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DSHS Authors: Research Articles by DSHS Staff

The following list includes peer-reviewed research articles or academic textbooks 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 or by calling (512) 458-7559.

If you are a DSHS author and have published a research article or textbook since September 2004 and you would like it to be included in this list, please contact the Medical and Research Library.

2007 Articles
2006 Articles
2005 Articles
2004 Articles
Textbooks

2007 Articles (in date order with most recent first)

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

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

A Rapid, Standardized, Susceptibility Method for Mycobacterium Tuberculosis using Mycolic Acid Analysis.
Parrish N, Osterhout G, Dionne K, Sweeney A, Kwiatkowski N, Carroll K, Jost KC Jr, Dick J.
J Clin Microbiol. 2007 Oct 3; [Epub ahead of print]
MDR- and XDR-TB are an emerging public health threat compounded by the fact that current susceptibility testing techniques for M. tuberculosis (MTB) require several days to weeks to complete. We investigated the use of HPLC-based quantitation of mycolic acids as a means to rapidly determine drug resistance and susceptibility in MTB. Standard susceptibility testing and determination of minimal inhibitory concentrations (MIC's) of drug susceptible (n=26) and drug resistant strains of MTB including MDR-TB (n=34) was performed using the BACTEC radiometric growth system as the reference method. HPLC-based susceptibilities were performed using current first-line drugs: isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA). Vials were incubated for 72 hours and aliquots removed for HPLC analysis using the Sherlock(R) Mycobacterial Identification System. HPLC quantitation of total mycolic acids (TMAP) was determined for treated and untreated cultures. At 72 hours HPLC agreement with the reference method was 99.5% for INH, EMB, and PZA, and 98.7% for RIF. Inter- and intra-assay reproducibility varied by drug with an average precision of 13.4%. In summary, TMAP is a rapid, sensitive, and accurate method for antibiotic susceptibility testing of all currently used first-line drugs against MTB and offers the potential of susceptibility testing results within hours, rather than days or weeks, for clinical isolates of MTB.

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

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

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

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

Wildfire-related deaths--Texas, March 12-20, 2006.
[LINK to Full-text: http://www.cdc.gov/mmwr//preview/mmwrhtml/mm5630a1.htm ]
Centers for Disease Control and Prevention (CDC). DSHS contributors: D Zane, J Henry, C Lindley, P Pendergrass, L Mansolo. Also acknowledged: J Alexander, B Hernandez, T Haywood, P Raimondo, J Walker, T Sidwa, S Elkins, D Johnson, A Whitley, P Tabor, C Tuttle, D McLellan, R Apodaca, M Widtfeldt, S Prosperie, B Ray, D Powell.
MMWR Morb Mortal Wkly Rep. 2007 Aug 3;56(30):757-60.
During March 12-20, 2006, wildfires burned approximately 1 million acres in the Panhandle region of Texas, advancing 45 miles in 9 hours, with dense smoke and flames up to 11 feet. The two largest fires, which together extended into nine counties, resulted from power lines downed by sustained winds of 46 mph and gusts up to 53 mph. The wildfires destroyed more than 89 structures, with losses estimated at $16 million. The fires caused evacuations in eight communities with a total population of 4,072. This report summarizes the circumstances of 12 deaths and describes the five separate incidents caused by the two wildfires that resulted in those deaths.

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

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

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

Adult Lisinopril Ingestions Reported to Texas Poison Control Centers, 1998-2005.
Forrester MB.
Hum Exp Toxicol 2007;26:483-489.
There is limited information on potentially adverse lisinopril ingestions reported to poison control centers. Using adult lisinopril ingestions reported to Texas poison control centers during 1998-2005, the proportion of cases involving serious outcomes was determined for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Of 468 cases identified, 43 (9%) involved serious outcomes. The severity of the outcome associated with adult lisinopril ingestions depended on the dose and the circumstances of the ingestion. Thus, serious outcomes were significantly more likely to occur with a maximum dose >80 mg (RR 5.69, CI 2.43-13.33) or, if the dose was unknown, >3 tablets (RR 9.57, CI 2.39-54.97), where the circumstances of the exposures involved self-harm or malicious intent (RR 6.96, CI 3.65-13.31), or the patient was already at or en route to a health care facility when the poison control center was contacted (RR 7.33, CI 3.09-17.85) or referred to a health care facility by the poison control center (RR 23.76, CI 10.62-55.67). The management of patients with severe outcomes was more likely to involve health care facilities. Such information is useful for creating of triage guidelines for the management of adult lisinopril ingestions.

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

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

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

Primary Cesarean Deliveries Prior to Labor in the United States, 1979-2004.
Joesch JM, Gossman GL, Tanfer K.
Matern Child Health J. 2007 Jul 24; [Epub ahead of print]
Objectives: To provide for the United States yearly estimates of first-time (primary) cesareans prior to labor and to examine factors associated with 1979-2004 trends. Methods: We estimated the annual percent of total, primary, and repeat cesareans with and without labor for 15- to 44-year-old women with live births in the 1979-2004 National Hospital Discharge Survey (NHDS; N = 706,062). For women without prior cesareans (N = 628,064), we used logistic regression to examine whether trends in primary cesarean before labor are explained by changes over time in: (1) the frequency of pregnancy complications, women's age, principal source of payment for delivery, hospital ownership, size, and region; and (2) the decision to deliver by cesarean when complications are present. Results: Annually 4.5-6.6% of women delivered by primary cesarean prior to labor in 1979-2004. Recently, there has been a rise. An increase in reported pregnancy complications contributed to more primary cesareans before labor in 1979-2004. Changes in women's age, principal payment source, and hospital characteristics do not explain 1979-2004 trends. Changes in delivery practices with respect to seven complications increased primary cesareans before labor in the 1980s. Conclusions: From 1979 to 2004, primary cesareans before labor contributed less to total cesareans than primary cesareans during labor and repeat cesareans without labor. Since 1998, primary cesareans pre-labor have increased less than previously reported. The recent increase is not explained by changes in the frequency of pregnancy complications, women's age, insurance, or delivery hospital characteristics. Changes in delivery practices regarding pregnancy complications may have contributed to the recent increase.

Maternal Exposures to Cigarette Smoke, Alcohol, and Street Drugs and Neural Tube Defect Occurrence in Offspring.
Suarez L, Felkner M, Brender JD, Canfield M, Hendricks K.
Matern Child Health J. 2007 Jul 20; [Epub ahead of print]
OBJECTIVES: Cigarettes, alcoholic beverages, and street drugs contain substances potentially toxic to the developing embryo. We investigated whether maternal cigarette smoking, secondhand smoke exposure, and alcohol or street drug use contributed to neural tube defect (NTD) occurrence in offspring. METHODS: 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 and delivered during 1995-2000. Control women were those who delivered live born infants in the same study area, without an apparent congenital malformation, randomly selected by year and facility. We interviewed women in person, 1-3 months postpartum, to solicit relevant information. RESULTS: Nonsmoking mothers exposed to secondhand smoke during the first trimester had an NTD odds ratio (OR) of 2.6 (95% confidence interval (CI) = 1.6, 4.0) compared to those who neither smoked nor were exposed to secondhand smoke. Compared to the referent, the OR among women who smoked less than half a pack a day during the first trimester was 2.2 (95% CI = 1.0, 4.8) and 3.4 (95% CI = 1.2, 10.0) among those who smoked a half pack or more. Adjustment for maternal age, education, body mass index, and folate intake had a negligible effect on results. Alcohol and street drug use had no relation to NTD risk when adjusted for cigarette smoking. CONCLUSIONS: This study suggests that cigarette smoke including secondhand exposure is not only hazardous to the mother but may also interfere with neural tube closure in the developing embryo.

Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2007.
[LINK to Full-text: http://www.cdc.gov/mmwr//preview/mmwrhtml/rr5605a1.htm ]
National Association of State Public Health Veterinarians, Inc. (NASPHV) and Centers for Disease Control and Prevention. DSHS member of NASPHV: James H. Wright.
MMWR Recomm Rep. 2007 Jul 6;56(RR-5):1-13.
Certain venues encourage or permit the public to contact animals, resulting in millions of human-animal interactions each year. These settings include county or state fairs, petting zoos, animal swap meets, pet stores, zoologic institutions, circuses, carnivals, farm tours, livestock-birthing exhibits, educational exhibits at schools, and wildlife photo opportunities. Although multiple benefits of human-animal contact exist, infectious diseases, rabies exposures, injuries, and other human health problems associated with these settings are possible. Infectious disease outbreaks reported during the previous decade have been caused by Escherichia coli O157:H7, Salmonella, Cryptosporidium, Coxiella burnetii, Mycobacterium tuberculosis, ringworm, and other pathogens. Such incidents have substantial medical, public health, legal, and economic effects. This report provides recommendations for public health officials, veterinarians, animal venue staff, animal exhibitors, visitors to animal venues, physicians, and others concerned with minimizing risks associated with animals in public settings. The recommendation to wash hands is the single most important prevention step for reducing the risk for disease transmission. Other critical recommendations are that venues not allow food in animal areas, venues include transition areas between animal areas and nonanimal areas, visitors be educated about disease risk and prevention procedures, and animals be properly cared for and managed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2006 Articles (in date order with most recent first)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Human Plague--Four States, 2006.
MMWR Morb Mortal Wkly Rep. 2006 Sep 1;55(34):940-3.
Centers for Disease Control and Prevention (CDC). DSHS contributors: B Nix, R Jones, T Sidwa, J Walker.
[LINK to Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5534a4.htm ]
Plague is a zoonotic disease caused by the bacterium Yersinia pestis. In 2006, a total of 13 human plague cases have been reported among residents of four states: New Mexico (seven cases), Colorado (three cases), California (two cases), and Texas (one case). This is the largest number of cases reported in a single year in the United States since 1994. Dates of illness onset ranged from February 16 to August 14; two (15%) cases were fatal. The median age of patients was 43 years (range: 13-79 years); eight (62%) patients were female. Five (38%) patients had primary septicemic plague, and the remaining eight (62%) had bubonic plague. Two (15%) patients developed secondary plague pneumonia, leading to administration of antibiotic prophylaxis to their health-care providers. This report summarizes six of the 13 cases, highlighting the severity and diverse clinical presentations of plague and underscoring the need for prompt diagnosis and treatment when plague is suspected.

