogger exposures. Among the patients 56.0% were females and 69.5% were 20 years or older. Considering the exposure circumstances 95.6% were unintentional and 62.2% occurred through inhalation. The management site was 75.2% on site. The medical outcomes were no effect (11.8%), minor effect (25.1%), moderate effect (7.4%), major effect (0.1%), not followed (no effects expected) (3.5%), not followed (minimal effects expected) (39.3%), not followed (potentially toxic) (4.9%), and effects probably unrelated to exposure (7.7%). The most frequently reported clinical effects were cough (25.4%), vomiting (13.3%), nausea (9.2%), dyspnea (8.7%), throat irritation (7.9%), and headache (5.6%). The public needs to be educated about the potential hazard of exposures to foggers. However, most fogger exposures reported to poison centers are not likely to be seriously toxic and can be managed at home.

Racial/Ethnic Disparities in Risk of Early Childhood Mortality among Children with Congenital Heart Defects.
Nembhard WN, Salemi JL, Ethen MK, Fixler DE, Dimaggio A, Canfield MA.
Pediatrics. 2011 May;127(5):e1128-38.
Background: Infants with congenital heart defects (CHDs) have increased risk of childhood morbidity and mortality. However, little is known about racial/ethnic differences in early childhood mortality. Patients and Methods: We conducted a retrospective cohort study with data from the Texas Birth Defect Registry on 19 530 singleton, live-born infants with a CHD and born January 1, 1996, to December 31, 2003, to non-Hispanic (NH) white, NH black, and Hispanic women. Texas Birth Defect Registry data were linked to Texas death records and the National Death Index to ascertain deaths between January 1, 1996, and December 31, 2005. Kaplan-Meier survival estimates were computed, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated from multivariable Cox-proportional hazard regression models to determine the effect of maternal race/ethnicity on mortality for selected CHD phenotypes. Results: After adjusting for covariates, compared with NH white children, NH black children had increased early childhood mortality risk for transposition of  the great arteries (HR: 2.04 [95% CI: 1.40-2.97]), tetralogy of Fallot (HR: 1.85  [95% CI: 1.09-3.12]), pulmonary valve atresia without ventricular septal defect (VSD) (HR: 2.60 [95% CI: 1.32-5.12]), VSD (HR: 1.56 [95% CI: 1.19-2.03]), and atrial septal defect (HR: 1.34 [95% CI: 1.08-1.66]). Hispanic children had higher mortality risk for pulmonary valve atresia without VSD (HR: 1.76 [95% CI: 1.06-2.91]) and hypoplastic left heart syndrome (HR: 1.51 [95% CI: 1.13-2.02]). Conclusions: We provide evidence that supports racial/ethnic disparities in early childhood mortality among infants with CHDs. Identifying infants with the greatest risk of early childhood mortality will facilitate development of interventions and policies to mitigate these risks.

Mass Evacuation of Medical and Functional Needs Populations.
Clements B.
Domestic Preparedness Journal. 2011;7(5):5-7. (No abstract available.)

Epidemiology of Ebstein Anomaly: Prevalence and Patterns in Texas, 1999-2005.
Lupo PJ, Langlois PH, Mitchell LE.
Am J Med Genet A. 2011 May;155A(5):1007-14.
Ebstein anomaly is a rare but serious cardiac defect, however, little is known about the etiology of this condition. The goal of this study was to expand our limited understanding of the epidemiology of Ebstein anomaly. Data for cases with Ebstein anomaly, as well as all live births, were obtained from the Texas Birth Defects Registry (TBDR) and Center for Health Statistics for the period 1999-2005. Descriptive analyses and estimates of birth prevalence and crude prevalence ratios were used to characterize this defect in Texas during the study period. There were 188 definite cases of Ebstein anomaly identified in the TBDR. The overall prevalence was 0.72 per 10,000 live births. Variables associated with an increased prevalence of non-syndromic Ebstein anomaly included: maternal age >39 years (compared to those 20-24 years), maternal residence along the Texas-Mexico border (compared to non-border residence), and conception in fall or winter (compared to summer). In addition, infants with Ebstein anomaly were at a  greater risk of preterm birth and being small for gestational age. These findings help to define subgroups of women at increased risk of having offspring affected  by Ebstein anomaly. Furthermore, our findings add to the limited body of literature on this rare but serious malformation.

