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DSHS Authors: 2012 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-diamond2012 Articles (in date order with most recent first)

Educating Health Professionals in Obstetrics and Gynecology Regarding Rapid Human Immunodeficiency Virus (HIV) Testing in Labor and Delivery: A Local Initiative.
Levison J, Williams LT, Moore A, McFarlane J, Davila JA.
Matern Child Health J. 2012 Dec;16(9):1748-53.
Although, the Centers for Disease Control and the American College of Obstetricians and Gynecologists have advised rapid HIV testing for laboring women of unknown human immunodeficiency virus (HIV) status since 2004 to ensure that results are known prior to delivery, physicians and hospital staff have been slow to follow the recommendation. A multi-component intervention was implemented to educate physicians and hospital staff. There was low baseline knowledge (<50% correct) in the areas of HIV prevalence, use of rapid testing in the prevention of perinatal HIV transmission, and treatment. On 9 out of 14 items, participants demonstrated a >35% increase in correct responses from pre-test to 3 month post-test. Baseline knowledge among obstetric health care providers about how to diagnose and treat newly diagnosed pregnant women was low. Brief exposure to an educational program yielded a marked increase in knowledge that was sustained over 3 months.

Spatial-Temporal Modeling of the Association between Air Pollution Exposure and Preterm Birth: Identifying Critical Windows of Exposure.
Warren J, Fuentes M, Herring A, Langlois P.
Biometrics. 2012 Dec;68(4):1157-67.
Exposure to high levels of air pollution during the pregnancy is associated with increased probability of preterm birth (PTB), a major cause of infant morbidity and mortality. New statistical methodology is required to specifically determine when a particular pollutant impacts the PTB outcome, to determine the role of different pollutants, and to characterize the spatial variability in these results. We develop a new Bayesian spatial model for PTB which identifies susceptible windows throughout the pregnancy jointly for multiple pollutants (PM(2.5) , ozone) while allowing these windows to vary continuously across space and time. We geo-code vital record birth data from Texas (2002-2004) and link them with standard pollution monitoring data and a newly introduced EPA product of calibrated air pollution model output. We apply the fully spatial model to a region of 13 counties in eastern Texas consisting of highly urban as well as rural areas. Our results indicate significant signal in the first two trimesters of pregnancy with different pollutants leading to different critical windows. Introducing the spatial aspect uncovers critical windows previously unidentified when space is ignored. A proper inference procedure is introduced to correctly analyze these windows.

Diabetes and Obesity-Related Genes and the Risk of Neural Tube Defects in the National Birth Defects Prevention Study.
Lupo PJ, Canfield MA, Chapa C, Lu W, Agopian AJ, Mitchell LE, Shaw GM, Waller DK, Olshan AF, Finnell RH, Zhu H.
Am J Epidemiol. 2012 Dec 15;176(12):1101-9.
Few studies have evaluated genetic susceptibility related to diabetes and obesity as a risk factor for neural tube defects (NTDs). The authors investigated 23 single nucleotide polymorphisms among 9 genes (ADRB3, ENPP1, FTO, LEP, PPARG, PPARGCIA, SLC2A2, TCF7L2, and UCP2) associated with type 2 diabetes or obesity. Samples were obtained from 737 NTD case-parent triads included in the National Birth Defects Prevention Study during 1999-2007. Log-linear models were used to evaluate maternal and offspring genetic effects. After application of the false discovery rate, there were 5 significant maternal genetic effects. The less common alleles at the 4 FTO single nucleotide polymorphisms showed a reduction of NTD risk (for rs1421085, relative risk (RR)=0.73 (95% confidence interval (CI): 0.62, 0.87); for rs8050136, RR=0.79 (95% CI: 0.67, 0.93); for rs9939609, RR = 0.79 (95% CI: 0.67, 0.94); and for rs17187449, RR = 0.80 (95% CI: 0.68, 0.95)). Additionally, maternal LEP rs2071045 (RR= 1.31, 95% CI: 1.08, 1.60) and offspring UCP2 rs660339 (RR=1.32, 95% CI: 1.06, 1.64) were associated with NTD risk. Furthermore, the maternal genotype for TCF7L2 rs3814573 suggested an increased NTD risk among obese women. These findings indicate that maternal genetic variants associated with glucose homeostasis may modify the risk of having an NTD-affected pregnancy.

Work-Related Health Emergency Cases Due to Hydrofluoric Acid Exposures Reported to Texas Poison Centers.
Forrester MB.
Int J Occup Med Environ Health 2012;25:456-462.
Objectives: Hydrofluoric acid is used in a number of industries. Work-related accidents involving hydrofluoric acid can result in serious injury and death. The intent of this investigation was to describe work-related hydrofluoric acid exposures in Texas. Materials and Methods: Work-related hydrofluoric acid exposures reported to Texas poison centers during 2000-2010 were identified. The distribution of exposures was determined for various demographic and clinical factors. Results: There were 409 work-related hydrofluoric acid exposures in years 2000-2010. The number of work-related exposures declined from 69 in 2000 to 18 in 2010. The patients were 85.3% male and 96.6% age 20 years or older. The distribution of cases by route of exposure was 69.4% dermal contact, 21.0% inhalation, 12.0% ocular, and 3.7% ingestion. At the time of reporting to Texas poison centers, the patient was already at or en route to a health care facility in 71.9% of the cases and referred to a healthcare facility in 20.5% of the cases. The medical outcome was known or expected to be not serious in 51.6% of the cases. Conclusions: Hydrofluoric acid exposures reported to Texas poison centers decreased over the eleven-year period. The patients were almost all adults and primarily male. Most of the exposures occurred by dermal contact followed by inhalation. The majority of patients were managed at healthcare facilities. Slightly over half of the exposures were known or expected to not result in serious outcomes.

Evaluation of the American Red Cross Disaster-Related Mortality Surveillance System Using Hurricane Ike Data--Texas 2008.
Farag NH, Rey A, Noe R, Bayleyegn T, Wood AD, Zane D.
Disaster Med Public Health Prep. 2012 Dec 7. [Epub ahead of print]
Objectives:  To evaluate key attributes, strengths, and limitations of the American Red Cross (ARC) disaster-related mortality surveillance system implemented during Hurricane Ike in Texas 2008, and to provide recommendations for system improvement. Methods:  We evaluated key attributes of the ARC mortality surveillance system. Evaluation included interviews with stakeholders and linking ARC data with the Texas Department of State Health Services' (DSHS) system for comparison. Results:  During September 11 through October 6, 2008, the ARC identified 38 deaths, whereas DSHS identified 74 deaths related to Hurricane Ike (sensitivity = 47%; positive predictive value = 92%). The ARC had complete data on 61% to 92% of deaths, and an 83% to 97% concordance was observed between the 2 systems for key variables. Conclusions:  The ARC surveillance system is simple, flexible, and stable. We recommend establishing written guidelines to improve data quality and representativeness. As an important supporting agency in disaster situations and the sole source of data regarding disaster-related mortality in multiple states, improvement of the ARC system will benefit stakeholders and promote dissemination of useful information for preventing future deaths.

Intention to Comply with Mandatory Hurricane Evacuation Orders among Persons Living along a Coastal Area.
Reininger BM, Raja SA, Carrasco AS, Chen Z, Adams B, McCormick J, Rahbar MH.
Disaster Med Public Health Prep. 2012 Dec 7. [Epub ahead of print]
Objectives:  We examined the intention to comply with mandatory hurricane evacuation orders among respondents living in coastal areas with pronounced poverty by demographic and location characteristics. Methods:  A 3-county door-to-door survey was conducted with 1 randomly selected resident per household. Households were selected using a 2-stage cluster sampling strategy and stratified by county. The final sample included 3088 households in 100 census tracts across 3 counties. Results:  Findings suggest that the majority of residents living in areas prone to hurricanes intend to comply with mandatory evacuation orders regardless of income level. Variation in intention to comply with mandatory evacuation orders is shown by age, gender, ethnicity, education, acculturation, county, and distance from shoreline. Conclusions:  The demonstrated high intention to comply with evacuation orders in impoverished areas suggests a need for improved planning to evacuate the most vulnerable residents. Demographic and location characteristics associated with decreased intention to comply may be considered for targeting messages and education before disasters to modifying intentions and plans to evacuate.