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

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

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

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

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

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

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

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

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

Unauthorized border crossings and migrant deaths: Arizona, New Mexico, and El Paso, Texas, 2002-2003.
Sapkota S, Kohl HW, Gilchrist J, McAuliffe J, Parks B, England B, Flood T, Sewell CM, Perrotta D, Escobedo M, Stern CE, Zane D, Nolte KB.
American Journal of Public Health, 2006 July;96(7):1-6.
LINK to Full-text: http://www.ajph.org/cgi/reprint/AJPH.2005.075168v1
Objectives. We examined the major causes of and risk factors for death among migrants who died while making unauthorized border crossings into the United States from Mexico. Methods. Decedents were included in the study if (1) their remains were found between January 1, 2002, and December 31, 2003, in any US county along the 650-mi (1040-km) section of the US-Mexico border from Yuma, Ariz, to El Paso, Tex; (2) their immigration status was unauthorized; and (3) they were believed to have died during transit from Mexico to the United States. Characteristics of the decedents and causes of and risk factors for their deaths were examined. Results. Among the 409 decedents meeting our inclusion criteria, environmental heat exposure (n=250; 61.1%) was the leading cause of death, followed by vehicle crashes (n=33; 8.1%) and drownings (n=24; 5.9%). Male decedents (n=298; 72.8%) outnumbered female decedents (n=105; 25.6%) nearly 3 to 1. More than half of the decedents were known to be Mexican nationals (n=235; 57.5%) and were aged 20 to 39 years (n=213; 52.0%); the nationality of 148 (36.2%) decedents was undetermined. Conclusions. Deaths among migrants making unauthorized US-Mexico border crossings are due to largely preventable causes. Prevention strategies should target young Mexican men, and focus on preventing them from conceiving plans to cross the border, discouraging them from using dangerous routes as crossing points, and providing search-and-rescue teams to locate lost or injured migrant crossers.

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

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

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

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

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

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

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

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

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

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

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

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

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

Settlement-funded tobacco control in Texas: 2000-2004 pilot project effects on cigarette smoking.
LINK to Full-text: http://www.publichealthreports.org/userfiles/121_3/121235.pdf
McAlister AL, Huang P, Ramirez AG.
Public Health Reports 2006 May-June;121:235-238.
Because settlement proceeds allocated for tobacco control in Texas are insufficient for statewide activity at federally recommended funding levels, the Texas Department of State Health Services has used the available funds in quasi-experimental pilot studies in which varying amounts of support are provided for selected parts of the state. Trends in tobacco use were measured in telephone surveys of 7,998 (2000), 5,150 (2002), and 5,721 (2004) adults. Prevalence of cigarette smoking declined by almost one-third in the pilot area where comprehensive and sustained pilot activities to reduce tobacco use were organized at close to the federally recommended funding level. Significantly smaller reductions were observed in other parts of the state. In the group with the highest use, white non-Hispanic men, cigarette consumption declined by half in the pilot area. It is reasonable to expect similar reductions in tobacco use if funds are provided for statewide expansion of the pilot activities.

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

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

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

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

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

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

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

Carbon monoxide poisonings after two major hurricanes--Alabama and Texas, August-October 2005.
[LINK to Full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5509a4.htm]
Centers for Disease Control and Prevention (CDC). DSHS contributors: J Villanacci, PhD, J Ryan, MD, C Barton, DVM, PhD, P McGaha, DO
MMWR Morb Mortal Wkly Rep. 2006 Mar 10;55(9):236-9.
Hurricanes Katrina and Rita struck the U.S. Gulf Coast on August 29, 2005, and September 24, 2005, respectively, causing widespread damage and leaving approximately 4 million households without electrical power. Despite public health measures to prevent carbon monoxide (CO) poisonings after major power outages, multiple CO poisonings were reported in Gulf Coast states in the wake of these hurricanes. The Alabama Department of Public Health and Texas Department of State Health Services asked CDC to assist in investigating the extent and causes of these hurricane-related CO poisonings. The investigation identified 27 incidents of CO poisoning resulting in 78 nonfatal cases and 10 deaths in hurricane-affected counties in Alabama and Texas, nearly all of which were caused by gasoline-powered generators. Most of the generators involved were placed outside but close to the home to power window air conditioners (ACs) or connect to central electric panels. Few homes had functioning CO detectors. CDC continues to recommend that generators be placed far from homes, away from window ACs, and that CO detectors be used by all households operating gasoline-powered appliances (e.g., generators and gas furnaces), with batteries replaced yearly. Although the risk for CO poisoning likely decreases as generators are placed further from the home, additional studies are needed to establish a safe distance for generator placement.

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

Deaths associated with hypocalcemia from chelation therapy--Texas, Pennsylvania, and Oregon, 2003-2005.
[LINK to full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5508a3.htm]
Centers for Disease Control and Prevention (CDC). DSHS contributors: RA Beauchamp, MD, TM Willis, TG Betz, MD, J Villanacci, PhD
MMWR Morb Mortal Wkly Rep. 2006 Mar 3;55(8):204-7.
Chelating agents bind lead in soft tissues and are used in the treatment of lead poisoning to enhance urinary and biliary excretion of lead, thus decreasing total lead levels in the body. During the past 30 years, environmental and dietary exposures to lead have decreased substantially, resulting in a considerable decrease in population blood lead levels (BLLs) and a corresponding decrease in the number of patients requiring chelation therapy. Chelating agents also increase excretion of other heavy metals and minerals, such as zinc and, in certain cases, calcium. This report describes three deaths associated with chelation-therapy--related hypocalcemia that resulted in cardiac arrest. Several drugs are used in the treatment of lead poisoning, including edetate disodium calcium (CaEDTA), dimercaperol (British anti-Lewisite), D-penicillamine, and meso-2,3-dimercaptosuccinic acid (succimer). Health-care providers who are unfamiliar with chelating agents and are considering this treatment for lead poisoning should consult an expert in the chemotherapy of lead poisoning. Hospital pharmacies should evaluate whether continued stocking of Na2EDTA is necessary, given the established risk for hypocalcemia, the availability of less toxic alternatives, and an ongoing safety review by the Food and Drug Administration (FDA). Health-care providers and pharmacists should ensure that Na2EDTA is not administered to children during chelation therapy.

Tuberculosis control activities after Hurricane Katrina--New Orleans, Louisiana, 2005.
[LINK to full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a2.htm]
Centers for Disease Control and Prevention. DSHS contributors: C Wallace, PE Cruise
Morb Mortal Wkly Rep. March 31, 2006 / 55(12);332-335.
On August 29, 2005, when Hurricane Katrina struck the U.S. Gulf Coast, 130 Louisiana residents in the greater New Orleans area were known to be undergoing treatment for tuberculosis (TB) disease. Standard treatment and cure of TB requires a multidrug regimen administered under directly observed therapy (DOT) for at least 6 months (1). This report updates previous information (2) and summarizes TB cases reported as of December 31, 2005, among persons undergoing TB treatment in the New Orleans area when Hurricane Katrina made landfall and among persons who were evacuated and subsequently received a diagnosis of TB in other parts of the country. By October 13, 2005, through intensive local, state, and national efforts involving both government and private sector partners, all 130 TB patients from the New Orleans area had been located and, if still indicated, had resumed TB treatment. As a result of heightened public health surveillance among Hurricane Katrina evacuees, six other New Orleans evacuees began treatment (i.e., two persons with known TB and four with previously undiagnosed TB) after arriving in other states. The success of these post-disaster TB control measures affirms the utility of alternative data sources during health-related emergencies and the importance of maintaining a strong TB control component in the public health sector.

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

Exposure to fumonisins and the occurrence of neural tube defects along the Texas-Mexico border.
[LINK to full-text at http://www.ehponline.org/members/2005/8221/8221.html]
Missmer SA, Suarez L, Felkner M, Wang E, Merrill AH Jr, Rothman KJ, Hendricks KA.
Environ Health Perspect. 2006 Feb;114(2):237-41.
Along the Texas-Mexico border, the prevalence of neural tube defects (NTDs) among Mexican-American women doubled during 1990-1991. The human outbreak began during the same crop year as epizootics attributed to exposure to fumonisin, a mycotoxin that often contaminates corn. Because Mexican Americans in Texas consume large quantities of corn, primarily in the form of tortillas, they may be exposed to high levels of fumonisins. We examined whether or not maternal exposure to fumonisins increases the risk of NTDs in offspring using a population-based case-control study. We estimated fumonisin exposure from a postpartum sphinganine:sphingosine (sa:so) ratio, a biomarker for fumonisin exposure measured in maternal serum, and from maternal recall of periconceptional corn tortilla intake. After adjusting for confounders, moderate (301-400) compared with low (< or = 100) consumption of tortillas during the first trimester was associated with increased odds ratios (ORs) of having an NTD-affected pregnancy (OR = 2.4; 95% confidence interval, 1.1-5.3). No increased risks were observed at intakes higher than 400 tortillas (OR = 0.8 for 401-800, OR = 1.0 for > 800). Based on the postpartum sa:so ratio, increasing levels of fumonisin exposure were associated with increasing ORs for NTD occurrences, except for the highest exposure category (sa:so > 0.35). Our findings suggest that fumonisin exposure increases the risk of NTD, proportionate to dose, up to a threshold level, at which point fetal death may be more likely to occur. These results also call for population studies that can more directly measure individual fumonisin intakes and assess effects on the developing embryo.

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

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

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

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

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

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

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

Improved national prevalence estimates for 18 selected major birth defects -- United States, 1999 -- 2001.
[LINK to full-text: http://www.cdc.gov/mmwr//preview/mmwrhtml/mm5451a2.htm]
Centers for Disease Control and Prevention (CDC). DSHS contributors: Canfield MA, Ramadhani TA
MMWR Morb Mortal Wkly Rep. 2006 Jan 6;54(51&52);1301-5.
Continuing efforts are needed to improve surveillance for birth defects, which are the leading cause of infant mortality in the United States (1). Although state and local surveillance data indicate that approximately 3% of births are affected by any of 45 birth defects, no national estimates based on population-based birth defects surveillance have been available for specific types of birth defects other than neural tube defects (spina bifida and anencephaly). This report describes estimates of national prevalence and number of affected births in the United States each year during 1999--2001 for 18 selected major birth defects. The findings indicated that 10 of the 18 defects affected more than 1,000 infants each year in the United States. The conditions with the highest prevalence included orofacial clefts, which affect approximately 6,800 infants annually, and Down syndrome, which affects approximately 5,500 infants annually. Population-based national prevalence estimates of birth defects can help determine resource needs for basic and public health research and assist in planning for the health-care and educational needs of the U.S. population.