Working Well - The Texas Demonstration to Maintain Independence and Employment: 18-Month Outcomes.
Bohman T, Wallisch L, Ostermeyer B, Stoner D, et al.
Journal of Vocational Rehabilitation. 2011 Apr;34(2):97-106.
Uninsured working adults with chronic mental, behavioral and physical health conditions may have greater difficulty in accessing needed health care due to health care costs and crowded public health systems. Untreated medical conditions can lead to poorer health, which is linked to loss of employment and eventual applications for and receipt of federal benefits such as Supplemental Security Income and Social Security Disability Insurance (SSI/SSDI). The Working Well study was designed to determine whether a coordinated set of health benefits and employment supports could help low-income, working adults maintain their employment and remain independent of publicly funded disability assistance. Patients from the Harris County Hospital District, a large public health system providing indigent care in the Houston metroplex, were recruited and randomized to the intervention (N = 904) and control (N = 712) groups. The Working Well case management intervention included health navigation, employment/vocational supports, expedited appointments, free medications, and no co-pays for medical visits. Participant outcomes were measured through surveys, health claims data, and state agency employment data. Intervention group participants reported greater access to care, greater likelihood of outpatient medical visits and less likelihood of receiving SSI/SSDI benefits. These findings suggest that public health care systems can provide disability prevention programs, improve access to care and reduce reliance on publicly funded disability assistance.

Personal Navigation, Life Coaching, and Case Management: Approaches for Enhancing Health and Employment Support Services.
Ozaki R, Schneider J, Stoner D, Ostermeyer B, et al.
Journal of Vocational Rehabilitation. 2011 Apr;34(2):83-95.
The national Demonstration to Maintain Independence and Employment (DMIE) projects examined whether providing comprehensive and coordinated health and employment services could help people with significant mental, physical and/or chronic health issues remain employed and independent of government benefits. Four states implemented interventions using different models that shared a person-centered approach. This paper describes how DMIE interventions were defined and implemented, compares models developed by states, and identifies factors that facilitated and/or limited their success.

Continuing Education Mitigates the Negative Consequences of Adolescent Childbearing.
Sullivan K, Clark J, Castrucci B, Samsel R, Fonseca V, Garcia I.
Matern Child Health J. 2011 Apr;15(3):360-6.
Beginning childbearing during adolescence is consistently linked with negative outcomes for both children and parents. Many have attributed this association to maternal background characteristics which are often difficult to change through policy. Though maternal educational attainment is often a side effect of adolescent childbearing, it also represents a potential avenue through which we can help young mothers overcome the obstacles associated with an early birth. The data for this study come from the 1997 Child Development Supplement of the Panel Study of Income Dynamics, a nationally representative sample of mothers and their children (N = 3,193). Data are used to explore the cognitive stimulation and emotional support in the home, measured using the HOME Scale (Caldwell and Bradley in Home observation for measurement of the environment. University of Arkansas at Little Rock, Little Rock, 1984). OLS regression models how maternal education moderates the association between age at first birth and quality of children's home environment. Adolescent mothers scored significantly lower on the indicator of home environment than older mothers. However, when continuing education was considered, maternal age at first birth was no longer significantly associated with the home environment. The negative consequences of early births were mediated by adolescent mothers' continuing education efforts. While interventions are needed to reduce adolescent childbearing, these results highlight the need to ensure that adolescent mothers are provided support to continue their education following delivery. The negative consequences of adolescent births are not inevitable. Encouraging school retention may help young mothers form a safe, healthy, nurturing, and developmentally appropriate home environment.

Should Aggregate US Census Data Be Used as a Proxy for Individual Household Income in a Birth Defects Registry?
Marengo L, Ramadhani T, Farag NH, Canfield MA.
J Registry Manag. 2011 Spring;38(1):9-14.
Background: Birth Defects Registries do not have access to income data and low household income is associated with adverse pregnancy outcomes of stillbirth preterm birth, and birth defects. We compared 1999 income data from the National Birth Defects Prevention Study (NBDPS) with 2000 Census block group income data for the residence location of these same mothers. Methods: We geocoded 339 case mothers and 121 control mothers and assessed household income among case and control mothers by using NBDPS and census block group data. Correlation and concordance were assessed between the 2 data sources' household income data. Results: The household income distribution was similar between case and control mothers within each data source. Both case and control mothers in the NBDPS's lowest household income category (<$20,000/year) reported lower income than was documented in their census block group's median household income (p-value<0.0001). A weak correlation was identified between NBDPS interview and census block group income data (control mothers, rs=0.53; case mothers, rs=0.32). There was also poor to fair concordance between the 2 data sources (control mothers, kw=0.28; 95% CI=0.19-0.37 and case mothers, kw=0.18; 95% CI=0.13-0.24). Conclusion: These findings demonstrate dissimilar household incomes between NBDPS and census block group data. Caution should be used if block-level data is used as a proxy for individual-level household incomes in population-based birth defects surveillance and research.

