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DSHS Authors: 2009 Research Articles by DSHS Staff

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The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services since its formation in September 2004. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by e-mail at library@dshs.state.tx.us by calling (512) 776-7559.

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mrl-diamond2009 Articles (in date order with most recent first)

Health Care Transmission of a Newly Emergent Adenovirus Serotype in Health Care Personnel at a Military Hospital in Texas, 2007.
Lessa FC, Gould PL, Pascoe N, Erdman DD, Lu X, Bunning ML, Marconi VC, Lott L, Widdowson MA, Anderson LJ, Srinivasan A.
J Infect Dis. 2009 Dec 1;200(11):1759-65.
BACKGROUND: Adenoviruses can cause outbreaks of febrile respiratory illness in military trainees, but until 2007, adenovirus serotype 14 (Ad14) was never associated with such outbreaks. From April through June 2007, 15 trainees at one base were hospitalized for pneumonia due to Ad14. Subsequent reports of febrile respiratory illness among health care personnel suggested nosocomial transmission. METHODS: Health care personnel participants completed a questionnaire and provided blood and nasal wash specimens for Ad14 diagnostic testing. We defined a confirmed case of Ad14 infection as one with titers > or = 1:80 or nasal wash specimens positive for Ad14 by polymerase chain reaction, whereas a possible case was defined by titers of 1:20 or 1:40. We also collected environmental samples. RESULTS: Among 218 tested health care personnel, 35 (16%) had titers > or = 1:20; of these, 7 had possible cases and 28 had confirmed cases of infection. Confirmed case patients were more likely to report febrile respiratory illness (57% vs 11%; P< .001) and to have had direct contact with patients with Ad14 infection (82% vs 62%; P.04 ). Of the 23 confirmed case patients with direct contact with Ad14-infected patients, 52% reported that patients were not in contact and droplet precautions at the time of exposure. Ad14 was recovered from several hospital surfaces. CONCLUSION: Our findings of possible nosocomial transmission of Ad14 highlight the need to reinforce infection control guidelines.

Hospitalized Patients with 2009 H1N1 Influenza in the United States, April-June 2009.
Jain S, Walker JD, et al.; 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team [with additional DSHS Collaborators: M, Damon S, Davis M, Fonseca VP, Martinez A, Mireles J, Smit JL]
N Engl J Med. 2009 Nov 12;361(20):1935-44.
BACKGROUND: During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009. METHODS: Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase-polymerase-chain-reaction assay. RESULTS: Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early. CONCLUSIONS: During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

Methods for Developing Useful Estimates of the Costs Associated with Birth Defects.
Case AP, Canfield MA.
Birth Defects Res A Clin Mol Teratol. 2009 Nov;85(11):920-4.
BACKGROUND: Cost estimates for birth defects are useful to policy makers in deciding the best use of resources to prevent these conditions. Much of the effort in this area has focused on spina bifida, in part because cost savings can be estimated from folic acid-preventable cases. However, comprehensive cost-of-illness estimates for this condition may be too outdated, too general, or not applicable to individual states' environments. METHODS: Using the live birth prevalence for spina bifida in Texas, we applied recent spina bifida cost estimates to approximate total lifetime medical and other costs for an average live birth cohort of spina bifida cases in Texas. In addition, we queried various government programs that provide services for persons with spina bifida to provide program-specific annual costs for this condition. RESULTS: Applying a recently published average lifetime medical cost of $635,000 per case of spina bifida to the average annual birth cohort of 120 Texas cases, an estimated $76 million in direct and indirect medical and other costs will be incurred in Texas over the life span of that cohort. Examples of estimated medical costs for one year are $5 million for infants using actual employer-paid insurance claims data and $6 million combined for children in two public sector programs. DISCUSSION: Stakeholders and state policy makers may look to state birth defects registries for useful cost data. Although comprehensive state-specific figures are not available, applying prevalence data to existing estimates and obtaining actual claims and program expenditures may help close this information gap.