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

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

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

2005 Articles (in date order with most recent first)

Pattern of stingray injuries reported to Texas poison centers from 1998 to 2004.
Forrester MB.
Hum Exp Toxicol. 2005 Dec;24(12):639-42.
This study examined the relationship between selected factors and all human exposures involving stingray injuries reported to Texas poison centers. Cases were obtained retrospectively from calls to poison centers in Texas and included all reported human exposures involving stingray injuries from 1998 to 2004. The distribution of cases was determined for a variety of demographic and clinical parameters. A total of 153 cases were identified. The reported stingray injury penetrance increased during the 7-year period. Of the cases with a known patient age, 2% were <6 years, 25% were 6-19 years and 73% were >19 years. The stingray injuries occurred in public areas in 54% of the cases. In 61% of cases, the management site was reported not to be a health care facility. Of the cases with a known clinical outcome, none involved no effects and 53% involved minor effects. The highest proportion of stingray injuries occurred during the summer months, particularly August. In 60% of the cases, the calls originated from counties along the coast. This information can be used to identify those portions of the population most in need of education regarding the prevention and treatment of stingray injuries.

Iron status indicators in women with prior neural tube defect-affected pregnancies.
Felkner MM, Suarez L, Brender J, Scaife B, Hendricks K.
Matern Child Health J. 2005 Dec;9(4):421-8.
OBJECTIVES: Iron deficiency is the most common nutrient deficiency in pregnant women and has been linked to negative impacts on the fetus. We describe the association of various iron-deficiency indices with risk of neural tube defect (NTD) among a high-risk Mexican-American population. METHODS: The study included 158 case-women (NTD-affected pregnancies) and 189 control-women (normal births) who were residents of the 14 Texas-Mexico border counties and delivered or terminated pregnancies during 1995-2000. In-person interviews and laboratory assays provided data. RESULTS: Case-women had higher odds of having minimal or no iron stores (serum ferritin <30 microg/L) compared to control-women (OR = 1.8, 95% CI = 1.0-3.3). The risk effect was not explained by low folate or B12 or other risk factors. CONCLUSION: Low serum ferritin may reflect the additive effect of multiple long-term factors, many of them related to poverty such as poor quality diet, lack of supplementation, and frequent pregnancies. Interpartum care is indicated in this population.

2005 Robley D. Evans Commemorative Medal.
Fogle D, Jablonski S.
Health Phys. 2005 Dec;89(6):609-12.
This medal is given in memory of Dr. Robley D. Evans who, over a period of more than 50 years, was exemplary as a physics educator, scientist, author, and humanitarian. His contributions and dedication to radiation safety and to the health physics profession were extraordinary in practice and outstanding in intellectual acumen. The 2005 recipient is John W. Poston, Sr.

Texas' community health workforce: from state health promotion policy to community-level practice.
[LINK to full-text: http://www.cdc.gov/pcd/issues/2005/nov/05_0059.htm]
Nichols DC, Berrios C, Samar H.
Prev Chronic Dis. 2005 Nov;2 Spec no:A13. Epub 2005 Nov 1.
BACKGROUND: Imagine yourself in Texas as a newly arrived immigrant who does not speak English. What would you do if your child became ill? How would you find a doctor? When you find one, will the doctor speak your native language or understand your culture? In a state of approximately 22 million people, many Texas residents, marginalized by poverty and cultural traditions, find themselves in this situation. To help them, some communities across Texas offer the services of promotores, or community health workers, who provide health education and assist with navigating the health care system. CONTEXT: In 1999, Texas became the first state in the nation to recognize these workers and their contributions to keeping Texans healthy. This paper examines a state health promotion policy that culminated in a training and certification program for promotores and the impact of this program on the lay health education workforce in Texas. METHODS: In 1999, the Texas legislature established the 15-member Promotor(a) Program Development Committee to study issues involved in developing a statewide training and certification program. During its 2-year term, the committee met all six of its objectives toward establishing and maintaining a promotor(a) certification program. CONSEQUENCES: By the end of December 2005, it is estimated that there will be more than 700 certified promotores in Texas. State certification brings community health workers into the public health mainstream as never before. INTERPRETATION: Promotores, a community health safety net and a natural extension of the health and human services agencies, improve health at the neighborhood level. Certification brings renewed commitment to serving others and a distinction to those who have been the unsung heroes of public health for decades.

Nutmeg intoxication in Texas, 1998-2004.
Forrester MB.
Hum Exp Toxicol. 2005 Nov;24(11):563-6.
Nutmeg is a spice that contains volatile oils comprised of alkyl benzene derivatives (myristicin, elemicin, safrole, etc.), terpenes and myristic acid. Nutmeg has a long history of abuse. This study describes the nutmeg ingestion calls received by Texas poison centers from 1998 to 2004. There were 17 calls involving nutmeg ingestion, of which 64.7% involved intentional abuse. When abuse and non-abuse ingestions were compared, abuse ingestions were more likely to involve males (100 versus 66.7%) and adolescents (55.6 versus 16.7%). The majority of both abuse and non-abuse calls were managed outside of health care facilities (54.5 and 66.7%, respectively). None of the ingestions resulted in more than moderate clinical effects or death.

Texas poisonings at the beginning of the 21st century: 2000 through 2002.
Morgan DL, Forrester MB.
Texas Medicine, November 2005;101(11):72-78.
Human exposure calls to poison centers may vary by geographic region. This investigation compared the pattern of human exposure calls to Texas poison centers with calls to those in other states from 2000 through 2002. Although the total number of human exposure calls increased for both Texas and non-Texas poison centers, the increase was twice as great for those in Texas. Patients in Texas human exposure calls tended to be younger. Texas calls were more likely to involve bites and stings, suspected suicides, and intentional abuse exposures and were less likely to involve unintentional environmental exposures. Texas exposures were less likely to occur by dermal, inhalation, and ocular routes. Texas patients were more likely to be treated with decontamination. The death rate from poisoning was slightly lower in Texas. Knowledge of the human exposure calls to particular poison centers allows the poison centers to use their resources most efficiently.

Changes in the birth prevalence of selected birth defects after grain fortification with folic acid in the United States: findings from a multi-state population-based study.
Canfield MA, Collins JS, Botto LD, Williams LJ, Mai CT, Kirby RS, Pearson K, Devine O, Mulinare J; National Birth Defects Prevention Network.
Birth Defects Res A Clin Mol Teratol. 2005 Oct;73(10):679-89.
BACKGROUND: Observational studies and clinical trials have suggested that periconceptional use of folic acid can reduce the risk of birth defects other than neural tube defects (NTDs). Using data reported by states to the National Birth Defects Prevention Network, we examined whether folic acid fortification might have decreased the prevalence of other specific birth defects. METHODS: For each of 16 birth defect categories selected for study, birth prevalence for two time periods was calculated with data submitted from a number of states in 1995-1996 ("pre-fortification") and 1999-2000 ("post-fortification"). Changes in birth prevalence between the two time periods were assessed by calculating prevalence ratios and 95% confidence intervals for each defect, and compared by maternal race/ethnicity and availability of prenatally diagnosed cases. RESULTS: We confirmed previously reported reductions in the birth prevalence of NTDs. In addition, we found modest, yet statistically significant, decreases in the birth prevalence for transposition of the great arteries(12%), cleft palate only (12%), pyloric stenosis (5%), upper limb reduction defects (11%), and omphalocele (21%). More substantial subgroup decreases were observed for renal agenesis among programs that conduct prenatal surveillance (28%), for common truncus among Hispanics (45%), and for upper limb reduction defects among Hispanics (44%). There were modest yet significant increases in the prevalence of obstructive genitourinary defects (12%) and Down syndrome (7%), but not among programs conducting prenatal surveillance for these defects. CONCLUSIONS: These results suggest some modest benefit from the folic acid fortification on the prevalence of a number of non-NTD birth defects.

Prevalence is the preferred measure of frequency of birth defects.
Mason CA, Kirby RS, Sever LE, Langlois PH.
Birth Defects Res A Clin Mol Teratol. 2005 Oct;73(10):690-2.
Researchers and other public health professionals continue to debate the use of prevalence versus incidence as the preferred term to represent the frequency of birth defects. This paper addresses this question by noting that incidence—the number of new cases of a disorder in a given at-risk population during a specified time period--cannot be reliably estimated with existing data. Consequently, it is not appropriate to use the term "incidence" in reporting the frequency of birth defects, and the term prevalence is recommended. The basis for this recommendation, and issues involved in calculating both measures, are discussed.

Pesticide-related illness and injury surveillance: a how-to guide for state-based programs.
[LINK to full-text at http://www.cdc.gov/niosh/docs/2006-102/pdfs/2006-102a.pdf]
National Institute for Occupational Safety and Health. DSHS contributor: R Rosales
DHHS (NIOSH) Publication No. 2006-102, October 2005.

Infectious disease and dermatologic conditions in evacuees and rescue workers after Hurricane Katrina -- multiple states, August -- September, 2005.
Centers for Disease Control and Prevention. DSHS contributors: BR Smith, MD, C Wallace
[LINK to full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5438a6.htm]
Morb Mortal Wkly Rep. September 30, 2005 / 54(38);961-964.
On August 29, 2005, Hurricane Katrina struck states along the Gulf Coast of the United States. In the days after the hurricane struck, approximately 750 evacuation centers were established in at least 18 states to accommodate more than 200,000 evacuees (1). State and local health departments, with assistance from CDC, initiated enhanced infectious disease surveillance and outbreak response activities, implemented by teams of public health and rescue workers, including military personnel. Outbreak monitoring included direct reporting of conditions of public health significance to public health agencies; daily contact between CDC and local public health officials; canvassing of reports from CDC, public health departments, and news media for potential infectious disease outbreaks; and investigation of reports of infectious disease with outbreak potential. This report summarizes infectious disease and dermatologic conditions reported during the first 3 weeks after the hurricane, before effective local surveillance was fully implemented. One outbreak of norovirus was reported among evacuees in Texas; no other outbreaks requiring unusual mobilization of public health resources were reported among evacuees or rescue workers.

Drug Adherence: Effects of Decreased Visit Frequency on Adherence to Clozapine Therapy.
Patel NC, Crismon ML, Miller AL, Johnsrud MT.
Pharmacotherapy. 2005 Sep;25(9):1242-7.
OBJECTIVE: To study the effects of visit frequency on drug-adherence parameters subsequent to the change in the United States Food and Drug Administration (FDA)-mandated monitoring of white blood cell counts from weekly to every 2 weeks (biweekly) after 6 months of clozapine therapy. METHODS: Paid prescription claims records for clozapine from September 1, 1995-August 31, 2001, were extracted from the Texas Medicaid Vendor Drug Program database. Two groups of subjects were identified: subjects treated before and those treated after the FDA labeling change in monitoring frequency, which occurred on April 1, 1998. Prescription claims records for each subject were assessed for 365 days after the initial 6 months of therapy. Adherence measures included persistence, medication possession ratio (MPR), and time taking clozapine. RESULTS: Subjects receiving weekly hematologic monitoring had significantly higher rates of persistence (0.79 +/- 0.35 vs 0.70 +/- 0.38, p < 0.001) and MPRs (0.75 +/- 0.36 vs 0.66 +/- 0.38, p < 0.001) and continued to take clozapine longer (p < 0.002) compared with subjects receiving biweekly monitoring. Fewer subjects in the weekly monitoring group discontinued clozapine therapy during the 1-year study period (49.4% vs 57.9%, p = 0.008). Similar results were observed when cohorts were matched according to age, sex, and index clozapine dosage. CONCLUSION: Significant effects of visit frequency on adherence to clozapine therapy were noted. For patients inadequately adherent to therapy, an increase in visit frequency may improve adherence, and based on these results, the extra visits do not need to be with a physician or have any specific purpose other than contact with a provider.