MECP2 Duplications in Six Patients with Complex Sex Chromosome Rearrangements.
Breman AM, Ramocki MB, Kang SH, Williams M, Freedenberg D, Patel A, Bader PI, Cheung SW.
Eur J Hum Genet. 2011 Apr;19(4):409-15.
Duplications of the Xq28 chromosome region resulting in functional disomy are associated with a distinct clinical phenotype characterized by infantile hypotonia, severe developmental delay, progressive neurological impairment, absent speech, and proneness to infections. Increased expression of the dosage-sensitive MECP2 gene is considered responsible for the severe neurological impairments observed in affected individuals. Although cytogenetically visible duplications of Xq28 are well documented in the published literature, recent advances using array comparative genomic hybridization (CGH) led to the detection of an increasing number of microduplications spanning MECP2. In rare cases, duplication results from intrachromosomal rearrangement between the X and Y chromosomes. We report six cases with sex chromosome rearrangements involving duplication of MECP2. Cases 1-4 are unbalanced rearrangements between X and Y, resulting in MECP2 duplication. The additional Xq material was translocated to Yp in three cases (cases 1-3), and to the heterochromatic region of Yq12 in one case (case 4). Cases 5 and 6 were identified by array CGH to have a loss in copy number at Xp and a gain in copy number at Xq28 involving the MECP2 gene. In both cases, fluorescent in situ hybridization (FISH) analysis revealed a recombinant X chromosome containing the duplicated material from Xq28 on Xp, resulting from a maternal pericentric inversion. These cases add to a growing number of MECP2 duplications that have been detected by array CGH, while demonstrating the value of confirmatory chromosome and FISH studies for the localization of the duplicated material and the identification of complex rearrangements.

Prevalence and Patterns of Choanal Atresia and Choanal Stenosis among Pregnancies in Texas, 1999-2004.
Case AP, Mitchell LE.
Am J Med Genet A. 2011 Apr;155A(4):786-91.
Congenital choanal atresia and stenosis (CA/S) are the most common craniofacial abnormalities of the nose. However, little is known about the epidemiology of these conditions. The present study was undertaken to expand our understanding of the epidemiology of CA/S by analyzing data from the Texas Birth Defect Registry (TBDR) for the period 1999-2004. Descriptive analyses and estimates of birth prevalence and crude prevalence ratios were used to characterize CA/S cases in Texas during the study period. Among the 2,209,758 live births in 1999-2004 in Texas, there were 202 cases of CA/S for an overall prevalence of 0.91 per 10,000 live births. The birth prevalence of isolated, multiple, and associated CA/S was 0.42, 0.21, and 0.28 per 10,000, respectively. The birth prevalence of isolated CA/S was similar in males and females, but was higher in the offspring of non-Hispanic white women (0.52/10,000), as compared to the offspring of non-Hispanic black (0.41/10,000) and Hispanic (0.37/10,000) women. There was also evidence of a significant association between birth year and isolated CA/S (P for trend=0.0003), with lower risks observed in more recent years. No significant associations were observed between isolated CA/S and maternal age, education, residence along the Texas-Mexico border, plurality of the pregnancy or trimester  in which prenatal care was initiated. These findings add to our limited understanding of the epidemiology of CA/S.

Ingestions of Hydrocodone, Carisoprodol, and Alprazolam in Combination Reported to Texas Poison Centers.
Forrester MB.
J Addict Dis. 2011 Apr;30(2):110-5.
The combination of hydrocodone, carisoprodol, and alprazolam is subject to abuse. Ingestions of this drug combination reported to Texas poison centers during 1998-2009 were identified (totaling 1,295 cases) and the distribution of ingestions by selected factors was determined. The number of cases increased from 0 in 1998 to 200 in 2007, and then decreased to 132 in 2009. The counties in eastern and southeastern Texas accounted for 80.9% of the cases. Of the patients, 57.3% were women and 94.6% were age 20 or older. Suspected attempted suicide accounted for 59.3% of the cases and intentional misuse or abuse for 27.3%. 