Descriptive Epidemiology of Non-syndromic Complete Atrioventricular Canal Defects.
Agopian A, Moulik M, Gupta-Malhotra M, Marengo L, Mitchell L.
Paediatr Perinat Epidemiol. 2012 Nov;26(6):515-24.
Background: Complete atrioventricular canal defects (CAVC) are a common heart defect, but few epidemiologic studies have evaluated non-syndromic CAVC. Risk factors for non-syndromic CAVC have not been well established. Methods: To assess the relationship between risk for non-syndromic CAVC in offspring and several sociodemographic and reproductive parental factors, including maternal diabetes and obesity, we conducted Poisson regression analyses, using data ascertained through the Texas Birth Defects Registry, a large, population-based birth defects registry. Data were evaluated for 563 non-syndromic cases with CAVC. Results: Significant associations were observed between non-syndromic CAVC in offspring and maternal pregestational diabetes (adjusted prevalence ratio (aPR) 6.74; 95% confidence interval (CI) 3.67, 12.37), gestational diabetes (aPR 1.69; 95% CI 1.03, 2.79) and obesity (aPR 1.69; 95% CI 1.24, 2.30). Conclusions: Our findings add non-syndromic CAVC to the growing list of birth defects that appear to be associated with maternal diabetes and obesity.

Geographic Distribution of Synthetic Cannabinoid Exposures Reported to Texas Poison Centers.
Forrester MB, Haywood T.
Am J Drug Alcohol Abuse. 2012 Nov;38(6):609-15.
Background: Among the novel classes of synthetic “designer” drugs that have become increasingly popular among recreational drug users are synthetic cathinones. There is limited information on exposures to these substances. Objective: The objective of this investigation was to describe the pattern of synthetic cathinone exposures reported to a statewide poison center network. Methods: Synthetic cathinone exposures reported to Texas poison centers during 2010–2011 were identified and the distribution by various demographic and clinical factors determined. Results: Of 362 total calls, 84.5% of the patients were 20 years or older and 74.0% male. The route of exposure was 47.8% by inhalation alone and 28.7% by ingestion alone. Other substances were involved in 19.3% of the exposures. The patient was already at or en route to a health-care facility in 75.1% of the exposures. The outcome was serious (moderate, major, potentially toxic, or death) in 74.0% of the exposures. The most frequently reported clinical effects were tachycardia (45.9%), agitation (39.2%), hypertension (21.0%), hallucinations (17.7%), and confusion (13.0%). The most common treatments were IV fluids (53.6%), benzodiazepines (40.9%), oxygen (11.0%), and other sedatives (7.5%). Conclusion: Synthetic cathinone exposures reported to Texas poison centers tended to occur through inhalation or ingestion, involve adult and male patients, be managed at health-care facilities, and involve potentially serious outcomes. Scientific Significance: This study adds to the limited information currently available on synthetic cathinone exposures.

Giving Babies the Chance They Deserve.
Lakey D.
J Public Health Manag Pract. 2012 Nov;18(6):631-2. (No abstract available.)

Eliminating Tuberculosis One Neighborhood at a Time.
Cegielski JP, Griffith DE, McGaha PK, Wolfgang M, Robinson CB, Clark PA, Hassell WL, Robison VA, Walker KP Jr, Wallace C.
Am J Public Health. 2012 Oct 18. [Epub ahead of print]
Objectives. We evaluated a strategy for preventing tuberculosis (TB) in communities most affected by it. Methods. In 1996, we mapped reported TB cases (1985-1995) and positive tuberculin skin test (TST) reactors (1993-1995) in Smith County, Texas. We delineated the 2 largest, densest clusters, identifying 2 highest-incidence neighborhoods (180 square blocks, 3153 residents). After extensive community preparation, trained health care workers went door-to-door offering TST to all residents unless contraindicated. TST-positive individuals were escorted to a mobile clinic for radiography, clinical evaluation, and isoniazid preventive treatment (IPT) as indicated. To assess long-term impact, we mapped all TB cases in Smith County during the equivalent time period after the project. Results. Of 2258 eligible individuals, 1291 (57.1%) were tested, 229 (17.7%) were TST positive, and 147 were treated. From 1996 to 2006, there were no TB cases in either project neighborhood, in contrast with the preintervention decade and the continued occurrence of TB in the rest of Smith County. Conclusions. Targeting high-incidence neighborhoods for active, community-based screening and IPT may hasten TB elimination in the United States.

Surveillance for Mycobacterium Bovis Transmission from Domestic Cattle to Wild Ruminants in a Mexican Wildlife-Livestock Interface Area.
Cisneros LF, Valdivia AG, Waldrup K, Díaz-Aparicio E, Martínez-de-Anda A, Cruz-Vázquez CR, Ortiz R.
Am J Vet Res. 2012 Oct;73(10):1617-25.
Objective: To assess the prevalence of Mycobacterium bovis infection in cattle and wild ruminants (WRs) in a wildlife-livestock interface area (WLIA) of the Mexican highland plateau. Animals: 24,400 cattle from 793 herds (including 17,351 commercially slaughtered cattle) and 142 WRs (110 white-tailed deer [Odocoileus virginianus], 20 red deer [Cervus elaphus], and 12 North American elk [Cervus canadensis]) harvested via controlled hunting. Procedures: Cattle were serially tested for M bovis infection via caudal fold tuberculin and comparative cervical tuberculin tests during field surveillance. Carcasses of cattle and WRs were inspected for gross lesions; samples suggestive of tuberculosis were analyzed via histologic evaluation and mycobacterial culture (HMC). A PCR assay to detect Mycobacterium tuberculosis complex organisms was performed to confirm positive results of HMC. Results: WRs had inflammatory lesions in lungs and lymph nodes, although HMC results did not indicate M bovis infection. Eight cattle had positive results for both tuberculin tests, and 31 had positive results for HMC of grossly detected lesions; all were from 7 herds, and ≥ 1 cow in each herd had positive PCR assay results. These 7 herds were depopulated; adjacent herds and herds related via commerce were quarantined. Calculated true prevalence of M bovis infection was 0.86% (95% confidence interval, 0.24% to 1.49%) in cattle; M bovis was not detected in any WRs. Conclusions and Clinical Relevance: M bovis infection was present in cattle. Although transmission to WRs in this WLIA was not detected, diagnosis and prevention activities should be implemented and consolidated to prevent potential M bovis transmission between cattle and WRs.

Cancer in Relation to Socioeconomic Status: Stage at Diagnosis in Texas, 2004-2008.
Risser DR, Miller EA.
South Med J. 2012 Oct;105(10):508-12.
Objectives: To determine whether stage of cancer diagnosis was associated with the socioeconomic status (SES) of the census tract where the patient resides, and to assess whether this is modified by race, ethnicity, or urban/rural residence, other factors known to affect cancer diagnosis stage. Methods: Using 2004-2008 data from the Texas Cancer Registry, we examined the distribution of stage at diagnosis in Texas residents for 15 cancer sites by the SES of the census tract of residence. Stage at diagnosis was categorized into the summary stage categories of early (in situ [preinvasive disease] and localized) and late stage (regional and distant spread). Age-adjusted odds ratios for late-stage versus early-stage cancer diagnosis in low versus high SES census tracts were evaluated by cancer site, race, ethnicity, and urban versus rural residence. Results: For most cancer sites, late-stage cancer diagnosis increased with decreasing SES. These findings were consistent by cancer site, race, ethnicity, and in urban and rural areas of the state. Conclusions: For most cancer sites, particularly those likely to have patients diagnosed early by screening, late-stage cancer diagnosis is increased in Texas populations residing in lower SES census tracts compared with higher SES census tracts.

Public Health Emergency Response to a Massive Wildfire in Texas (2011).
Zane D, Jones R, Huss J, Sanches K, Hoogheem J, Clements B.
Texas Public Health Journal. 2012 Fall;64(4):6-10.
The article focuses on the public health emergency response to wildfires in Texas in 2011. The authors identify the issues during the initial response for wildfires in the state including responder safety and health, disaster behavioral health and emergency public information. They state that medical officials from other jurisdiction can learn from the states’ best practices in emergency response.