Evaluation of oral rabies vaccination programs for control of rabies epizootics in coyotes and gray foxes: 1995-2003.
Sidwa TJ, Wilson PJ, Moore GM, Oertli EH, Hicks BN, Rohde RE, Johnston DH.
J Am Vet Med Assoc. 2005 Sep 1;227(5):785-92.
OBJECTIVE: To evaluate the effectiveness of intervention efforts to halt 2 wildlife rabies epizootics from 1995 through 2003, including 9 oral rabies vaccination campaigns for coyotes and 8 oral rabies vaccination campaigns for gray foxes. DESIGN: Retrospective study. ANIMALS: 98 coyotes during prevaccination surveillance and 963 coyotes and 104 nontarget animals during postvaccination surveillance in south Texas, and 699 gray foxes and 561 nontarget animals during postvaccination surveillance in west-central Texas. PROCEDURES: A recombinant-virus oral rabies vaccine in edible baits was distributed by aircraft for consumption by coyotes and gray foxes. Bait acceptance was monitored by use of microscopic analysis of tetracycline biomarker in upper canine teeth and associated bone structures in animals collected for surveillance. Serologic responses were monitered by testing sera for rabies virus-neutralizing antibodies by use of the rapid fluorescent focus inhibition test. The incidence of rabies in the distribution area was recorded via active and passive surveillance activities; tracking of rabies virus variants in confirmed rabid animals was used to determine the number and type of rabies cases before and after distributions of the vaccine. RESULTS: The expansion of both epizootics was halted as a result of the vaccine bait program. The number of laboratory-confirmed rabid animals attributable to the domestic dog-coyote rabies virus variant in south Texas declined to 0, whereas the number of laboratory-confirmed rabid animals attributable to the Texas fox rabies virus variant in west-central Texas decreased. CONCLUSIONS AND CLINICAL RELEVANCE: Data indicated that oral rabies vaccination resulted in protective immunity in a sufficient percentage of the target wildlife population to preclude propagation of the disease and provided an effective means of controlling rabies in these species.

Duloxetine Hydrochloride: A New Dual-Acting Medication for the Treatment of Major Depressive Disorder.
Hunziker ME, Suehs BT, Bettinger TL, Crismon ML.
Clin Ther. 2005 Aug;27(8):1126-43.
BACKGROUND: Duloxetine hydrochloride has recently been approved by the US Food and Drug Administration for the treatment of major depressive disorder (MDD). Duloxetine is a potent inhibitor of serotonin and norepinephrine reuptake, with weak effects on dopamine reuptake. OBJECTIVE: This article reviews the literature on duloxetine with regard to its pharmacodynamics, pharmacokinetics, clinical efficacy, and tolerability. METHODS: A comprehensive search of MEDLINE was performed using the terms duloxetine, Cymbalta, and major depressive disorder, with no restriction on year. The Eli Lilly and Company clinical trial registry, and abstracts and posters from recent American Psychiatric Association meetings were also reviewed. RESULTS: Duloxetine exhibits linear, dose-dependent pharmacokinetics across the approved oral dosage range of 40 to 60 mg/d. No dose adjustment appears to be needed based on age. Duloxetine has shown efficacy in reducing depressive symptoms compared with placebo, and duloxetine recipients have shown significant improvements in global functioning compared with placebo (both, P < 0.05). Response and remission rates have been comparable to or greater than those seen with fluoxetine or paroxetine. Duloxetine is generally well tolerated, with nausea, dry mouth, and fatigue being the most common treatment-emergent adverse effects. Cardiovascular adverse effects do not appear to result in sustained blood pressure elevations, QTc-interval prolongation, or other electrocardiographic changes. CONCLUSIONS: Based on the available evidence, duloxetine is a well-tolerated and effective treatment for MDD in adults. Randomized head-to-head comparisons against established antidepressants are needed to determine the relative safety and efficacy of duloxetine.

Epidemiology of noncomplex left ventricular outflow tract obstruction malformations (aortic valve stenosis, coarctation of the aorta, hypoplastic left heart syndrome) in Texas, 1999-2001.
McBride KL, Marengo L, Canfield M, Langlois P, Fixler D, Belmont JW.
Birth Defects Res A Clin Mol Teratol. 2005 Aug;73(8):555-61.
BACKGROUND: The left ventricular outflow tract (LVOT) malformations aortic valve stenosis (AVS), coarctation of the aorta (CoA), and hypoplastic left heart syndrome (HLHS) contribute significantly to infant mortality due to birth defects. Previous epidemiology data showed rate differences between male and female and white and black ethnic groups. The Texas Birth Defects Registry, an active surveillance program, enables study in a large, diverse population including Hispanics. METHODS: Records of children up to 1 year old with AVS, CoA, and HLHS born in Texas from 1999 to 2001, were collected from the registry. Those including additional heart defects or a chromosomal anomaly were excluded. Multivariate analysis included: infant sex; United States-Mexico border county residence; and maternal age, race/ethnicity, birthplace, and education. RESULTS: There were 910 cases among 1.08 million live births, of which 499 met inclusion criteria. Multivariate modeling of all LVOT malformations combined demonstrated lower prevalence rate ratios (PRRs) for black males (0.26) and Hispanic males (0.70). Similar results were found for CoA but not AVS or HLHS. Higher PRRs were noted for increased maternal age for LVOT (1.3 for 24-34 years; 1.7 for >34 years), AVS, and HLHS, but not CoA, and higher PRRs across all diagnoses for males (LVOT PRR, 2.4) were noted. CoA PRRs were higher in border county vs. non-border county residents (PRR, 2.1). Maternal education and birthplace were not significant factors. CONCLUSIONS: There are rate differences for males among all 3 ethnic groups. Sex and ethnic differences suggest genetic etiologies, where the ethnic differences could be used to find susceptibility loci with mapping by admixture linkage disequilibrium. Increased CoA rates along the U.S.-Mexico border suggest environmental causes that will require further monitoring. Copyright 2005 Wiley-Liss, Inc.

Folic acid calls to poison centers in Texas, 1998-2003.
Forrester MB.
Hum Exp Toxicol. 2005 Aug;24(8):423-7.
Folic acid (folacin, pteroylglutamic acid) is a monoglutamate form of the water-soluble B vitamin that is involved in the synthesis of nucleotides and amino acids and the normal maturation of red blood cells. This study describes the folic acid calls received by Texas poison centers during 1998-2003. There were 650 calls involving folic acid as a single-ingredient product, of which 55.1% were human exposures. Children age <6 years accounted for 80.1% of the human exposures. Patients were managed outside of the health care facilities in 92.1% of the cases. Of those cases with a known medical outcome, 94.8% had no clinical effects. This study found folic acid exposures reported to poison centers were unlikely to have more than minor adverse affects.

An exploration of self-reported negative affect by adolescents as a reason for smoking: implications for tobacco prevention and intervention programs.
Stevens SL, Colwell B, Smith DW, Robinson J, McMillan C.
Prev Med. 2005 Aug;41(2):589-96.
BACKGROUND: Negative affect is related to initiation and maintenance of smoking among youth and understanding its role is important when developing effective prevention and cessation programs. This study investigates the relationship between adolescent negative affect and smoking dependence, behaviors, attitudes, and self-efficacy in order to shed light on differences in adolescent smoking maintenance and cessation. METHODS: 721 smoking youth participated in a cognitive-behavioral smoking cessation program. Reasons for smoking were categorized (alpha = 0.87) and youth were placed into one of two groups based on presence or absence of negative affect. One-way repeated measures ANOVA determined if differences existed between the groups on smoking behaviors, attitudes, and self-efficacy. One-way ANOVA determined if differences existed on Fagerstrom Nicotine Tolerance Dependence (FTND) scores. RESULTS: Adolescents indicating negative affect for smoking were significantly more likely to have future smoking intentions and had significantly less self-efficacy to quit smoking than adolescent reporting other reasons. CONCLUSIONS: This study supports the need to address negative affect among adolescents participating in prevention and cessation programs. An examination of negative affect will provide program developers and facilitators with information to improve their interventions, assist with cessation, and provide an avenue to access other needed health services.

Relation between ambient air quality and selected birth defects, seven county study, Texas, 1997-2000.
Gilboa SM, Mendola P, Olshan AF, Langlois PH, Savitz DA, Loomis D, Herring AH, Fixler DE.
Am J Epidemiol. 2005 Aug 1;162(3):238-52. Epub 2005 Jun 29.
A population-based case-control study investigated the association between maternal exposure to air pollutants, carbon monoxide, nitrogen dioxide, ozone, sulfur dioxide, and particulate matter <10 microm in aerodynamic diameter during weeks 3-8 of pregnancy and the risk of selected cardiac birth defects and oral clefts in livebirths and fetal deaths between 1997 and 2000 in seven Texas counties. Controls were frequency matched to cases on year of birth, vital status, and maternal county of residence at delivery. Stationary monitoring data were used to estimate air pollution exposure. Logistic regression models adjusted for covariates available in the vital record. When the highest quartile of exposure was compared with the lowest, the authors observed positive associations between carbon monoxide and tetralogy of Fallot (odds ratio = 2.04, 95% confidence interval: 1.26, 3.29), particulate matter <10 microm in aerodynamic diameter and isolated atrial septal defects (odds ratio = 2.27, 95% confidence interval: 1.43, 3.60), and sulfur dioxide and isolated ventricular septal defects (odds ratio = 2.16, 95% confidence interval: 1.51, 3.09). There were inverse associations between carbon monoxide and isolated atrial septal defects and between ozone and isolated ventricular septal defects. Evidence that air pollution exposure influences the risk of oral clefts was limited. Suggestive results support a previously reported finding of an association between ozone exposure and pulmonary artery and valve defects.