Geographic Differences in Time to Culture Conversion in Liquid Media: Tuberculosis Trials Consortium Study 28.Culture Conversion Is Delayed in Africa.
MacKenzie WR, Heilig CM, Bozeman L, Johnson JL, Muzanye G, Dunbar D, Jost KC, Diem L, Metchock B, Eisenach K, Dorman S, Goldberg S.
PLoS ONE 6(4): e18358.
Background: Tuberculosis Trials Consortium Study 28, was a double blind, randomized, placebo-controlled, phase 2 clinical trial examining smear positive pulmonary Mycobacterium tuberculosis. Over the course of intensive phase therapy, patients from African sites had substantially delayed and lower rates of culture conversion to negative in liquid media compared to non-African patients. We explored potential explanations of this finding. Methods: In TBTC Study 28, protocol-correct patients (n = 328) provided spot sputum specimens for M. tuberculosis culture in liquid media, at baseline and weeks 2, 4, 6 and 8 of study therapy. We compared sputum culture conversion for African and non-African patients stratified by four baseline measures of disease severity: AFB smear quantification, extent of disease on chest radiograph, cavity size and the number of days to detection of M. tuberculosis in liquid media using the Kaplan-Meier product-limit method. We evaluated specimen processing and culture procedures used at 29 study laboratories serving 27 sites. Results: African TB patients had more extensive disease at enrollment than non-African patients. However, African patients with the least disease by the 4 measures of disease severity had conversion rates on liquid media that were substantially lower than conversion rates in non-African patients with the greatest extent of disease. HIV infection, smoking and diabetes did not explain delayed conversion in Africa. Some inter-site variation in laboratory processing and culture procedures within accepted practice for clinical diagnostic laboratories was found. Conclusions: Compared with patients from non-African sites, African patients being treated for TB had delayed sputum culture conversion and lower sputum conversion rates in liquid media that were not explained by baseline severity of disease, HIV status, age, smoking, diabetes or race. Further investigation is warranted into whether modest variation in laboratory processes substantially influences the efficacy outcomes of phase 2 TB treatment trials or if other factors (e.g., nutrition, host response) are involved.  

Tracking Deaths Related to Hurricane Ike, Texas, 2008.
Zane DF, Bayleyegn TM, Hellsten J, Beal R, Beasley C, Haywood T, Wiltz-Beckham D, Wolkin AF.
Disaster Med Public Health Prep. 2011 Mar;5(1):23-8.
Background: On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals. Methods: Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis. Results: The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n=57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths. Conclusions: Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the  state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have  been preventable by educating the public.

Racial/Ethnic Disparities in Survival among Men Diagnosed with Prostate Cancer in Texas.
White A, Coker AL, Du XL, Eggleston KS, Williams M.
Cancer. 2011 Mar 1;117(5):1080-8.
Background: To the authors' knowledge, few studies to date have examined racial differences in prostate cancer survival while controlling for socioeconomic status (SES). No such studies have examined this association in Texas, a large state with significant ethnic and racial diversity. The objective of this analysis was to determine whether racial disparities in survival for men diagnosed with prostate cancer in Texas from 1995 through 2002 remained after adjusting for SES, rural residence, and stage of disease. Methods: A cohort of 87,449 men who were diagnosed with prostate cancer was identified from the Texas Cancer Registry. The SES measure was based on census tract data reflecting median household income, median home value, and percentages of men living below poverty, with a college education, and with a management or professional occupation. The 5-year survival rates were calculated using the Kaplan-Meier method and Cox proportional hazard modeling was used to estimate hazard ratios (HRs) for race and all-cause and disease-specific mortality. Results: After adjusting for SES, age, stage of disease, tumor grade, year of diagnosis, and rural residence, both black and Hispanic men were more likely (adjusted HR [aHR], 1.70 [95% confidence interval (95% CI), 1.58-1.83] and aHR, 1.11 [95% CI, 1.02-1.20], respectively) to die of prostate cancer compared with white men. The pattern of survival disadvantage for black men held for those diagnosed with localized disease and advanced disease, and for those with an unknown stage of disease at diagnosis. Conclusions: Substantial racial disparities in prostate cancer survival were found for men in Texas. Future studies should incorporate treatment data as well as comorbid conditions because this information may explain noted survival disparities.

Maternal Exposure to Ambient Levels of Benzene and Neural Tube Defects among Offspring: Texas, 1999-2004.
Lupo PJ, Symanski E, Waller DK, Chan W, Langlois PH, Canfield MA, Mitchell LE.
Environ Health Perspect. 2011 Mar;119(3):397-402.
Background: Previous studies have reported positive associations between maternal exposure to air pollutants and several adverse birth outcomes. However, there have been no studies assessing the association between environmental levels of hazardous air pollutants, such as benzene, and neural tube defects (NTDs), a common and serious group of congenital malformations. Objective: Our goal was to conduct a case-control study assessing the association between ambient air levels of benzene, toluene, ethylbenzene, and xylene (BTEX) and the prevalence of NTDs among offspring. Methods: The Texas Birth Defects Registry provided data on NTD cases (spina bifida and anencephaly) delivered between 1999 and 2004. The control group was a  random sample of unaffected live births, frequency matched to cases on year of birth. Census tract-level estimates of annual BTEX levels were obtained from the U.S. Environmental Protection Agency 1999 Assessment System for Population Exposure Nationwide. Restricted cubic splines were used in mixed-effects logistic regression models to determine associations between each pollutant and NTD phenotype. Results: Mothers living in census tracts with the highest benzene levels were more likely to have offspring with spina bifida than were women living in census tracts with the lowest levels (odds ratio = 2.30; 95% confidence interval, 1.22-4.33). No significant associations were observed between anencephaly and benzene or between any of the NTD phenotypes and toluene, ethylbenzene, or xylene. Conclusion: In the first study to assess the relationship between environmental levels of BTEX and NTDs, we found an association between benzene and spina bifida. Our results contribute to the growing body of evidence regarding  air pollutant exposure and adverse birth outcomes.