Assessment of a Child Injury Prevention Intervention in the Texas-Mexico Border.
Garza N, Zuniga G, Luohua J, Mier N, Hellsten J, Rene A.
Texas Public Health Journal. 2012 Fall;64(4):19-22.
The article looks into the intervention programs for child injury prevention in the Texas-Mexico border. The authors examine the effectiveness of injury prevention training for Mexican American households living in the border. They also conducted home hazards assessments in low-income areas such as in the Texas-Mexico border. 

Changes in Texas Poison Center Call Patterns in Response to H1N1 Influenza Outbreak.
Forrester MB.
TPHA J 2012;64(4):14-18.
Background: As a consequence of the H1N1 influenza outbreak first reported in April 2009, numerous recommendations were made to reduce the risk of or manage infection. This investigation examined whether the H1N1 outbreak changed the pattern of exposures reported to poison centers. Methods: This retrospective study use data collected by a Texas poison centers. The monthly number of exposures during 2008 2010 was determined for the following exposures: total exposures, cough/cold medications, neuraminidase inhibitor drugs, adamantane drugs, influenza vaccines, and hand sanitizers. The monthly number of exposures in 2009 was then compared to that reported in 2008 and 2010. Results: Monthly total exposures and cough/cold medication exposures reported in 2009 were similar to the other years. Monthly adamantane exposures in 2009 were similar to 2008 and 2010. Monthly neuraminidase inhibitors in 2009 were higher than the other years for July December. Monthly influenza vaccine exposures were higher in 2009 in September December. Hand sanitizer exposures were higher in 2009 than in 2008 and 2010 for April-July and September-December. Discussion: After the H1N1 outbreak was first reported, the number of neuraminidase inhibitor, influenza vaccine, and hand sanitizer exposures reported to Texas poison centers increased. A similar trend was not observed for total exposures, cough/cold medications, and adamantanes. These exposures might be of limited use as surrogates for conducting influenza surveillance because even those exposures that increased would likely only do so after an influenza outbreak is already recognized.

Back to School Poison Control Alert: Adverse Effects from Ingestion of Energy Drinks.
Forrester MB.
TPHA J 2012;64(4):34-35. (No abstract available.)

Neural Tube Defects on the Texas-Mexico Border: What We've Learned in the 20 Years since the Brownsville Cluster.
Suarez L, Felkner M, Brender JD, Canfield M, Zhu H, Hendricks KA.
Birth Defects Res A Clin Mol Teratol. 2012 Nov;94(11):882-92.
We reviewed the published findings from the Texas Neural Tube Defect Project, a 6-year case-control study (1995-2000) of neural tube defects (NTDs) on the Texas-Mexico border. In this review, we highlight what was learned about environmental, genetic, and nutritional factors (i.e., those related to the folate and other metabolic pathways) and the novel putative risk factors that emerged from this study of Mexican American women living on the Texas-Mexico border. Our investigations of the micronutrients and metabolic pathways involved confirmed the findings of other researchers that increased folate intake has a protective effect and that low serum B(12), high serum homocysteine levels, and obesity independently contribute to risk. Studies of this population also have implicated hyperinsulinemia and low ferritin, metabolic risk factors, which require additional study to elucidate their physiologic mechanism. Environmental contaminants such as heavy metals, pesticides, and polychlorinated biphenyls (PCBs), which were of community concern, did little to explain NTD risk. Studies in this folic acid deficit-population also revealed several novel risk factors, namely, diarrhea, stress, fumonisins, and the combination of nitrosatable drug exposure with high nitrate/nitrite intake. In conclusion, the 23 studies among the Mexican American women living along the Texas-Mexico border have demonstrated the multifactorial nature of NTDs and that a population deficient in folic acid will be vulnerable to a variety of insults whether brought on by individual behaviors (e.g., obesity) or through the surrounding environment (e.g., fumonisins).

Surveillance Detection of Concentrated Laundry Detergent Pack Exposures.
Forrester MB.
Clin Toxicol (Phila) 2012;50:847-850.
Context: In early 2012, concentrated laundry detergent packs began to be marketed in the United States. Around May 2012, poison centers began to notice that they were handling serious exposures among young children to these products. Objective: This investigation examined whether a surveillance algorithm might have identified the exposures to laundry detergent packs among young children. Methods: Cases were exposures reported to Texas poison centers during January – June in 2009, 2010, 2011, and 2012. The monthly number of exposures reported in 2012 was determined. The mean for the corresponding month in the preceding 3 years (2009, 2010, 2011) was calculated. If the 2012 monthly value was greater than the historic mean plus two standard deviations, then the 2012 value was considered to be elevated. The comparison was made for eight case definitions involving combinations of age (5 years or less), vomiting, and substance being laundry detergent. Results: When compared to historic values, in 2012 the monthly total exposures and all exposures involving young children were not elevated. Exposures among young children involving vomiting did not become elevated until June 2012. Exposures involving any laundry detergent became elevated in March and remained elevated through June. Discussion:. Surveillance of total exposures, all exposures involving young children, and exposures involving vomiting would not have been effective for identifying the influx of calls due to exposures to laundry detergent packs involving young children. Surveillance of any laundry detergent exposures would have identified these calls almost immediately.

Adolescent Synthetic Cannabinoid Exposures Reported to Texas Poison Centers.
Forrester MB.
Pediatr Emerg Care 2012;28:985-989.
Objective: This study describes the pattern of adolescent synthetic cannabinoid exposures reported to a large statewide poison center system. Methods: Synthetic cannabinoid exposures among patients younger than 20 years reported to Texas poison centers during January 2010 to June 2011 were identified. The distribution of exposures by various demographic and clinical factors was determined. Results: For 305 adolescent exposures, the mean age was 16.7 years (range, 12-19 y). The exposure was by inhalation in 77.4% of the cases, and 72.1% involved males. The exposure site was the patient's own residence in 70.5% of the cases, and a health care facility was the caller site in 68.9%. The patient was already at or en route to a health care facility in 80.3% of the cases, and the medical outcome was serious in 61.0%. The most frequently reported adverse clinical effects were tachycardia (41.6%), drowsiness/lethargy (24.3%), agitation/irritability (16.4%), vomiting (13.1%), hallucinations/delusions (11.5%), nausea (8.5%), confusion (8.2%), hypertension (7.5%), chest pain (6.9%), and dizziness/vertigo (5.2%). Conclusions: Adolescent synthetic cannabinoid exposures reported to Texas poison centers were more likely to involve inhalation. The adolescents were more likely to be male. The exposures more often occurred at the patient's own residence and managed at a health care facility with a serious outcome. This pattern of exposures was similar to that observed among adults.

Relationship between Prenatal Lead Exposure and Infant Blood Lead Levels.
Archer NP, Bradford CM, Klein DM, Barnes J, Smith LJ, Villanacci JF.
Matern Child Health J. 2012 Oct;16(7):1518-24.
Recent literature has shown that analyzing newborn dried blood spots (DBS) may be effective in assessing some prenatal environmental exposures, such as exposure to lead. The purpose of this study was to evaluate the relationship between prenatal exposure to lead (as measured by newborn DBS results) and blood lead levels (BLLs) in infants 6 months of age or younger, using public health registry data for infants born in Texas from July 2002 through July 2006. The Texas Child Lead Registry (TCLR) was used to identify infants with documented elevated BLLs of 10 μg/dL or higher as well as infants with documented low BLLs. BLLs for these children were compared to their corresponding newborn DBS results using Pearson correlation coefficients and exact logistic regression models. Overall, a significant but weak positive correlation was found between infant BLLs and corresponding newborn DBS lead levels (r = 0.48). However, the odds of an infant with an elevated newborn DBS lead level having an elevated BLL at 6 months of age or younger were much greater than for an infant with a low newborn DBS lead level of <5 μg/dL (adjusted odds ratio 27.95, 95% CI: 5.52-277.28). Although an association was observed between newborn DBS lead levels and BLLs in infants tested between 0 to 6 months of age, our findings suggest that prenatal exposure may not be the only significant source of lead exposure for infants ≤6 months of age.