Exposure to polychlorinated biphenyls and risk of neural-tube defects in a Mexican American population.
Suarez L, Gilani Z, Felkner M, Brender J, Henry J, Hendricks K.
Int J Occup Environ Health. 2005 Jul-Sep;11(3):233-7.
The authors examined the association between maternal polychlorinated biphenyl (PCB) levels and risk of neural tube defects (NTDs) in Mexican American women with NTD-affected pregnancies who resided in the 14 Texas-Mexico border counties during 1995-2000 (cases). Controls were randomly selected from study area women delivering normal live births. For PCB congeners with sufficient numbers of detectable values (PCB 99, 101, 110, 118, 138, 153, 180), there was little association between the proportions with detectable PCB levels in cases and controls. Odds ratios were <1 or compatible with the null, but power was low for some congeners. An index of seven PCB congeners (105, 118, 138, 153, 170, 180, 194) was also not associated with NTD risk. The maternal serum PCB levels in this study population (median PCB 153 level: 18 ng/g) were comparable to those with background exposure and do not appear to have contributed to the high prevalence of NTDs in this population.

Assessment of adherence measures with different stimulants among children and adolescents.
Sanchez RJ, Crismon ML, Barner JC, Bettinger T, Wilson JP.
Pharmacotherapy. 2005 Jul;25(7):909-17.
STUDY OBJECTIVE: To examine adherence measures with different stimulants in children and adolescents. DESIGN: Retrospective analysis. DATA SOURCE: Texas Medicaid prescription claims database. PATIENTS: A total of 9549 patients aged 5-18 years with attention-deficit-hyperactivity disorder. MEASUREMENTS AND MAIN RESULTS: Paid prescription claims for newly started stimulants during the 2001-2002 school year were extracted from a database; 28,344 prescriptions (9549 patients) were available for analysis. Adherence was evaluated based on the drug therapy prescribed (i.e., mixed amphetamine salts, immediate-release methylphenidate, and extended-release methylphenidate-OROS [oral-osmotic formulation]) and the age and sex of the patient. Adherence measures were persistence and medication possession ratio (MPR). Persistence was higher for extended-release methylphenidate-OROS (0.50 +/- 0.33) than for mixed amphetamine salts (0.42 +/- 0.29) or immediate-release methylphenidate (0.37 +/- 0.26; p < 0.001). The MPR was also higher for extended-release methylphenidate-OROS (0.76 +/- 0.37) than for mixed amphetamine salts (0.73 +/- 0.37) or immediate-release methylphenidate (0.69 +/- 0.37; p < 0.001). Patients aged 5-9 years had equal or better persistence and MPR than those aged 10-14 and 15-18 years (p < 0.001). No sex-related differences in adherence were observed. CONCLUSION: Adherence measures in our study were low. Although they were significantly better for extended-release methylphenidate-OROS than the other stimulants, the clinical significance of these differences are unclear. Further research should be conducted regarding pharmaceutical products, administration methods, and clinical interventions that may enhance adherence.

Acute illnesses associated with pesticide exposure at schools.
Alarcon WA, Calvert GM, Blondell JM, Mehler LN, Sievert J, Propeck M, Tibbetts DS, Becker A, Lackovic M, Soileau SB, Das R, Beckman J, Male DP, Thomsen CL, Stanbury M.
JAMA. 2005 Jul 27;294(4):455-65.
CONTEXT: Pesticides continue to be used on school property, and some schools are at risk of pesticide drift exposure from neighboring farms, which leads to pesticide exposure among students and school employees. However, information on the magnitude of illnesses and risk factors associated with these pesticide exposures is not available. OBJECTIVE: To estimate the magnitude of and associated risk factors for pesticide-related illnesses at schools. DESIGN, SETTING, AND PARTICIPANTS: Analysis of surveillance data from 1998 to 2002 of 2593 persons with acute pesticide-related illnesses associated with exposure at schools. Nationwide information on pesticide-related illnesses is routinely collected by 3 national pesticide surveillance systems: the National Institute for Occupational Safety and Health’s Sentinel Event Notification System for Occupational Risks pesticides program, the California Department of Pesticide Regulation, and the Toxic Exposure Surveillance System. MAIN OUTCOME MEASURES: Incidence rates and severity of acute pesticide-related illnesses. RESULTS: Incidence rates for 1998-2002 were 7.4 cases per million children and 27.3 cases per million school employee full-time equivalents. The incidence rates among children increased significantly from 1998 to 2002. Illness of high severity was found in 3 cases (0.1%), moderate severity in 275 cases (11%), and low severity in 2315 cases (89%). Most illnesses were associated with insecticides (n = 895, 35%), disinfectants (n = 830, 32%), repellents (n = 335, 13%), or herbicides (n = 279, 11%). Among 406 cases with detailed information on the source of pesticide exposure, 281 (69%) were associated with pesticides used at schools and 125 (31%) were associated with pesticide drift exposure from farmland. CONCLUSIONS: Pesticide exposure at schools produces acute illnesses among school employees and students. To prevent pesticide-related illnesses at schools, implementation of integrated pest management programs in schools, practices to reduce pesticide drift, and adoption of pesticide spray buffer zones around schools are recommended.

Implementation and outcomes of recommended folic acid supplementation in Mexican-American women with prior neural tube defect-affected pregnancies.
Felkner M, Suarez L, Hendricks K, Larsen R.
Prev Med. 2005 Jun;40(6):867-71.
BACKGROUND: Upon discovering an NTD incidence rate of 27/10,000 in a Texas border county, the Texas Department of Health initiated folic acid intervention for prevention of recurrent NTDs in this predominantly Mexican-American population. This paper describes compliance of this population with USPHS folic acid recommendations and the impact of supplementation on pregnancy outcomes. METHODS: Based upon information from active surveillance, field teams personally contacted women having NTD-affected pregnancies to enroll them in FA intervention. Enrollees were provided FA at home visits at 3-month intervals throughout the project. RESULTS: Of 405 women identified with NTD-affected pregnancies, 299 (73.8%) enrolled in the intervention. One hundred ninety-three pregnancies occurred among 138 women. FA supplementation of 0.4 mg/day or more occurred during the last month preconception in 161 (83.4%) of the 193 pregnancies. No NTDs were detected in the 130 livebirths to women who received supplementation nor were NTDs detected in the 23 supplemented women who experienced pregnancy loss. CONCLUSIONS: Supplementation was successful in preventing recurrent NTDs in Mexican-American women.

Improving the use of data for HIV prevention decision making: lessons learned.
Jenkins RA, Averbach AR, Robbins A, Cranston K, Amaro H, Morrill AC, Blake SM, Logan JA, Batchelor K, Freeman AC, Carey JW.
AIDS Behav. 2005 Jun;9(2 Suppl):S87-99.
HIV prevention community planning was developed to promote identification of local prevention priorities through a process that was evidence-based and provided community input. There are a variety of barriers to effective use of data in community planning which include characteristics of data (availability, timeliness, relevance to planning tasks), characteristics of planning group members and providers of data (e.g., skills in understanding and applying data), and social-organizational aspects of community-planning groups (CPGs). Lessons learned from this project illustrate how to create locally relevant sources of data, build data use skills of CPG members and data providers, and address social-organizational aspects of planning, while also better integrating community planning with implementation of prevention plans. Adaptation of tools and methods is discussed along with future considerations for research and planning practice.

After the innovation: outcomes from the Texas behavioral data project.
Batchelor K, Robbins A, Freeman AC, Dudley T, Phillips N.
AIDS Behav. 2005 Jun;9(2 Suppl):S71-86.
The Texas Department of Health and University of Texas Southwestern staff, using formative assessment data, developed a set of innovative methods and tools to increase the use of behavioral and epidemiologic data in decision-making about HIV prevention interventions by HIV prevention community planning groups (CPGs) and HIV prevention providers. Semistructured interviews, mail surveys, meeting observations, and content analysis of funding proposals were used to measure the results of the multifaceted intervention. Compared to baseline measures, CPG members reported that data played a more central and desired role in their decision-making. HIV prevention providers exposed to the project's materials were more likely to choose evidence-based interventions to conduct. The tools and structural intervention methods of this project were diffused and had an impact on the use of behavioral data by community planning groups and HIV prevention providers. The structural interventions were not sufficient without the additional effect of the trained peers acting as advocates and intervention innovators.

Bridging data and decision making: development of techniques for improving the HIV prevention community planning process.
Jenkins RA, Robbins A, Cranston K, Batchelor K, Freeman AC, Averbach AR, Amaro H, Morrill AC, Blake SM, Logan JA, Carey JW.
AIDS Behav. 2005 Jun;9(2 Suppl):S41-53.
Assessments of community planning in Massachusetts and Texas were used to develop tools for increasing the use of data by HIV prevention community planning groups (CPGs) and prevention providers while also increasing participation of CPG members. Barriers to data use included organizational problems in CPGs (e.g., lack of clear procedures, distrust of peers and leadership) and technical assistance needs for CPG members and researchers who provide data. The absence of data relevant to local epidemics was another barrier. Specific linkages are provided between the assessments of these needs and the development of a technical assistance tools (e.g., websites, templates for data presentation, experiential involvement in data use) and strategies for organizational change in CPGs, as well as efforts to better use available data and create or identify new sources of local data.

Formative assessment of use of behavioral data in HIV prevention: Texas.
Batchelor K, Freeman AC, Robbins A, Dudley T, Phillips N.
AIDS Behav. 2005 Jun;9(2 Suppl):S29-40.
A formative assessment was conducted with Texas HIV prevention community planning group (CPG) members, prevention provider staff, and supervisors of those staff to better understand how to enhance their use of epidemiologic and behavioral data in the selection and prioritization of prevention interventions. Semi-structured interviews, mail surveys, and content analysis of funding proposals were used to determine the current use of these data, their perceived value, and the most trusted sources for data. CPG members, prevention provider staff, and supervisors valued information from their peers and networking most, and made more use of socially available information than they did research or systematically collected assessment data. CPG members wanted more local data and data on specific sub-populations of interest. Prevention providers viewed the utility of behavioral data as limited, and were primarily concerned with the pragmatic aspects of fielding interventions; however, this group also expressed an interest in rapid community assessment methods and learning more about new and effective prevention interventions. These results led to the development of training and technical assistance materials.