Oleander: A Poisonous Plant that Does Not Live Up to Its Urban Legend.
Forrester MB.
TPHJ 2011;63(2):36-37. [No abstract available]

2008 Outbreak of Salmonella Saintpaul Infections Associated with Raw Produce.
Barton Behravesh C, Mody RK, Jungk J, Gaul L, et al.; the Salmonella Saintpaul Outbreak Investigation Team.
N Engl J Med. 2011 Mar 10;364(10):918-927
Background: Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008. Methods: We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted. Results: Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source. Conclusions: Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Public Health Emergency Resilience: The Next Challenging Step.
Clements B.
Domestic Preparedness Journal. 2011;7(2):7-8. (No abstract available.)

Effect of Specimen Storage Conditions on Newborn Dried Blood Spots Used to Assess Toxoplasma Gondii Immunoglobulin M (Igm).
Mei JV, Li L, Rasmussen SA, Collier S, Frias JL, Honein MA, Shaw GM, Lorey F, Meyer R, Chaing S, Canfield MA, Jones J, Hannon WH.
Clin Chim Acta. 2011 Feb 20;412(5-6):455-9.
Background: Newborn screening programs store—under varying conditions—residual dried blood spots (DBS). Residual DBS were used to investigate the contribution of congenital infection with Toxoplasma gondii to the etiology of hydrocephalus and as a key step, we assessed the effect of storage conditions on the stability of newborn screening biomarkers. Methods: Infants with hydrocephalus (410 cases) were identified using population-based birth defects surveillance systems in California, North Carolina, and Texas. Infants without birth defects (448 controls) were randomly selected from the same geographic areas and time periods. California stores DBS with controlled temperature, while North Carolina and Texas store DBS under ambient conditions. After removal of personal identifiers, DBS were tested for Toxo-specific immunoglobulin-M (Toxo-IgM). Because of poor elution of DBS stored in ambient conditions, additional biomarkers were tested on a specimen subset. Results: Among 858 DBS tested, Toxo-IgM was found in 3 cases and no controls from California (N =515) and in no specimens from North Carolina or Texas (N =343). Among the 98 specimens tested for selected biomarkers, statistically significant differences were found for California vs. combined North Carolina and Texas DBS (thyroid stimulating hormone, phenylalanine, methionine, leucine and citrulline p <0.0001; tyrosine and valine p <0.001). Conclusions: Storage conditions for residual DBS had an effect on the ability to extract, recover, and accurately measure Toxo-IgM and other biomarkers from the filter paper matrix.

History of Maltreatment among Unintentional Injury Deaths: Analyses of Texas Child Fatality Review Data, 2005-2007.
Parks SE, Mirchandani G, Rodriguez S, Hellsten J.
Inj Prev. 2011 Feb;17 Suppl 1:14-8.
Objective This report examines unintentional injury deaths among children with and without a history of child maltreatment. Methods Data are from reviews of 1192 unintentional injury deaths occurring among children in Texas during 2005e2007. The study examined differences in child demographic characteristics, injury mechanism, and supervisor status at time of death between children with and without maltreatment history by using descriptive statistics and c2 tests. Separate analyses compared characteristics of asphyxia, drowning, and poisoning deaths. Results In 10% of the unintentional injury deaths that were reviewed, the child had a history of maltreatment. The prevalence of a history of maltreatment was highest among black decedents and lowest among white decedents. Prevalence of a history of maltreatment was highest among infant decedents and lowest among youth decedents, ages 10e14 years. Among deaths where there was no maltreatment history, 54% were due to motor vehicle related incidents, whereas 51% of deaths among children with maltreatment history were caused by drowning, asphyxia, and poisoning. Supervisors of child decedents with a history of maltreatment were significantly more likely to have been alcohol impaired (6.9% vs 1.6%; p<0.0005), or asleep (12.1% vs 6.6%; p¼0.03) at the time of death. Differences between child decedents with and without maltreatment history were observed in infant sleep surface in suffocation deaths, location and barrier type in drowning deaths, and substance type in poisoning deaths. Conclusions These data show that the mechanisms and circumstances surrounding unintentional injury deaths among children with a history of maltreatment differ from those without a history of maltreatment. This underscores the need for appropriate interventions to prevent unintentional and intentional injuries in families with a history of maltreatment.