Differences in Folic Acid Use, Prenatal Care, Smoking, and Drinking in Early Pregnancy by Occupation.
Agopian AJ, Lupo PJ, Herdt-Losavio ML, Langlois PH, Rocheleau CM, Mitchell LE
Prev Med. 2012 Oct;55(4):341-5.
Objective: To describe differences in four high risk periconceptional behaviors (lack of folic acid supplementation, lack of early prenatal care, smoking, and drinking) by maternal occupation. Methods: Analyses were conducted among women in the National Birth Defects Prevention Study who delivered liveborn infants without birth defects. Periconceptional occupational data were collected using a computer-assisted telephone interview and occupational coding was performed using the 2000 Standard Occupational Classification System. Logistic regression analyses were conducted to determine whether prevalence of behaviors differed between occupational groups. Results: Subjects included 5153 women employed during early pregnancy from 1997 to 2007. Compared to women in management, business, science, and arts occupations, women in other occupations (e.g., service occupations) were significantly more likely to engage in all four high risk behaviors. Specifically, women in food preparation/serving-related occupations were significantly more likely to engage in all four behaviors compared to women in all other occupational groups (odds ratios: 1.8–3.0), while women in education/training/library occupations were significantly less likely to do so (odds ratios: 0.2–0.5). Conclusion: We identified several occupational groups with an increased prevalence of high-risk maternal behaviors during pregnancy. Our findings could aid in developing interventions targeted towards women in these occupational groups.

Are Poison Ivy (Toxicodendron radicans) Exposures Becoming More Serious in Texas?
Forrester MB, Prosperie S.
TPHJ 2012;64(3):35.

Potential Pediatric Hazard: New Laundry Detergent Packs or Pods.
Forrester MB.
TPHJ 2012;64(3):37.

Texas Black Widow Spiders Take the Heat.
Forrester MB.
TPHJ 2012;64(3):36.

Evaluating Patient Adherence to Antidepressant Therapy among Uninsured Working Adults Diagnosed with Major Depression: Results of the Texas Demonstration to Maintain Independence and Employment Study.
Nwokeji ED, Bohman TM, Wallisch L, Stoner D, Christensen K, Spence RR, Reed BC, Ostermeyer B.
Adm Policy Ment Health. 2012 Sep;39(5):374-82.
This study examined antidepressant adherence and persistence among uninsured working adults diagnosed with major depression enrolled in the Texas Demonstration to Maintain Independence and Employment (DMIE) program. Antidepressant adherence was measured between intervention and control cohorts using proportion of days covered (PDC) during a 365-day observation period. Persistence examined duration of time from drug initiation to discontinuation based on a ≥35-day refill supply gap. Older, non-minority patients with higher education were more adherent or persistent to antidepressant therapy. Adjusting for covariates, results showed no significant difference in PDC at the end of 12-months between intervention and control participants ( b = .07, P = .054, semi-partial η = .02). Exploratory analysis found subgroup differences in PDC among the study recruitment cohorts. No significant difference between intervention and control groups was found in persistence between the groups. Follow-up investigation is planned to assess the longer term impact of the DMIE program on antidepressant adherence and persistence.

Design, Methodological Issues and Participation in a Multiple Sclerosis Case-Control Study.
Williamson DM, Marrie RA, Ashley-Koch A, Schiffer R, Trottier J, Wagner L.
Acta Neurol Scand. 2012 Sep;126(3):197-204.
Objectives: This study was conducted to determine whether the risk of developing multiple sclerosis ( MS) was associated with certain environmental exposures or genetic factors previously reported to influence MS risk. This paper describes the methodological issues, study design and characteristics of the study population. Materials and methods: Individuals with definite MS were identified from a prevalence study conducted in three geographic areas. The target number of cases was not reached, so an additional study area was added. Identifying clinic controls was inefficient, so controls were recruited using random digit dialing. All study participants completed a detailed questionnaire regarding environmental exposures using computer-assisted telephone interviewing, and blood was collected for genetic analysis. Results: In total, 276 cases and 590 controls participated, but participation rates were low, ranging from 28.4% to 38.9%. Only one-third (33.6%) of individuals identified in the prevalence study agreed to participate in the case-control study. Cases were more likely to be non-Hispanic white and older than their source populations as identified in the preceding prevalence study ( P < 0.05). Most participants provided a blood sample for genotyping (91%; n = 789). Conclusions: Epidemiological studies play a key role in identifying genetic and environmental factors that are associated with complex diseases like MS. Methodological issues arise in every study, and investigators need to be able to detect, respond to and correct problems in a timely and scientifically valid manner.

Maternal Occupational Exposure to Polycyclic Aromatic Hydrocarbons and Risk of Neural Tube Defect-Affected Pregnancies.
Langlois PH, Hoyt AT, Lupo PJ, Lawson CC, Waters MA, Desrosiers TA, Shaw GM, Romitti PA, Lammer EJ; and the National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2012 Sep;94(9):693-700.
Background: This study evaluated whether there is an association between maternal occupational exposure to polycyclic aromatic hydrocarbons (PAHs) and neural tube defects (NTDs) in offspring. This is the first such study of which the authors are aware. Methods: Data were analyzed from 1997 to 2002 deliveries in the National Birth Defects Prevention Study, a large population-based case-control study in the United States. Maternal interviews yielded information on jobs held in the month before through 3 months after conception. Three industrial hygienists blinded to case or control status assessed occupational exposure to PAHs. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using unconditional logistic regression. Results: Of the 520 mothers of children with NTDs, 5.0% were classified as exposed to occupational PAHs, as were 3.5% of the 2989 mothers of controls. The crude OR for PAH exposure was 1.43 (95% CI, 0.92-2.22) for any NTD and 1.71 (95% CI, 1.03-2.83) for spina bifida. Adjusted ORs were smaller in magnitude and not significant. Among women who were normal weight or underweight, the crude OR for spina bifida was 3.13 (95% CI, 1.63-6.03) and adjusted OR was 2.59 (95% CI, 1.32-5.07). Based on estimated cumulative exposure, a statistically significant dose-response trend was observed for spina bifida; however, it was attenuated and no longer significant after adjustment. Conclusion: Maternal occupational exposure to PAHs may be associated with increased risk of spina bifida in offspring among women who are normal weight or underweight. Other comparisons between PAHs and NTDs were consistent with no association.

Challenges in Confirming a Varicella Outbreak in the Two-Dose Vaccine Era.
Mahamud A, Wiseman R, Grytdal S, Basham C, Asghar J, Dang T, Leung J, Lopez A, Schmid DS, Bialek SR.
Vaccine.Nov2012;30(48):6935-9.
Background: A second dose of varicella vaccine was recommended for U.S. children in 2006. We investigated a suspected varicella outbreak in School District X, Texas to determine 2-dose varicella vaccine effectiveness (VE). Methods: A varicella case was defined as an illness with maculopapulovesicular rash without other explanation with onset during April 1-June 10, 2011, in a School District X student. We conducted a retrospective cohort in the two schools with the majority of cases. Lesion, saliva, and environmental specimens were collected for varicella-zoster virus (VZV) PCR testing. VE was calculated using historic attack rates among unvaccinated. Results: In School District X, 82 varicella cases were reported, including 60 from Schools A and B. All cases were mild, with a median of 14 lesions. All 10 clinical specimens and 58 environmental samples tested negative for VZV. Two-dose varicella vaccination coverage was 66.4% in Schools A and B. Varicella VE in affected classrooms was 80.9% (95% CI: 67.2-88.9) among 1-dose vaccinees and 94.7% (95% CI: 89.2-97.4) among 2-dose vaccinees in School A, with a second dose incremental VE of 72.1% (95% CI: 39.0-87.3). Varicella VE among School B students did not differ significantly by dose (80.1% vs. 84.2% among 1-dose and 2-dose vaccinees, respectively). Conclusion: Laboratory testing could not confirm varicella as the etiology of this outbreak; clinical and epidemiologic data suggests varicella as the likely cause. Better diagnostics are needed for diagnosis of varicella in vaccinated individuals so that appropriate outbreak control measures can be implemented.