CSHCN in Texas: meeting the need for specialist care.
Young MC, Drayton VL, Menon R, Walker LR, Parker CM, Cooper SB, Bultman LL.
Matern Child Health J. 2005 Jun;9(2 Suppl):S49-57.
OBJECTIVE: Assuring the sufficiency and suitability of systems of care and services for children with special health care needs (CSHCN) presents a challenge to Texas providers, agencies, and state Title V programs. To meet the need for specialist care, referrals from primary care doctors are often necessary. The objective of this study was to describe the factors associated with the need for specialist care and problems associated with obtaining referrals in Texas. METHODS: Bivariate and multivariate analyses were performed using the National Survey of Children with Special Health Care Needs (NS-CSHCN) weighted sample for Texas (n = 719,014) to identify variables associated with the need for specialist care and problems obtaining referrals for specialist care. RESULTS: Medical need of the CSHCN and sensitivity to family values/customs was associated with greater need for specialist care, and Hispanic ethnicity and lower maternal education were associated with less need. Medical need, amount of time spent with doctors and sensitivity to values/customs, living in a large metropolitan statistical area, and lack of medical information were associated with problems obtaining a specialist care referral. CONCLUSIONS: Findings revealed some similarities and differences with meeting the need for specialist care when comparing Texas results to other studies. In Texas, aspects of customer satisfaction variables, especially doctors' sensitivity to family values/customs and parents' not receiving enough information on medical problems, were significantly associated with problems obtaining specialist referrals. Findings indicate a need to further research relationships and communication among doctors, CSHCN, and their families.

Unintentional topical lindane ingestions -- United States, 1998-2003.
[LINK to full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5421a2.htm]
Centers for Disease Control and Prevention. DSHS contributor: J Sievert
Morb Mortal Wkly Rep. June 3, 2005 / 54(21);533-535.
Lindane is an organochlorine pesticide found in certain prescription-only shampoos and topical lotions used to treat pediculosis (i.e., lice infestation) and scabies; lindane has been associated with human neurologic toxicity (1,2). In 2004, CDC was alerted to cases of illness caused by unintentional ingestion of lindane by persons mistaking the product for a liquid oral medication (e.g., cough syrup). To assess the extent of illness from ingestion of lindane, CDC, with assistance from the U.S. Environmental Protection Agency, Food and Drug Administration (FDA), and state health departments, collected case reports and analyzed data from the Sentinel Event Notification System for Occupational Risks-Pesticides (SENSOR-Pesticides) program and the Toxic Exposure Surveillance System (TESS). This report summarizes the results of that analysis, which identified 870 cases of unintentional lindane ingestion during 1998--2003, and describes two examples of lindane ingestions. To reduce the risk of lindane ingestion, public health authorities should alert clinicians to the hazards of lindane and the importance of following FDA usage guidelines, which include dispensing lindane in manufacturer-produced, 1- or 2-ounce single-use containers.

A national agenda for Latino cancer prevention and control.
Ramirez AG, Gallion KJ, Suarez L, Giachello AL, Marti JR, Medrano MA,
Perez-Stable EJ, Talavera GA, Trapido EJ.
Cancer. 2005 Jun 1;103(11):2209-15.
Although cancer is a leading cause of morbidity and premature death among Latinos, there is limited knowledge of cancer-related issues and priorities of greatest significance to the Latino population, the largest minority group in the nation. This information is vital in helping to guide Latino cancer research, training, and awareness efforts at national, regional, and local levels. To help identify cancer issues of greatest relevance to Latinos, Redes En Accion, The National Hispanic/Latino Cancer Network, a major network among the National Cancer Institute's Special Populations Networks, conducted a survey of 624 key opinion leaders from around the country. Respondents were asked to rank the three cancer sites most important to Latinos in their region and the five issues of greatest significance for this population's cancer prevention and control. Recommendations were prioritized for three specific areas: 1) research, 2) training and/or professional education, and 3) awareness and/or public education. Among cancers, breast carcinoma was ranked number one, followed in order by cervical and lung carcinomas. The issues of greatest significance to Latinos were 1) access to cancer screening and care, 2) tobacco use, 3) patient-doctor communication, 4) nutrition, and 5) risk communication. This survey solicited information from scientists, health care professionals, leaders of government agencies, professional and community-based organizations, and other stakeholders in Latino health. The results laid the foundation for a national Redes En Accion Latino cancer agenda, thus providing a useful tool for individuals and organizations engaged in cancer prevention and control efforts among the Hispanic-Latino population.

Rural residence is not a risk factor for frequent mental distress: a behavioral risk factor surveillance survey.
Rohrer JE, Borders TF, Blanton J.
BMC Public Health. 2005 May 16;5(1):46.
LINK to Full-text: http://www.biomedcentral.com/1471-2458/5/46
BACKGROUND: Residents of rural areas may be at increased risk of mental health problems. If so, public health programs aimed at preventing poor mental health may have to be customized for delivery to rural areas. The purpose of this study was to examine the relationship between residing in a rural area and frequent mental distress, which is one indicator of poor mental health. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) survey for the state of Texas was the source of information about obesity, demographic characteristics, and frequent mental distress (FMD). FMD was defined as poor self-rated mental health during at least half of the days in the last month. Adjusted odds for FMD were computed for rural and suburban respondents relative to urban respondents. RESULTS: FMD was found to be independently associated with lower education, being younger, being non-Hispanic, being unmarried, and being female. FMD also was associated with being obese or underweight and suburban residence (relative to metro-central city). FMD was not more common among rural respondents than in the metro-central city. CONCLUSION: Rural respondents were not at greater risk of frequent mental distress than urban respondents in this sample. Programs seeking to improve community mental health should target persons with less education and extremes in body weight, along with women and single persons, regardless of whether they live in rural or urban areas.

Prevalence of nonsyndromic oral clefts in Texas: 1995-1999.
Hashmi SS, Waller DK, Langlois P, Canfield M, Hecht JT.
Am J Med Genet A. 2005 May 1;134(4):368-72.
Nonsyndromic cleft lip with/without cleft palate (NSCLP) and nonsyndromic cleft palate only (NSCPO) are common complex birth defects affecting 4,000 newborns annually. We undertook a descriptive study of oral clefts in Texas, focusing on the effect of folic acid fortification and Hispanic ethnicity on the prevalence of oral clefts as these factors have not previously been described. Data on 896 infants with NSCLP and NSCPO born between 1995 and 1999 in Texas were compared to all births in Texas during the same period. Prevalence odds ratios (POR) were calculated for maternal ethnicity, race, age, parity, public health region of residence, highest level of education, and infant gender. The effect of folic acid fortification on oral clefts was also examined. Compared with whites, adjusted POR were 0.97 (95% CI = 0.77-1.23) and 0.90 (95% CI 0.72-1.14) for NSCLP and 0.46 (95% CI = 0.30-0.72) and 0.62 (95% CI = 0.42-0.90) for NSCPO in foreign-born and US-born Hispanics, respectively. After fortification was implemented, the rate of NSCLP did not decrease. However, there was a 13% decrease in the prevalence of NSCPO (adjusted POR = 0.87, 95% CI = 0.68-1.15). Compared to whites, the rates in US-born and foreign-born Hispanic women were similar for NSCLP and much lower for NSCPO. The small reduction of 13% in NSCPO after folic acid fortification is imprecise and should be interpreted cautiously. Overall, it appears that folic acid fortification has had very little or no effect on the prevalence of oral clefts in infants born in Texas. Copyright 2005 Wiley-Liss, Inc.

The wound care team: a new source of group a streptococcal nosocomial transmission.
Felkner M, Pascoe N, Shupe-Ricksecker K, Goodman E.
Infect Control Hosp Epidemiol. 2005 May;26(5):462-5.
BACKGROUND: In August 2001, the Centers for Disease Control and Prevention (CDC) notified the Texas Department of Health (TDH) of an unusually high number of wounds infected with group A streptococci (GAS) in an acute care facility. The TDH initiated an investigation, ultimately identifying 28 cases of non-pharyngeal, non-community-acquired GAS that had occurred between December 2000 and August 2001 and resulted in 3 deaths and 4 nonfatal cases of invasive disease. Ten specimens were sent to the CDC for emm typing; all isolates were emm type 114. However, the source of the outbreak could not be confirmed through laboratory testing at that time. METHODS: A case-control study was conducted comparing the 10 case-patients with 52 control-patients with wounds that were not infected with GAS. Age, gender, type of wound, underlying medical conditions, and treatment by the wound care team were examined for association with GAS infection. RESULTS: The odds of having wound care team treatment versus not having it were 424.2 (95% confidence interval, 19.0 to 9,495.2) among case-patients when compared with control-patients. No other risk factor showed this magnitude of association. CONCLUSIONS: This study provided overwhelming epidemiologic evidence that the wound care team was the means of transmission. One year later, when two patients receiving wound care were concurrently diagnosed as having GAS, a member of the wound care team was found to be GAS positive for the matching emm type. This is the first report of a GAS hospital outbreak linked to a wound care team.

Association between sociodemographic factors and exposures and utilization of poison centers in Texas, 1998-2002.
Forrester MB.
J Toxicol Environ Health A. 2005 May 28;68(10):755-61.
This study evaluated whether selected sociodemographic factors and exposures may be associated with utilization of poison centers in Texas during 1998-2002. Data were obtained from the six poison centers that service the entire state. Cases were all human exposures where the caller county was known. The utilization rate (calls per 1000 population) was calculated for the entire state and for each county. Counties were then grouped into those with utilization rates lower than the utilization rate for the entire state and those with utilization rates higher than the rate for the entire state. The two groups were then compared with respect to sociodemographic factors derived from the 2000 Census and exposure categories derived from the poison centers. The group of counties with lower utilization rates had a lower population density, higher African-American and Hispanic populations, lower median household incomes, and higher percentage of the population who spoke a language other than English at home and spoke English less than "very well." Gender, age, and education factors were not related to utilization rates, and the most frequently reported exposure categories were similar between counties with lower and higher utilization rates. This information can be used to focus education and prevention efforts at those populations with lower utilization of the Texas Poison Center Network.

Human exposures to tilmicosin reported to poison centres, Texas, 1998-2003.
Forrester MB.
Hum Exp Toxicol. 2005 May;24(5):275-8.
Tilmicosin, or 20-deoxo-20-(3,5-dimethylpiperidin-1-yl)-desmycosin, is a macrolide antibiotic primarily utilized in livestock. This study examined 46 human exposure calls involving tilmicosin received by Texas poison centres during 1998-2003. The majority (91%) of the calls were received from northern and central Texas. All of the cases were unintentional exposures. The most frequent route of exposure was parenteral (48%). The majority of the patients were males (80%) and adults (84%). Only 46% of the patients were managed outside of health care facilities. Some sort of adverse medical outcome was reported in 93% of parenteral exposures and 54% of other-route exposures. However, only 21% of parenteral exposures and 15% of other-route exposures involved medical outcomes that were judged to be moderate or worse. No deaths were reported. The most frequently reported clinical effects among parenteral cases were dermal (79%), while only 9% of other-route exposures had dermal effects. Cardiovascular clinical effects were observed in a single case of parenteral exposure and a single case of other-route exposure. Although the majority of cases were managed with the assistance of health care facilities, the medical outcomes were usually not serious. Outcome depended on the route of exposure.