Postdiarrheal Hemolytic Uremic Syndrome in Persons Aged 65 and Older in Foodnet Sites, 2000-2006.
Gould LH, Jordan JG, Dunn J, Apostol M, Griffin PM; for the Emerging Infections Program FoodNet Working Group.
J Am Geriatr Soc. 2011 Feb;59(2):366-368.
Hemolytic uremic syndrome (HUS) is the leading cause of acute renal failure in children in the United States. Most postdiarrheal HUS follows infection with Shiga toxin–producing Escherichia coli O157 (STEC O157).1 HUS and STEC infection are also serious illnesses in older adults, but little is known about the clinical characteristics and course of HUS in this population.

Men's Attitudes toward Breastfeeding: Findings from the 2007 Texas Behavioral Risk Factor Surveillance System.
Vaaler ML, Castrucci BC, Parks SE, Clark J, Stagg J, Erickson T
Matern Child Health J. 2011 Feb;15(2):148-57.
Past research on breastfeeding demonstrates that male partners' support is a significant factor in mothers' decisions to breastfeed. This study explored the diversity of men's opinions about breastfeeding, for the purpose of increasing breastfeeding support among men. This study used the Texas sample of the 2007 Behavioral Risk Factor Surveillance System (BRFSS) to examine whether men's attitudes toward breastfeeding varied by their demographic characteristics and whether fathers' breastfeeding attitudes were related to couples' choice of infant feeding method. Descriptive statistics and linear regression estimated the influence of each demographic characteristic on breastfeeding attitudes. Among a subsample of fathers, multinomial logistic regression analyzed the influence of men's breastfeeding attitudes on their choice of infant feeding method. Findings showed that Spanish-speaking Hispanic men were most likely to agree that breastfeeding had social limitations (e.g. interfere with social life) for mothers, yet they viewed public images of breastfeeding as more acceptable compared with other men. In comparison to U.S.-born men, foreign-born men were in greater agreement that employers should accommodate breastfeeding. Among fathers, support of public images of breastfeeding and attitudes toward employers' accommodations were positively associated with the choice to use breast milk. Men's ethnicity, country of origin, education level, and socioeconomic status all contribute to different norms and expectations about breastfeeding. Men's attitudes about public images of breastfeeding and employers' accommodations for breastfeeding mothers influence the choice of breast milk as the sole infant-feeding method.

Comparison of Desvenlafaxine and Venlafaxine Ingestions Reported to Texas Poison Centers.
Forrester MB, Villarreal CL.
J Pharm Technol 2011;27:35-40.
Background: Desvenlafaxine is the major active metabolite of the serotonin norepinephrine reuptake inhibitor venlafaxine and is prescribed for the treatment of major depressive disorder. Objective: To compare desvenlafaxine and venlafaxine ingestions reported to a statewide poison center system. Methods: Cases included all desvenlafaxine and venlafaxine ingestions reported to Texas poison centers during 2008-2009. The distribution of all cases by selected demographic factors was identified. After cases that involved coingestants and/or were not followed to a final medical outcome were excluded, the distribution of the remaining cases by clinical and management factors was determined. Results: There were 144 desvenlafaxine and 777 venlafaxine ingestions. The distribution of desvenlafaxine and venlafaxine ingestions was, respectively, female patients 61.8% versus 64.2%, age 0-5 years 31.9% versus 19.3%, unintentional 47.2% versus 39.8%, and involving no coingestants 56.3% versus 46.7%. There were no coingestants and the medical outcome was known for 47 desvenlafaxine and 208 venlafaxine cases. The distribution of this subset of ingestions was, respectively, managed on site 40.4% versus 24.0%, already at or en route to a health-care facility 36.2% versus 52.9%, and referred to a health-care facility 23.4% versus 23.1%. The medical outcome was no effect 72.3% versus 56.3%, minor 14.9% versus 26.4%, moderate 10.6% versus 14.9%, and major 2.1% versus 2.4% for desvenlafaxine and venlafaxine, respectively. Conclusions: The patterns of desvenlafaxine and venlafaxine ingestions were generally similar. However, desvenlafaxine ingestions were more likely to involve young children, be unintentional, not involve coingestants, be managed on site, and involve no effect.