Evaluation of active mortality surveillance system data for monitoring hurricane-related deaths, Texas, 2008.
Choudhary E, Zane DF, Beasley C, Jones R, Rey A, Noe RS, Martin C, Wolkin AF, Bayleyegn TM.
Prehosp Disaster Med. 2012 Aug;27(4):392-7.
Introduction: The Texas Department of State Health Services (DSHS) implemented an active mortality surveillance system to enumerate and characterize hurricane-related deaths during Hurricane Ike in 2008. This surveillance system used established guidelines and case definitions to categorize deaths as directly, indirectly, and possibly related to Hurricane Ike. Objective: The objective of this study was to evaluate Texas DSHS’ active mortality surveillance system using US Centers for Disease Control and Prevention’s (CDC) surveillance system evaluation guidelines. Methods: Using CDC’s Updated Guidelines for Surveillance System Evaluation, the active mortality surveillance system of the Texas DSHS was evaluated. Data from the active mortality surveillance system were compared with Texas vital statistics data for the same time period to estimate the completeness of reported disaster-related deaths. Results: From September 8 through October 13, 2008, medical examiners (MEs) and Justices of the Peace (JPs) in 44 affected counties reported deaths daily by using a one page, standardized mortality form. The active mortality surveillance system identified 74 hurricane-related deaths, whereas a review of vital statistics data revealed only four deaths that were hurricane-related. The average time of reporting a death by active mortality surveillance and vital statistics was 14 days and 16 days, respectively. Conclusions: Texas’s active mortality surveillance system successfully identified hurricane related deaths. Evaluation of the active mortality surveillance system suggested that it is necessary to collect detailed and representative mortality data during a hurricane because vital statistics do not capture sufficient information to identify whether deaths are hurricane related. The results from this evaluation will help improve active mortality surveillance during hurricanes which, in turn, will enhance preparedness and response plans and identify public health interventions to reduce future hurricane-related mortality rates.

Effect of cough and cold medication withdrawal and warning on ingestions by young children reported to Texas poison centers.
Forrester MB.
Pediatr Emerg Care 2012;28:510-513.
Objective: This study examined whether the withdrawal of over-the-counter cough and cold medication labeled for use in children younger than 2 years in October 2007 and the warning against use of the products in children younger than 4 years in October 2008 affected cough and cold medication ingestions by young children reported to a statewide poison system. Methods: Cases were all cough and cold medication ingestions by children aged 0 to 5 years reported to the Texas Poison Center Network during October 1998 to September 2009. The annual number of ingestions was determined, and the percent change from the previous year calculated. Results: During October 1998 to September 2007, the number of ingestions exhibited a mean annual increase of 2.5%. The number of ingestions declined by 16.0% during October 2007 to September 2008 and 9.3% during October 2008 to September 2009. During October 2007 to September 2008, the number decreased by 26.5% in children aged 0 to 1 years, 13.5% in those aged 2 to 3 years, 5.4% in those aged 4 to 5 years, 23.4% therapeutic errors or adverse drug reactions, and 11.5% in all other circumstances. Conclusions: The voluntary withdrawal and subsequent voluntary warning of over-the-counter cough and cold medications appear to have resulted in a decline in ingestions reported to Texas poison centers not only among children aged 0 to 1 and 2 to 3 years but also among children aged 4 to 5 years, although the degree of decline was greatest for the youngest age groups. The decrease was observed not only among therapeutic errors and adverse drug reactions, but also in other circumstances of ingestion, although the decrease was greater for the former circumstances.

Synthetic cannabinoid and marijuana exposures reported to poison centers.
Forrester M, Kleinschmidt K, Schwarz E, Young A.
Hum Exp Toxicol 2012;31:1006-1011.
Synthetic cannabinoids have recently gained popularity as a recreational drug because they are believed to result in a marijuana-like high. This investigation compared synthetic cannabinoids and marijuana exposures reported to a large statewide poison center system. Synthetic cannabinoid and marijuana exposures reported to Texas poison centers during 2010 were identified. The distribution of exposures to the two agents with respect to various demographic and clinical factors were compared by calculating the rate ratio (RR) of the synthetic cannabinoid and marijuana percentages for each subgroup and 95% confidence interval (CI). The proportion of synthetic cannabinoid and marijuana exposures, respectively, were 87.3% and 46.5% via inhalation (RR 1.88, 95% CI 1.38-2.61), 74.9% and 65.7% in male (RR 1.14, 95% CI 0.87-1.51), 40.2% and 56.6% age ≤19 years (RR 0.71, 95% CI 0.52-0.98), 79.2% and 58.6% occurring at a residence (RR 1.35, 95% CI 1.02-1.82), 8.4% and 16.2% managed on-site (RR 0.52. 95% CI 0.28-1.00), and 59.3% and 41.4% with serious medical outcomes (RR 1.43, 95% CI 1.03-2.05). Compared to marijuana, synthetic cannabinoid exposures were more likely to be used through inhalation, to involve adults, to be used at a residence, and to result in serious outcomes.

Preconception Health Indicators among Women--Texas, 2002-2010.
MMWR Morb Mortal Wkly Rep. 2012 Jul 27;61(29):550-5.
Centers for Disease Control and Prevention (CDC). DSHS employees: Rochelle Kingsley, Rebecca Martin, Mark Canfield, Amy Case, Noha H. Farag.
The first few weeks after conception are the most critical for fetal development; because most women are not aware that they are pregnant until after this critical period, health-care interventions should begin before conception. Promoting preconception health is an essential component of any broad strategy to prevent adverse pregnancy outcomes. Women who are planning pregnancy or could become pregnant should have a preconception health evaluation and adopt appropriate health behaviors. The Pregnancy Risk Assessment Monitoring System (PRAMS) tracks maternal behaviors, experiences, and health conditions, including preconception health. PRAMS is a state-specific, population-based surveillance system. The Texas Department of State Health Services analyzed PRAMS responses regarding preconception health of Texas women who delivered a live-born infant during 2002-2010. Among women who responded, 48% had no health-care insurance coverage before pregnancy and 46% reported an unintended pregnancy. In addition, 45% of the women reported consuming alcohol during the 3 months before pregnancy, and 18% reported binge drinking. Differences in demographic and socioeconomic variables were observed for the majority of preconception health indicators. Compared with non-Hispanic white women, non-Hispanic black and Hispanic women reported a 20% higher prevalence of not consuming a daily multivitamin and of being physically inactive, and approximately twice the prevalence of prepregnancy diabetes. Women without health-care coverage (public or private) before pregnancy generally were more likely to report unfavorable behavioral characteristics and health conditions compared with women with health-care coverage, regardless of whether the pregnancy was planned or not. Targeted public health interventions addressing the observed disparities in the preconception health and health care of women in Texas are needed.

Effect of Acculturation and Distance from Cardiac Center on Congenital Heart Disease Mortality.
Fixler DE, Nembhard WN, Xu P, Ethen MK, Canfield MA.
Pediatrics. 2012 Jun;129(6):1118-24.
Background and Objective: Despite improvements in congenital heart disease (CHD) survival over the past 4 decades, ethnic disparities persist. Several studies have shown higher postoperative CHD adjusted mortality in black and Hispanic children. Others noted that non-English-speaking language at home was associated with appointment noncompliance, which the parents attributed to misunderstanding and living too far from a health center. The purpose of this study was to determine the effect of home distance to a cardiac center, or having a Latin American-born parent, on first-year mortality in infants with severe CHD. Methods: Infants with severe CHD, having an estimated first-year mortality >25%, born 1996-2003, were identified from the Texas Birth Defects Registry and linked to state and national vital records. We examined the effects of defect type; birth weight; gestational age; extracardiac anomalies; infant gender; maternal race/ethnicity, marital status, and education; residence in a Texas county bordering Mexico; home distance to cardiac center; and parental birth country on first- year survival. Results: Overall first-year survival was 59.9%, and no race/ethnic differences were noted; however, survival was significantly [P < .05) lower for Hispanic infants with hypoplastic left heart syndrome. Neither home distance to a cardiac center nor parental birth country was related to first-year survival; however, survival was noted to be lower in Texas counties bordering Mexico, counties that have high rates of poverty. Conclusions: Further studies are needed to determine if these disparities in survival of infants with severe CHD are attributable to delays in referral to a cardiac center.