Deaths of Clients in Methadone Treatment in Texas: 1994-2002.
Maxwell JC, Pullum TW, Tannert K.
Drug Alcohol Depend. 2005 Apr 4;78(1):73-81.
This study analyzes causes of deaths of 766 patients who died while in methadone treatment in Texas between 1994 and 2002. Compared with deaths in the general population of Texas, deaths of clients in methadone treatment were 4.6 times more likely to be from a drug overdose, 3.4 times more likely to be from liver disease, 1.7 times more likely to be from a respiratory disease, 1.5 times more likely to be from a homicide and 1.4 times more likely to be from AIDS, but less likely to be from suicide, motor vehicle accidents, cardiovascular diseases or cancer. Of the clients, 20% died of liver disease, 18% of cardiovascular disease and 14% of drug overdose. An older cohort had been in treatment longer, had more take-homes, were on higher doses and tended to die of chronic diseases. A younger cohort tended to die from traumas, including drug overdose. Time in treatment was 43.3 months; mean daily dose was 77.3mg; number of days/month dosed in the clinic was 13.9. Given these rates, the scope of services should include on-site treatment for other medical conditions and staff should be educated about and counsel about the risk of death for new patients.

Trends in antiretroviral therapy use and survival rates for a large cohort of HIV-infected children and adolescents in the United States, 1989-2001.
McConnell MS, Byers RH, Frederick T, Peters VB, Dominguez KL, Sukalac T, Greenberg AE, Hsu HW, Rakusan TA, Ortiz IR, Melville SK, Fowler MG; Pediatric Spectrum of HIV Disease Consortium.
J Acquir Immune Defic Syndr. 2005 Apr 1;38(4):488-94.
BACKGROUND: In the United States, HIV-infected children and adolescents are aging and using antiretroviral (ARV) therapy for extended periods of time. OBJECTIVE: To assess trends in ARV use and long-term survival in an observational cohort of HIV-infected children and adolescents in the United States. METHODS: The Pediatric Spectrum of HIV Disease Study (PSD) is a prospective chart review of more than 2000 HIV-infected children and adolescents. Patients were included in the analysis from enrollment until last follow-up. RESULTS: Triple-ARV therapy use (for 6 months or more) increased from 27% to 66% during 1997 to 2001 (P < 0.0001, chi for trend). The proportion of patients receiving 3 or more sequential triple-therapy regimens also increased from 4% to 17% during 1997 to 2001 (P < 0.0001, chi for trend), however, and the durability of triple-therapy regimens decreased from 13 to 7 months from the first to third regimen. Survival rates for the 1997 to 2001 birth cohorts were significantly better than for the 1989 to 1993 and 1994 to 1996 cohorts (P < 0.0001). CONCLUSIONS: Survival rates in the PSD cohort have increased in association with triple-ARV therapy use. With continued changes in ARV regimens, effective modifications in ARV therapy and the sustainability of gains in survival need to be determined.

Transmission of Rabies Virus from an Organ Donor to Four Transplant Recipients.
Srinivasan A, Burton EC, Kuehnert MJ, Rupprecht C, Sutker WL, Ksiazek TG,
Paddock CD, Guarner J, Shieh WJ, Goldsmith C, Hanlon CA, Zoretic J, Fischbach B,
Niezgoda M, El-Feky WH, Orciari L, Sanchez EQ, Likos A, Klintmalm GB, Cardo D,
LeDuc J, Chamberland ME, Jernigan DB, Zaki SR.
N Engl J Med. 2005 Mar 17;352(11):1103-11.
BACKGROUND: In 2004, four recipients of kidneys, a liver, and an arterial segment from a common organ donor died of encephalitis of an unknown cause. METHODS: We reviewed the medical records of the organ donor and the recipients. Blood, cerebrospinal fluid, and tissues from the recipients were tested with a variety of assays and pathological stains for numerous causes of encephalitis. Samples from the recipients were also inoculated into mice. RESULTS: The organ donor had been healthy before having a subarachnoid hemorrhage that led to his death. Encephalitis developed in all four recipients within 30 days after transplantation and was accompanied by rapid neurologic deterioration characterized by agitated delirium, seizures, respiratory failure, and coma. They died an average of 13 days after the onset of neurologic symptoms. Mice inoculated with samples from the affected patients became ill seven to eight days later, and electron microscopy of central nervous system (CNS) tissue demonstrated rhabdovirus particles. Rabies-specific immunohistochemical and direct fluorescence antibody staining demonstrated rabies virus in multiple tissues from all recipients. Cytoplasmic inclusions consistent with Negri bodies were seen in CNS tissue from all recipients. Antibodies against rabies virus were present in three of the four recipients and the donor. The donor had told others of being bitten by a bat. CONCLUSIONS: This report documenting the transmission of rabies virus from an organ donor to multiple recipients underscores the challenges of preventing and detecting transmission of unusual pathogens through transplantation.

Pseudomonas bloodstream infections associated with a heparin/saline flush--Missouri, New York, Texas, and Michigan, 2004-2005.
[LINK to full-text: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5411a1.htm]
Centers for Disease Control and Prevention. DSHS contributor: N Pascoe, M Richardson
Morb Mortal Wkly Rep. March 25, 2005 / 54(11);269-272.
On January 26, 2005, CDC was notified of four cases of Pseudomonas fluorescens bloodstream infection among patients at an oncology clinic in Missouri. All patients had received a heparin/saline flush to prevent clotting of indwelling, central venous catheters. The flushes were preloaded in syringes by IV Flush and distributed by Pinnacle Medical Supply (Rowlett, Texas). On January 31, a nationwide alert against use of all heparin or saline flushes preloaded in syringes by IV Flush was issued by the Food and Drug Administration; the company recalled these products. As of February 15, state and local health departments and CDC had identified a total of 36 Psuedomonas species infections in patients in four states who were administered the heparin/saline flushes from multiple lots. This report describes the ongoing investigation and provides recommendations for investigation and management of potential cases.

Weight changes in teens on psychotropic medication combinations at Austin State Hospital.
Becker EA, Shafer A, Anderson R.
Texas Medicine, March 2005;101(3):62-70.
Psychiatrists commonly treat adolescents with multiple psychotropic medications simultaneously. We studied the effects of psychotropic medications on the weight of adolescent patients at Austin State Hospital between June 1997 and December 2001. The medication combinations that caused the largest weight increases were olanzapine with valproic acid, and olanzapine with venlafaxine. The biggest weight loss combinations were valproic acid with bupropion, and valproic acid with venlafaxine. Medications drove a substantial portion of the changes in weight, not other variables. The specific medication prescribed, rather than the total number of medications, predicted weight gain. As current inpatient adolescents are receiving multiple medications and their weight is subsequently being affected, more study is needed to better understand these effects.

A psychoeducational program for children with ADHD or depression and their families: results from the CMAP feasibility study.
Lopez MA, Toprac MG, Crismon ML, Boemer C, Baumgartner J.
Community Ment Health J. 2005 Feb;41(1):51-66.
For children and adolescents with behavioral and emotional disorders and their families, education about their disorders and the treatments is an essential component of a comprehensive approach to their care. Education can encourage active participation in treatment, enhance adherence to treatment regimens, and provide patients and families with important coping skills. Thus, the Children's Medication Algorithm Project (CMAP) incorporated a psychoeducational program into the medication algorithm created to improve treatment of children with ADHD and/or depression in the Texas public mental health sector. This article describes the process by which a comprehensive educational program was developed in partnership with parents and advocates. The final program is described, as well as a pilot study to examine the feasibility of implementation in four community clinics.

Idiopathic talipes equinovarus (ITEV) (clubfeet) in Texas.
Moorthi RN, Hashmi SS, Langois P, Canfield M, Waller DK, Hecht JT.
Am J Med Genet A. 2005 Feb 1;132(4):376-80.
Idiopathic talipes equinovarus (ITEV) is the most common form of clubfoot with a birth prevalence of 1 per 1,000 births. Serial casting and surgical correction impose a substantial financial burden on families and the health care system. While the etiology of ITEV is considered to be complex, the causes remain elusive. Genetic, maternal, and environmental factors have been suggested to play an etiologic role. This study was undertaken to determine the prevalence of ITEV and define maternal and environmental factors associated with ITEV in Texas from 1996 to 1999. Data on 682 cases of nonsyndromic ITEV were compared with all births (n = 923,543) in Texas during the same period. The overall prevalence and prevalence odds ratios (PORs) were calculated for gender, year of birth, public health region (PHR), race, maternal age, education, folic acid fortification, and parity. The overall prevalence of ITEV was 0.74/1,000 or 1/1,354 live births. Adjusted PORs were similar among blacks and US and foreign-born Hispanics (POR = 0.92, 95% CI = 0.69-1.21; POR = 0.99, 95% CI = 0.79-1.25; and POR = 0.94, 95% CI = 0.74-1.19), respectively, compared to whites. College education and higher parity were significantly associated with a lower risk of giving birth to offspring with ITEV. Babies born after folic acid fortification of grains had a very small decrease in ITEV that may be due to chance. (c) 2005 Wiley-Liss, Inc.

Unplanned pregnancy among active duty servicewomen, U.S. Air Force, 2001.
Robbins AS, Chao SY, Frost LZ, Fonseca VP.
Mil Med. 2005 Jan;170(1):38-43.
Unplanned pregnancy is a major public health problem in the United States. Although the U.S. Air Force has the highest proportion of active duty women of any of the U.S. military services, there are no published data on the occurrence of unplanned pregnancy among active duty Air Force (ADAF) women. Civilian female interviewers conducted telephone interviews with a random sample of 2,348 ADAF women during early 2002, using questions that were closely based on the 1995 National Survey of Family Growth. During 2001, approximately 12% of ADAF women had one or more pregnancies. By National Survey of Family Growth criteria, approximately 54% of these pregnancies were unplanned. Thus, approximately 7% of ADAF women had one or more unplanned pregnancies during 2001. Roughly one-half of unplanned pregnancies represented contraceptive nonuse and the other half represented contraceptive failure or misuse. Unplanned pregnancy is a serious and frequently occurring problem among ADAF women, with many opportunities for prevention.