On Linkages: A Multi-Institutional Collaboration to Develop Asthma Education for School Settings in South Texas.
Zuniga GC, Hernandez T, Kirk S, Nadeau N, Chong-Menard B, Lucio RL, Zuniga M.
Public Health Reports. 2011 Jan/Feb;126(1):124-39.
This article discusses the collaboration of numerous institutions to implement an asthma education program for targeted schools in Hidalgo County, Texas, including the McAllen-Edinburg metropolitan area. The cooperating organizations range from academia to local government agencies to community-based organizations. The overall purpose of the program was to promote healthy indoor environments, with a focus on asthma and exposure to environmental triggers among low-income Mexican American elementary and middle-school students in Hidalgo County. Individuals with well-controlled asthma experience better health outcomes, such as reduced inpatient and emergency department visits and increased quality of life. By educating students with asthma, their parents, and personnel at all targeted schools, the partnering institutions aimed to reduce the number of missed school days and health-care encounters due to asthma while increasing the number of symptom-free days for asthma sufferers.

Poinsettia Ingestions by Young Children: A Non-Toxic Wintertime Exposure.
Forrester MB.
TPHJ 2011;63(1):63-64. [No abstract available]

Does directly observed therapy (DOT) reduce drug resistant tuberculosis?
Moonan PK, Quitugua TN, Pogoda JM, Woo G, Drewyer GB, Sahbazian B, Dunbar D, Jost KC Jr, Wallace C, Weis SE.
BMC Public Health. 2011 Jan 7;11(1):19.
Background: Directly observed therapy (DOT) is a widely recommended and promoted strategy to manage tuberculosis (TB), however, there is still disagreement about the role of DOT in TB control and the impact it has on reducing the acquisition and transmission of drug resistant TB. This study compares the portion of drug resistant genotype clusters, representing recent transmission, within and between communities implementing programs differing only in their directly observed therapy (DOT) practices. Methods: Genotype clusters were defined as 2 or more patient members with matching IS6110 restriction fragment length polymorphism (RFLP) and spoligotype patterns from all culture-positive tuberculosis cases diagnosed between January 1, 1995 and December 31, 2001. Logistic regression was used to compute maximum-likelihood estimates of odds ratios (ORs) and 95% confidence intervals (CIs) comparing cluster members with and without drug resistant isolates. In the universal DOT county, all patients received doses under direct observation of health department staff; whereas in selective DOT county, the majority of received patients doses under direct observation of health department staff, while some were able to self-administer doses. Results: Isolates from 1,706 persons collected during 1,721 episodes of tuberculosis were genotyped. Cluster members from the selective DOT county were more than twice as likely than cluster members from the universal DOT county to have at least one isolate resistant to isoniazid, rifampin, and/or ethambutol (OR = 2.3, 95% CI: 1.7, 3.1). Selective DOT county isolates were nearly 5 times more likely than universal DOT county isolates to belong to clusters with at least 2 resistant isolates having identical resistance patterns (OR = 4.7, 95% CI: 2.9, 7.6). Conclusions: Universal DOT for tuberculosis is associated with a decrease in the acquisition and transmission of resistant tuberculosis.

Maternal Smoking, Passive Tobacco Smoke, and Neural Tube Defects.
Suarez L, Ramadhani T, Felkner M, Canfield MA, Brender JD, Romitti PA, Sun L.
Birth Defects Res A Clin Mol Teratol. 2011 Jan;91(1):29-33.
Background: Although cigarette smoke is a well-established toxin and harmful to the developing embryo, the evidence for an independent effect on the occurrence of neural tube defects (NTDs) is mixed. In this study, we examined the relation between NTDs and maternal exposures to cigarette smoke, including passive smoke exposure. Methods: We used cases and controls from the large, multistate, population-based National Birth Defects Prevention Study. A total of 1041 NTD cases and 5862 live birth controls, delivered during 1997 to 2004, were available for analyses. Mothers were interviewed by telephone between 6 weeks and 24 months after delivery. Participation rates were 71% for NTD case mothers and 69% for control mothers. Results: Compared with nonsmokers (and also not exposed to passive cigarette smoke), mothers exposed only to passive smoke had an increased NTD odds ratio (OR, 1.7; 95% confidence interval [CI], 1.4-2.0), adjusted for race-ethnicity, and study center. There was no increased OR for mothers who actively smoked 24 or fewer cigarettes per day. Mothers who smoked 25 or more cigarettes per day had an elevated OR (OR, 1.6; 95% CI, 0.9-3.0), but the OR adjusted for race-ethnicity, and center was compatible with the null. Conclusion: Results suggest that maternal exposure to passive smoke is associated with NTDs. Women who plan on becoming pregnant should minimize their exposure to passive smoke and refrain from smoking.