Maternal Occupational Exposure to Polycyclic Aromatic Hydrocarbons: Effects on Gastroschisis among Offspring in the National Birth Defects Prevention Study.
Langlois PH, Hoyt AT, Lupo PJ, Lawson CC, Waters MA, Desrosiers TA, Shaw GM, Romitti PA, Lammer EJ.
Cleft Palate Craniofac J. 2012 Nov 8. [Epub ahead of print]
Background: Exposure to polycyclic aromatic hydrocarbons (PAHs) occurs in many occupational settings. There is evidence in animal models that maternal exposure to PAHs during pregnancy is associated with gastroschisis in offspring; however, to our knowledge, no human studies examining this association have been conducted. Objective: Our goal was to conduct a case–control study assessing the association between estimated maternal occupational exposure to PAHs and gastroschisis in offspring. Methods: Data from gastroschisis cases and control infants were obtained from the population-based National Birth Defects Prevention Study for the period 1997–2002. Exposure to PAHs was assigned by industrial hygienist consensus, based on self-reported maternal occupational histories from 1 month before conception through the third month of pregnancy. Logistic regression was used to determine the association between estimated occupational PAH exposure and gastroschisis among children whose mothers were employed for at least 1 month during the month before conception through the third month of pregnancy. Results: The prevalence of estimated occupational PAH exposure was 9.0% in case mothers (27 of 299) and 3.6% in control mothers (107 of 2,993). Logistic regression analyses indicated a significant association between occupational PAHs and gastroschisis among mothers ≥ 20 years of age [odds ratio (OR) = 2.53; 95% confidence interval (CI): 1.27, 5.04] after adjusting for maternal body mass index, education, gestational diabetes, and smoking. This association was not seen in mothers < 20 years (OR = 1.14; 95% CI: 0.55, 2.33), which is notable because although young maternal age is the strongest known risk factor for gastroschisis, most cases are born to mothers ≥ 20 years. Conclusion: Our findings indicate an association between occupational exposure to PAHs among mothers who are ≥ 20 years and gastroschisis. These results contribute to a body of evidence that PAHs may be teratogenic.

Mapping Late Testers for HIV in Texas.
Oppong JR, Tiwari C, Ruckthongsook W, Huddleston J, Arbona S.
Health Place. 2012 May;18(3):568-75
Understanding the spatial patterns of late testing for HIV infection is critically important for designing and evaluating intervention strategies to reduce the social and economic burdens of HIV/AIDS. Traditional mapping methods that rely on frequency counts or rates in predefined areal units are known to be problematic due to issues of small numbers and visual biases. Additionally, confidentiality requirements associated with health data further restrict the ability to produce cartographic representations at fine geographic scales. While kernel density estimation methods produce stable and geographically detailed patterns of the late testing burden, the resulting pattern depends critically on the definition of the at-risk population. Using three definitions of at risk groups, we examine the cartographic representation of HIV late testers in Texas and show that the resulting spatial patterns and the interpretation of disease burdens are different based on the choice of the at-risk population. Disease mappers should exercise considerable caution in selecting the denominator population for mapping.

Dieting to Lose Weight and Occurrence of Neural Tube Defects in Offspring of Mexican-American Women.
Suarez L, Felkner M, Brender JD, Canfield MA.
Matern Child Health J. 2012 May;16(4):844-9.
Lowered maternal weight gain and reduction in early pregnancy have been associated with risk of neural tube defects (NTDs) in offspring. We examined the association of self-reported maternal dieting behaviors on the occurrence of NTDs. We conducted a population based case-control study among Mexican-American women who were residents of the 14 Texas counties bordering Mexico. Case women had an NTD-affected pregnancy identified at birth or prenatally and had deliveries during the years 1995-2000. Control women were those who delivered live born infants without an apparent congenital malformation, randomly selected and frequency-matched to cases by year and facility. One hundred eighty-four case women and 225 control women were asked in person about the use of nutritional supplements, dieting to lose weight, and type of weight reduction supplements used during the 3 months before conception. Women who reported being on a diet to lose weight during the 3 months before conception had an NTD odds ratio (OR) of 1.9 (95% confidence interval (CI) = 1.1, 3.3) compared with those not reporting being on a diet. Neither consuming vitamin drinks (OR = 1.2) nor using diet pills (OR = 1.6) during the 3 months before conception had ORs that were different from the null, when compared to women not reporting those behaviors. The risk effect for dieting did not differ markedly among normal or underweight (OR = 2.0, 95% CI = 0.7, 5.6), overweight (OR = 1.9, 95% CI = 0.7, 5.0), or obese women (OR = 1.5, 95% CI = 0.6, 4.0). No effect was seen among dieting women who were consuming at least 1.0 mg/day of folate (OR = 1.1, CI = 0.3, 4.5). Maternal dieting prior to conception may increase the risk of NTDs in offspring.

Actions to Control High Blood Pressure among Hypertensive Adults in Texas Counties along the Mexico Border: Texas BRFSS, 2007.
Ayala C, Fang J, Escobedo L, Pan S, Balcazar HG, Wang G, Merritt R.
Public Health Rep. 2012 Mar-Apr;127(2):173-85.
Objectives: We examined the prevalence of actions taken to control blood pressure as measured by taking antihypertensive medication or making lifestyle modifications among hypertensive adults residing along the Texas/Mexico border. Methods: We used self-reported data from the 2007 Texas Behavioral Risk Factor Surveillance System, with oversampling of border counties. We calculated the age-standardized prevalence of actions taken to control hypertension by selected characteristics. Results: In analyses that combined ethnicity with predominant language spoken, those least likely to take any action to control their blood pressure- either by taking an antihypertensive medication or by making any of four lifestyle modifications-were Spanish-speaking Hispanic people (83.2% ± 2.7% standard error [SE]), with English-speaking non-Hispanic people (88.9% ± 0.8% SE) having the highest prevalence of taking action to control blood pressure. When analyzed by type of medical category, uninsured Hispanic people (63.8% ± 4.8% SE) had the lowest prevalence of taking action to control their blood pressure compared with uninsured non-Hispanic people (75.4% ± 4.7% SE). Nonborder Texas residents with hypertension were more likely to take antihypertensive medications (78.4% ± 1.0% SE) than border county residents with hypertension (70.7% ± 2.0% SE). Conclusions: Public health efforts must be undertaken to improve the control of hypertension among residents of Texas counties along the Mexico border, particularly for uninsured Hispanic people.

Prenatal Diagnosis and Cesarean Section in a Large, Population-Based Birth Defects Registry.
Case AP, Colpitts LR, Langlois PH, Scheuerle AE.
J Matern Fetal Neonatal Med. 2012 Apr;25(4):395-402.
Objective. To describe the patterns of cesarean section (CS) and vaginal delivery by type of birth defect and determine whether prenatal diagnosis predicts a higher or lower likelihood of CS for selected defect categories. Methods. Data from a large population-based registry were analyzed to determine percentages of vaginal versus CS delivery for each of 49 categories of birth defects. Odds ratios and statistical significance were computed to determine if a record of prenatal diagnosis (PND) predicted delivery mode. Cases were liveborn children with any of these defects born in Texas between 1997 and 2005. Results. Forty-three percent of infants in the study were delivered by CS, with a range of 25.3% (aniridia) to 62.4% (spina bifida). A record of prenatal diagnosis of the primary assigned birth defect was found in 43.0% of all records but varied substantially by defect category. PND significantly predicted higher CS percentages for spina bifida without anencephaly, encephalocele, hydrocephaly, transposition of the great vessels, ventricular septal defect, pulmonary valve atresia/stenosis, craniosynostosis, diaphragmatic hernia, gastroschisis, and trisomy 21. Vaginal delivery was predicted by PND of anencephaly, agenesis, aplasia, or hypoplasia of the lung, renal agenesis or dysgenesis, and trisomy 18. Conclusion. Texas children with birth defects are more likely to have been delivered by CS than the population in general. For several types of defects, prenatal diagnosis is predictive of higher odds of CS; for others, especially fatal defects, PND predicts lower CS likelihood.