Maternal obesity, gestational diabetes, and central nervous system birth defects.
Anderson JL, Waller DK, Canfield MA, Shaw GM, Watkins ML, Werler MM.
Epidemiology. 2005 Jan;16(1):87-92
BACKGROUND: Maternal obesity and diabetes are both associated with increased risk of congenital central nervous system (CNS) malformations in the offspring and may share a common underlying mechanism. Our objective was to evaluate whether gestational diabetes influenced the association of prepregnancy maternal obesity and risks for CNS birth defects. METHODS: This Texas population-based case-control study evaluated births occurring January 1997 through June 2001. Data came from structured telephone interviews. Cases (n=477) were mothers of offspring with anencephaly (n=120), spina bifida (n=184), holoprosencephaly (n=49), or isolated hydrocephaly (n=124). Controls (n=497) were mothers of live infants without abnormalities randomly selected from the same hospitals as cases. Response rates were approximately 60% for both cases and controls. We evaluated maternal obesity (body mass index > or =30.0 kg/m) and risks for CNS birth defects, as well as whether gestational diabetes influenced the risks. RESULTS: After adjusting for maternal ethnicity, age, education, smoking, alcohol use, and periconceptional vitamin use, obese women had substantially increased risks of delivering offspring with anencephaly (odds ratio=2.3; 95% confidence interval=1.2-4.3), spina bifida (2.8; 1.7-4.5), or isolated hydrocephaly (2.7; 1.5-5.0), but not holoprosencephaly (1.4; 0.5-3.8). Odds ratios were higher for the joint effects of maternal obesity and gestational diabetes, with evidence for interaction on a multiplicative scale. CONCLUSIONS: Maternal obesity and gestational diabetes may increase the risk of CNS birth defects through shared causal mechanisms.

Impact of legislation on illicit substance surveillance by poison centers in Texas.
Forrester MB.
J Registry Management 2005;32:118-123.
ABSTRACT: This study observed and compared surveillance of selected illicit substances by poison centers in Texas before and after a state law was enacted on September 1, 1999, requiring mandatory reporting of overdoses of certain controlled substances. Penetrance for cocaine, heroin, and marijuana calls received by the Texas Poison Center Network ( TPCN ) was compared for several time periods. The call distribution by various other factors was determined before and after legislation enactment and compared. The cocaine penetrance increased by 69%, heroin by 30%, and marijuana by 100% between 1999 and 2000. Comparing cases reported before and after legislation enactment, statistically significant differences were observed for exposure site, caller site, management site, medical outcome, and geography. While the evidence for proof is not present, these results are consistent with the premise that enactment of this legislation appears to have altered the types of cocaine, heroin, and marijuana exposures reported to the TPCN.

2004 Articles (in date order with most recent first)

Melatonin exposures reported to Texas poison centers in 1998-2003.
Forrester MB.
Vet Hum Toxicol. 2004 Dec;46(6):345-6.
Melatonin regulates circadian rhythms, and although widely used in the US, information on the public use of melatonin and patterns of reported adverse effects associated with the substance is limited. To describe the patterns of melatonin calls to poison centers in Texas during 1998-2003, data on all melatonin calls reported to the Texas Poison Center Network were analyzed. During 1998-2003, there were 779 identified human exposures to melatonin identified. Of those patients with a known age, 59.1% were < 6 y. Males accounted for 54.1% of preschool-age patients while more of the older patients were female. Melatonin exposures were unintentional in 99.3% of the cases among children less than 6y and unintentional in < 41% among the older age groups. While 92.4% of exposures involving the youngest age group were managed outside of a health care facility, 42% or less of the exposures occurring to patients > age 6 years were managed outside of a health care facility. Of those cases with a known outcome, the proportion of cases with at least minor effects rose with increasing age. The majority of melatonin exposures reported to Texas poison centers involved children < 6 y. Younger patients were more likely to be male, have unintentional exposures, have no clinical effect, and to not require management at health care facilities. The observed clinical effects and treatment methods were consistent with the literature.

slo K(+) Channel Gene Regulation Mediates Rapid Drug Tolerance.
Ghezzi A, Al-Hasan YM, Larios LE, Bohm RA, Atkinson NS.
Proc Natl Acad Sci U S A. 2004 Dec 7;101(49):17276-81.
Changes in neural activity caused by exposure to drugs may trigger homeostatic mechanisms that attempt to restore normal neural excitability. In Drosophila, a single sedation with the anesthetic benzyl alcohol changes the expression of the slo K(+) channel gene and induces rapid drug tolerance. We demonstrate linkage between these two phenomena by using a mutation and a transgene. A mutation that eliminates slo expression prevents tolerance, whereas expression from an inducible slo transgene mimics tolerance in naive animals. The behavioral response to benzyl alcohol can be separated into an initial phase of hyperkinesis and a subsequent phase of sedation. The hyperkinetic phase causes a drop in slo gene expression and makes animals more sensitive to benzyl alcohol. It is the sedative phase that stimulates slo gene expression and induces tolerance. We demonstrate that the expression level of slo is a predictor of drug sensitivity.

Insight from a breastfeeding peer support pilot program for husbands and fathers of Texas WIC participants.
Stremler J, Lovera D.
J Hum Lact. 2004 Nov;20(4):417-22.
A Father-to-Father Breastfeeding Support Pilot Program conducted by the Texas Department of Health provides a model of a viable way to increase breastfeeding rates in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program). The pilot concept was based on previous success with a breastfeeding peer counselor program and research documenting the father's attitude as an important influence on a mother's decision to breastfeed. Peer dads are fathers of breastfed infants participating in the WIC Program. They are recruited, trained, and hired to give breastfeeding and parenting information to other WIC fathers. WIC fathers rated the information they received as "very important" and indicated that counseling sessions would help them support their infants'mothers with breastfeeding and be better fathers. Breastfeeding initiation rates increased at clinics employing peer dads. Father-to-father breastfeeding education was successful in educating and empowering fathers, enabling them to support their breastfeeding family members.

Epidemiology of spider bites in Texas, 1998-2002.
Forrester MB, Stanley SK.
Public Health. 2004 Oct;118(7):506-7.

The effect of fever, febrile illnesses, and heat exposures on the risk of neural tube defects in a Texas-Mexico border population.
Suarez L, Felkner M, Hendricks K.
Birth Defects Res A Clin Mol Teratol. 2004 Oct;70(10):815-9.
BACKGROUND: Hyperthermia produces neural tube defects (NTDs) in a variety of animal species. Elevated maternal body temperatures may also place the developing human embryo at risk. We examined the relation between maternal hyperthermia and the development of NTDs in a high-risk Mexican-American population. METHODS: Case-women were Mexican-American women with NTD-affected pregnancies who resided and delivered in any of the 14 Texas counties bordering Mexico, during 1995-2000. Control-women were randomly selected from study area residents delivering normal live births, frequency-matched to cases by hospital and year. Information on maternal fevers, febrile illnesses, exposures to heat generated from external sources, and hyperthermia-inducing activities was gathered through in-person interviews, conducted about six weeks postpartum. RESULTS: The risk effect (OR) associated with maternal fever in the first trimester, compared to no fever, was 2.9 (95% CI, 1.5-5.7). Women taking fever-reducing medications showed a lower risk effect (OR, 2.4; 95% CI, 1.0-5.6) than those who did not (OR, 3.8; 95% CI, 1.4-10.9). First-trimester maternal exposures to heat devices such as hot tubs, saunas, or electric blankets were associated with an OR of 3.6 (95% CI, 1.1-15.9). Small insignificant effects were observed for activities such as cooking in a hot kitchen (OR, 1.6; 95% CI, 1.0-2.6) and working or exercising in the sun (OR, 1.4; 95% CI, 0.9-2.2). CONCLUSIONS: Maternal hyperthermia increases the risk for NTD-affected offspring. Women intending to become pregnant should avoid intense heat exposures, carefully monitor and manage their febrile illnesses, and routinely consume folic acid supplements. (c) 2004 Wiley-Liss, Inc.

Medical records vs. interview responses: a comparative analysis of selected variables for linked birth defect cases.
Ramadhani TA, Canfield MA, Waller DK, Case AP.
Birth Defects Res A Clin Mol Teratol. 2004 Sep;70(9):592-6.
BACKGROUND: Data pertaining to birth defects are subject to certain limitations depending on the collection method. This study compares the agreement of data from medical records and maternal interviews. METHODS: The medical records and maternal interviews were linked for 1017 deliveries. Prevalence, concordance and kappa coefficients were calculated for maternal gestational and non-gestational diabetes, insulin use, seizures/epilepsy, Hispanic ethnicity, and infant/fetus sex. RESULTS: The prevalence of non-gestational diabetes was 4.3% in the medical records and 3.4% in the maternal interviews, with 98.1% agreement. The prevalence of gestational diabetes was 7.9% in medical records and 9.2% in maternal interviews, with 94.3% agreement. Similar prevalences and high levels of agreement were observed between the two systems for infant/fetus sex and mother's Hispanic ethnicity. Although high concordance was observed for seizures/epilepsy, kappa value was moderate. CONCLUSIONS: The availability of two distinct sources of data provides an exceptional opportunity to compare and validate both data sources. We found that the data for certain variables from maternal interviews strongly agreed with information from medical records. However, the extent of that agreement depended on the type of variable measured. Our results suggest that for some variables such as demographic variables, researchers can use either of the two data sources. Copyright 2004 Wiley-Liss, Inc.

Epidemiology of snakebites reported to poison centers in Texas from 1998 through 2002.
Forrester MB, Stanley SK.
Tex Med 2004;100:64-70.
ABSTRACT: The 15 species and subspecies of poisonous snakes endemic to Texas include all of the major poisonous snakes in the United States. Rates of poisonous snakebites have been reported to be higher in Texas than in most other states. However, epidemiologic data on poisonous and nonpoisonous snakebites are limited. Using data on snakebites to humans reported to the six poison centers in Texas, we examined associations with various demographic and clinical factors. The reported snakebite penetrance increased from 1998 through 2002. Most of the reported snakebites involved adults. Males were more likely to have reported snakebites than females. Most reported snakebites had mild-to-moderate outcomes. Snakebites were reported more frequently in the spring and summer. The geographic pattern of reported snakebites was generally consistent with the reported distribution of the types of poisonous snakes.

Textbooks

Biostatistics for the health sciences by R. Clifford Blair and Richard A. Taylor. New York: Prentice Hall, 2007, 552 p.
This book provides a solid foundation in introductory biostatistics. It explains commonly used biostatistical methods and provides real-world data with case studies. It is aimed primarily at health science students and professionals who need to increase their understanding of biostatistics.

The Dental hygienist's guide to nutritional care by Cynthia A. Stegeman and Judi Ratliff Davis. St. Louis, MO : Elsevier Saunders, 2005, 540 p.
This textbook for dental hygienists covers the basics of nutrition, as well as relevant topics specific to different life stages and states of health. Readers learn how to assess clients' eating habits and learn all about the nutritional aspects of oral health.

Last updated November 19, 2007