Disparities in Health Care Utilization among Latino Children Suffering from Asthma in California.
Chang J, Patel I, Liu ST, Ortega AN, Srivastava J, Park YS, Kirk S, Balkrishnan R.
Pediatric Health, Medicine and Therapeutics. 2011;2:1-8.
Objectives: To examine any racial and ethnic differences in health care utilization among children with asthma by application of the Aday and Anderson’s behavioral model of health care utilization. Methods: The California Health Interview Survey (CHIS) is a noninstitutionalized household survey of California residents conducted biannually since 2001. Cross-sectional survey data were analyzed to identify differences by race and ethnicity among children with asthma. After adjusting for sample weights and design effects, children with asthma comprised a sample size of 400,000 in the 2007 CHIS database. Disparities in health care utilization across all racial and ethnic categories were analyzed using multivariate logistic regression analysis. Results: Latino children with asthma were 49% more likely to have visited an emergency department in the previous year (P < 0.05) and 57% less likely to have visited a doctor (P < 0.05) compared with non-Latino children with asthma, after controlling for confounding variables. Furthermore, Puerto Rican children were 72% more likely to have visited an emergency department (P < 0.05) in the previous year and 38% less likely to have visited a doctor (P < 0.07) compared with non-Puerto Rican children. Conclusion: This study provides evidence of disparities in health care utilization among Latino children overall as well as in Latino children belonging to different subgroups suffering from asthma. Examining factors leading to differences within the Latino subgroups could help to guide the tailoring of interventions and health care programs for children with asthma, thereby improving access to health care services for this underrepresented minority.

Hospitalized Patients with 2009 Pandemic Influenza A (H1N1) Virus Infection in the United States--September-October 2009.
Skarbinski J, Jain S, Bramley A, Lee EJ, Huang J, Kirschke D, Stone A, Wedlake T, Richards SM, Page S, Ragan P, Bullion L, Neises D, Williams RM, Petruccelli BP, Vandermeer M, Lofy KH, Gindler J, Finelli L; 2009 Pandemic Influenza A H1N1 Virus Fall Hospitalizations Investigation Team.
Clin Infect Dis. 2011 Jan 1;52 Suppl 1:S50-9.
Given the potential worsening clinical severity of 2009 pandemic influenza A (H1N1) virus (pH1N1) infection from spring to fall 2009, we conducted a clinical case series among patients hospitalized with pH1N1 infection from September through October 2009. A case patient was defined as a hospitalized person who had test results positive for pH1N1 virus by real-time reverse-transcription polymerase chain reaction. Among 255 hospitalized patients, 34% were admitted to an intensive care unit and 8% died. Thirty-four percent of patients were children <18 years of age, 8% were adults ≥ 65 years of age, and 67% had an underlying medical condition. Chest radiographs obtained at hospital admission that had findings that were consistent with pneumonia were noted in 103 (46%) of 255 patients. Among 255 hospitalized patients, 208 (82%) received neuraminidase inhibitors, but only 47% had treatment started ≤ 2 days after illness onset. Overall, characteristics of hospitalized patients with pH1N1 infection in fall 2009 were similar to characteristics of patients hospitalized with pH1N1 infection in spring 2009, which suggests that clinical severity did not change substantially over this period.

Epidemiology of 2009 Pandemic Influenza A (H1N1) Deaths in the United States, April-July 2009.
Fowlkes AL, Arguin P, Biggerstaff MS, Gindler J, Blau D, Jain S, Dhara R, McLaughlin J, Turnipseed E, Meyer JJ, Louie JK, Siniscalchi A, Hamilton JJ, Reeves A, Park SY, Richter D, Ritchey MD, Cocoros NM, Blythe D, Peters S, Lynfield R, Peterson L, Anderson J, Moore Z, Williams R, McHugh L, Cruz C, Waters CL, Page SL, McDonald CK, Vandermeer M, Waller K, Bandy U, Jones TF, Bullion L, Vernon V, Lofy KH, Haupt T, Finelli L.
Clin Infect Dis. 2011 Jan1;52 Suppl 1:S60-8.
During the spring of 2009, pandemic influenza A (H1N1) virus (pH1N1) was recognized and rapidly spread worldwide. To describe the geographic distribution and patient characteristics of pH1N1-associated deaths in the United States, the Centers for Disease Control and Prevention requested information from health departments on all laboratory-confirmed pH1N1 deaths reported from 17 April through 23 July 2009. Data were collected using medical charts, medical examiner reports, and death certificates. A total of 377 pH1N1-associated deaths were identified, for a mortality rate of .12 deaths per 100,000 population. Activity was geographically localized, with the highest mortality rates in Hawaii, New York, and Utah. Seventy-six percent of deaths occurred in persons aged 18-65 years, and 9% occurred in persons aged ≥ 65 years. Underlying medical conditions were reported for 78% of deaths: chronic lung disease among adults (39%) and neurologic disease among children (54%). Overall mortality associated with pH1N1 was low; however, the majority of deaths occurred in persons aged <65 years with underlying medical conditions.



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Last updated February 28, 2014