Urban-Rural Differences in Attitudes and Practices toward Long-Acting Reversible Contraceptives among Family Planning Providers in Texas.
Vaaler ML, Kalanges LK, Fonseca VP, Castrucci BC.
Women’s Health Issues. 2012 Mar;22(2):e157-62.
Background: Despite the elevated rates of teen and unplanned pregnancies across the United States, long-acting reversible contraceptives (LARCs) remain a less utilized birth control method. The present study investigated family planning providers' attitudes and considerations when recommending family planning methods and LARCs to clients. Additionally, this study explored whether urban-rural differences exist in providers' attitudes toward LARCs and in clients' use of LARCs. Methods: Data were collected using an online survey of family planning providers at Title X clinics in Texas. Survey data was linked to family planning client data from the Family Planning Annual Report (2008). Results: Findings indicated that, although providers were aware of the advantages of LARCs, clients' LARC use remains infrequent. Providers reported that the benefits of hormone implants include their effectiveness for 3 years and that they are an option for women who cannot take estrogen-based birth control. Providers acknowledged the benefits of several types of LARCs; however, urban providers were more likely to acknowledge the benefits of hormone implants compared with their rural counterparts. Results also indicated barriers to recommending LARCs, such as providers' misinformation about LARCs and their caution in recommending LARCs to adolescents. However, findings also indicated providers lack training in LARC insertion, specifically among those practicing in rural areas. Conclusions: In light of the effectiveness and longevity of LARCs, teenagers and clients living in rural areas are ideal LARC candidates. Increased training among family planning providers, especially for those practicing in rural areas, may increase their recommendations of LARCs to clients.

Oseltamivir-Resistant Pandemic (H1N1) 2009 Virus Infections, United States, 2010-11.
Storms AD, Gubareva LV, Su S, Wheeling JT, Okomo-Adhiambo M, Pan CY, Reisdorf E, St George K, Myers R, Wotton JT, Robinson S, Leader B, Thompson M, Shannon M, Klimov A, Fry AM;
Emerg Infect Dis. 2012 Feb;18(2):308-11.
During October 2010-July 2011, 1.0% of pandemic (H1N1) 2009 viruses in the United States were oseltamivir resistant, compared with 0.5% during the 2009-10 influenza season. Of resistant viruses from 2010-11 and 2009-10, 26% and 89%, respectively, were from persons exposed to oseltamivir before specimen collection. Findings suggest limited community transmission of oseltamivir-resistant virus. 

Advances in Medical Countermeasures for Chemical Terrorism.
Clements B.
Domestic Preparedness Journal. 2012;8(3):24-25. (No abstract available.)

Mortality of Public Mental Health Clients Treated at the Local Mental Health Authorities of Texas.
Reynolds RJ, Shafer AB, Becker EA.
TPHJ 2012;64(2):35-40.
Objective: To catalog and compare the mortality experience of Public Mental Health Clients (PHMCs) in the 38 Local Mental Health Authorities (LMHAs) of Texas in the years 2006-2008. Methods: Client service records for PHMCs from the Mental Health and Substance Abuse Division of the Texas Department of State Health Services (DSHS) were linked to death records from the DSHS Center for Vital Statistics. Age-adjusted death rates (AADRs) per 100,000 person years were calculated for PHMCs and for the general population in each of the LMHAs in Texas. Frequencies were computed for the most common causes of death in each LMHA. Results: PHMCs had increased mortality in comparison to the general population across the three years studied in each of the 38 Texas LMHAs. Rates ranged from 645-2060 compared to 586-929 deaths per 100,000 person years. Higher rates for four of the LMHAs approached statistical significance when compared to the general population. Though there was a wide range in the magnitude of excess death, the most frequent causes of death were consistently external causes and diseases of the circulatory system. Conclusions: Care providers in the LMHAs should focus more attention on the assessment and management of non-psychiatric medical conditions, especially circulatory diseases. Care providers in non-psychiatric settings should also learn to better assess and refer patients with psychiatric and substance abuse diagnoses to appropriate treatment programs. Such interventions may complement existing public health prevention programs in the effort to lower death rates in this vulnerable population.

An Assessment of the Distribution of Physicians in Texas.
King B, Menon R.
TPHJ 2012;64(2):31-34.
Objective: It has often been reported that Texas has a shortage of physicians.  However, analyzing shortages based on the overall number of physicians does not paint a complete picture of the problem or fully suggest remedies.  In a state as geographically large and culturally diverse as Texas, it is important to know exactly where the shortages are and which specific physician specialties are experiencing shortages, and highlight the issue of inequitable distribution of physicians statewide. Method: We obtained data on health professionals from the licensing boards for the year 2010 and conducted statistical analyses. Physicians were grouped by county and specialty, and the population composition of counties was analyzed by county, gender, and age.  Other indicators that could affect demand were considered, such as death rates and birth rates, and the supply of other health professionals such as mid-level providers.  The findings are presented in a series of maps. Results: Outside of the major metropolitan areas, Texas has high population-to-provider ratios for many health professionals; and, there are many counties, mostly rural, that do not have any of certain types of specialists.  In particular, as indicated through a series of maps, the areas west of I-35 face shortages, in some cases requiring patients to travel significant distances to see a specialist. Conclusions: Simply increasing the number of doctors in Texas will not fully address the problem of shortages.  While physicians need to be incentivized to practice in the rural and underserved areas, they should also be encouraged to practice in the areas that have a higher need for that type of specialist and where indicators show a high need for their services.

Data to Action: Reducing Adult Potentially Preventable Hospitalizations in Texas.
Gilliam M.
TPHJ 2012;64(2):29-30.
Rates, statistical significance, and confidence intervals are all important measures to describe data.  However, these data measures may not be the most effective in engaging community health stakeholders and policymakers who do not have a working knowledge of statistical methodology.  This article outlines how the Texas Department of State Health Services (DSHS) transformed data on adult potentially preventable hospitalizations, a major financial burden, into more user-friendly information to use in improving community health and reducing healthcare costs.  By transforming the data, DSHS significantly increased the engagement of local elected officials and community groups to deal with the problem of adult potentially preventable hospitalizations. Transformation of the data focused on making the information easier to understand and more relevant to these stakeholders.  For example, policymakers are more engaged when data is presented in financial perspectives rather than risk-adjusted rates.   A key example of transforming data into action was when the 82nd Texas Legislature appropriated funding for DSHS to implement interventions to target adult potentially preventable hospitalizations.

The Importance of Data to Public Health: An Introduction.
Medina C.
TPHJ 2012;64(2):25-28.
Data is crucial to the creation of evidence-based public health practices. This article explains what data are available from the Texas Dept. of State Health Services. It introduces several articles from the same journal issue showing the use of these data in the public health setting, as well as giving other examples of the importance of data to create knowledge and wise choices within public health.

Potassium Iodide and Its Use in Radiation Protection.
Forrester MB.
TPHJ 2012;64(2):41.

Product Recalls as a Public Health Problem.
Forrester MB.
TPHJ 2012;64(2):41-42.

Bacillus Thuringiensis Pesticide Exposures Reported to Texas Poison Centers.
Forrester MB.
Toxicol Environ Chem 2012;94:799-804
One of the most common types of microbial pesticides uses Bacillus thuringiensis. Although generally considered safe, exposures to B. thuringiensis pesticide do occur where management by healthcare providers is sought. The objective of this investigation was to describe B. thuringiensis pesticide exposures reported to Texas poison centers. Cases were all B. thuringiensis pesticide exposures reported to Texas poison centers during 2000-2010. The distribution of cases was determined for various demographic and clinical factors. Of 155 total cases, 64% occurred during May-July. The rate per 1,000,000 population was 14.3 in central Texas and 4.4 in the rest of the state. Of the patients, 56% were of an age 20 years or older and 55% were male. The exposure routes were 57% by ingestion, 30% by dermal contact, and 11% by inhalation. The patient was managed on site in 93% of the exposures and only 1 exposure was judged to be potentially serious. B. thuringiensis pesticide exposures reported to Texas poison centers were more frequently reported from the central region of the state. The majority of exposures occurred during April-July, involved adults and males, occurred by ingestion or dermal route, were managed on site and did not result in serious outcomes.

Ramelteon Ingestions Reported to Texas Poison Centers, 2005-2009.
Todd CM, Forrester MB.
J Emerg Med 2012;43:e189-e193.
Background: The only data that currently exist on ramelteon (Rozerem®; Takeda Pharmaceuticals North America, Inc., Deerfield, IL) ingestions is from clinical trials. To fill this gap, data on ramelteon ingestions reported to Texas poison centers during 2005-2009 were collected and analyzed. Objectives: The objective of this study was to describe how reported ramelteon ingestions were handled by Texas poison center staff and when known, the patient's final medical outcome. In cases where the dosage was significant enough to refer the patient to a health care facility, adverse clinical reactions and treatments are also described. Methods: Cases were analyzed for selected demographic and clinical factors. Of 222 total patients, 67.6% were women and 73.9% were over the age of 19 years. Cases were analyzed by motivating factors (e.g., unintentional, intentional), management site, adverse reactions, and final medical outcome. Results: Of the ramelteon ingestions reported to Texas poison centers, 67.6% involved adult women and were suspected attempted suicides; 75% of ramelteon ingestions not involving other substances were managed at a health care facility. However, 88.3% of these ingestions resulted in no significant clinical effect. Conclusion: The management strategies used by Texas poison centers for the 56 cases reported in this study were adequate.

Predictors of Trisomy 21 in the Offspring of Older and Younger Women.
Agopian AJ, Marengo LK, Mitchell LE.
Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):31-5.
Background: Advanced maternal age is the only well-established risk factor for trisomy 21, yet the majority of affected individuals are born to younger women. To identify factors associated with the risk of trisomy 21 in the offspring of younger and older women, we analyzed data for cases with trisomy 21 from the Texas Birth Defects Registry for 1999 to 2007. Methods: Data were analyzed separately for younger (i.e., <35 years of age at delivery; n = 2306) and older (i.e., ≥35 years of age at delivery; n = 1811) women using Poisson regression. Results: After adjustment for maternal age and several other covariates, the prevalence of trisomy 21 in the offspring of women in both maternal age groups was higher in male than in female infants and in offspring of women who were Hispanic (compared with non-Hispanic white women) or who had at least one previous liveborn child compared to those with none. In the offspring of older women only, the prevalence of trisomy 21 was also significantly higher when the father was 20to 24 years old (compared with 25 to 29 years old; adjusted prevalence ratio [aPR], 2.27; 95% confidence interval [CI], 1.47-3.49) and Hispanic (compared with non-Hispanic white; aPR, 1.34; 95% CI, 1.13-1.58) and among women with less than a high school education (compared with greater than high school). Conclusions: This study identified several factors, in addition to maternal age, that were associated with trisomy 21 risk. In general, these factors were similar for both maternal age groups, although paternal characteristics were significantly associated with risk of trisomy 21 only in offspring of older women.

Valentine’s Day Is Not Just for Chocolate Anymore.
Forrester MB.
TPHJ 2012;64(1):15-16. (No abstract available.)

Did a Digoxin Recall Result in an Increase in Digoxin Exposures Reported to Texas Poison Centers?
Forrester MB.
TPHJ 2012;64(1):16-17. (No abstract available)

Association between Depressed Mood and Perceived Weight in Middle and High School Age Students: Texas 2004-2005.
Schiefelbein EL, Mirchandani GG, George GC, Becker EA, Castrucci BC, Hoelscher DM.
Matern Child Health J. 2012 Jan;16(1):169-76.
Research exploring the relationship between weight perception and depressed mood among adolescents is limited in the United States. The purpose of this study is to examine the association of perceived versus actual body weight and depressed mood in a representative sample of 8th and 11th grade public school students in Texas. Using data from the 2004-2005 School Physical Activity and Nutrition (SPAN) study, logistic regression analyses were conducted to assess the association of weight perception with depressed mood. Healthy weight students who perceived themselves to be a healthy weight were the reference group for all analyses. A high prevalence of misperception of body weight was observed. Overweight and obese 8th grade girls and boys who perceived themselves to be overweight had increased odds of depressed mood [Girls: OR 1.70 (95% CI: 1.07-2.69), Boys: OR 2.05 (95% CI: 1.16-3.62)]. Healthy weight 8th grade girls who perceived themselves to be overweight had 2.5 times greater odds of depressed mood (OR 2.63, 95% CI: 1.54-4.50). Healthy weight boys who perceived themselves to be underweight had more than twice the odds (OR 2.18, 95% CI: 1.23-3.89) of depressed mood. No weight category was significantly associated with depressed mood in boys or girls in 11th grade. The present study suggests that weight misperceptions are associated with depressed mood in young adolescents. Education about healthy body size is necessary to correct the common weight misperceptions observed. The high prevalence rates of depressed mood suggest a greater need for research into understanding factors that may contribute to depressed mood in adolescents.

All-Terrain Vehicle Injuries in Texas, Mapping the Path to Intervention with a Geographic Information System.
Huff SD, McGaha PK, Reed M, Kratz M, Peters JA, Atkinson V.
J Agromedicine. 2012 Jan;17(1):51-62.
The state of Texas was ranked 10th for all-terrain vehicle-related deaths among all states from 2007-2009. Health Service Region 4/5N of eastern Texas has a statistically significant higher rate of all-terrain vehicle-related injuries in children under the age of 18 than Texas as a whole (p < 0.001.) It is unknown why east Texas has a higher all-terrain vehicle-related injury rate. A retrospective analysis of the registry of the Texas Trauma Service Area G, which serves the east Texas area, from the years 2004-2010 was performed. Variations within the region were assessed using a geographic information system and the analysis demonstrated that the highest rates of all-terrain vehicle-related injuries in east Texas are found in two neighboring rural eastern counties. Recording mechanism of injury was an important adjunct to identifying all-terrain vehicle-related injuries. Using E-codes alone underestimated the actual injuries. Other findings demonstrated that children under age 16 had a high rate of injury, one third of those injured sustained a head injury, and helmet use was very low. This analysis can be used by the Texas Department of State Health Services in conjunction with key regional partners to direct further investigation in these areas into the role of the rural environment, other factors associated with the high injury rates, and to plan and conduct preventive intervention at the community level.

How We Didn't Clean Up until We Washed Our Hands: Shigellosis in an Elementary and Middle School in North Texas.
Schulte JM, Williams L, Asghar J, Dang T, Bedwell S, Guerrero K, Hamaker D, Stonecipher S, Zoretic J, Chow C.
South Med J. 2012 Jan;105(1):1-4.
Background: Shigella outbreaks often continue for months and are linked frequently to poor hygiene and hand washing. Such outbreaks are found often in day care facilities, but rarely are reported in schools. We present the investigation of an outbreak in autumn 2007 at a building that housed an elementary school and a middle school in separate wings in a small Texas city north of Dallas-Fort Worth. Methods: We canvassed local hospitals, school attendance records, and physician offices for cases. Ill individuals were interviewed using a standard questionnaire for symptoms, disease onset, and the presence of the illness in an ill person's household. Results: A music teacher was the index case for this outbreak of gastrointestinal illness caused by S. sonnei. Ten percent of the students in the school building were ill, and 15 households had secondary cases. Installing liquid soap in dispensers in student restrooms was the initial control measure, followed by sustained instruction in hand washing, scheduled hand washing times, and monitored cleaning and disinfection procedures for surfaces and inanimate objects. Enhanced surveillance detected no new cases in the school district. Conclusions: Appropriate soap supplies and repeated instruction in hand washing and its monitoring were needed to control the outbreak.

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Last updated February 28, 2014