Epidemiologic Features and Clinical Subgroups of Anotia/Microtia in Texas.
Canfield MA, Langlois PH, Nguyen LM, Scheuerle AE.
Birth Defects Res A Clin Mol Teratol. 2009 Nov;85(11):905-13.
BACKGROUND: Few studies have investigated the epidemiologic features of clinically defined subgroups of anotia/microtia. METHODS: Data on cases of anotia and/or microtia among 1999-2005 deliveries were obtained from the Texas Birth Defects Registry, a population-based active surveillance system. We determined crude and adjusted associations between selected factors and seven clinical subgroups of anotia/microtia. RESULTS: In total, 742 cases were diagnosed with anotia and/or microtia, corresponding to a prevalence of 2.86 per 10,000 live births. Of those, 45% had no other major birth defect ("isolated"), 77% were unilateral, and 22% bilateral. Anotia alone made up 6%, whereas microtia made up 94%. Birth prevalence was higher with increasing maternal age and among Mexico-born Hispanics. Compared to white mothers, Hispanic mothers were two-to-three times more likely to have infants with all but the syndromic and bilateral groups (adjusted prevalence ratios [aPRs] = 2.05-2.61). Non-Hispanic blacks had significantly lower risk for total anotia/microtia, and for the isolated, unilateral, and microtia subgroups (aPRs = 0.42-0.64). Less educated mothers were three-to-four times more likely to have children with anotia (aPRs = 2.98 for less than high school, 3.97 for high school graduates). Males were more likely to be born with total anotia/microtia and with syndromic, unilateral, and microtia subtypes (aPRs = 1.27-1.41). CONCLUSIONS: In Texas, most anotia/microtia cases were in the unilateral and microtia groups, and 45% were isolated. Several clinical subgroups exhibited higher prevalence in males and among older mothers. Relative to whites, blacks were at lower risk and Hispanics (especially Mexico-born mothers) were at higher risk for selected types of anotia/microtia.

Landscape-Genetic Analysis of Population Structure in the Texas Gray Fox Oral Rabies Vaccination Zone.
Deyoung RW, Zamorano A, Mesenbrink BT, Campbel TA, Leland BR, Moore GM, Honeycutt RL, RootJJ.
J Wildl Manage. 2009 Nov;73(8):1292-9
In west-central Texas, USA, abatement efforts for the gray fox (Urocyon cinereoargenteus) rabies epizootic illustrate the difficulties inherent in large-scale management of wildlife disease. The rabies epizootic has been managed through a cooperative oral rabies vaccination program (ORV) since 1996. Millions of edible baits containing a rabies vaccine have been distributed annually in a 16-km to 24-km zone around the perimeter of the epizootic, which encompasses a geographic area .4 3 105 km2. The ORV program successfully halted expansion of the epizootic into metropolitan areas but has not achieved the ultimate goal of eradication. Rabies activity in gray fox continues to occur periodically outside the ORV zone, preventing ORV zone contraction and dissipation of the epizootic. We employed a landscape-genetic approach to assess gray fox population structure and dispersal in the affected area, with the aim of assisting rabies management efforts. No unique genetic clusters or population boundaries were detected. Instead, foxes were weakly structured over the entire region in an isolation by distance pattern. Local subpopulations appeared to be genetically non-independent over distances .30 km, implying that long-distance movements or dispersal may have been common in the region. We concluded that gray foxes in west-central Texas have a high potential for long-distance rabies virus trafficking. Thus, a 16-km to 24-km ORV zone may be too narrow to contain the fox rabies epizootic. Continued expansion of the ORV zone, although costly, may be critical to the long-term goal of eliminating the Texas fox rabies virus variant from the United States.

The Association between Use of Spermicides or Male Condoms and Major Structural Birth Defects.
Gallaway MS, Waller DK, Canfield MA, Scheuerle A; National Birth Defects Prevention Study.
Contraception. 2009 Nov;80(5):422-9.
BACKGROUND: Women may become pregnant while using contraceptives. Commonly used contraceptives containing spermicides may or may not be associated with an increased occurrence of structural birth defects. STUDY DESIGN: Utilizing data from the National Birth Defects Prevention Study, we assessed maternal reports of spermicide and male condom use 1 to 3 months following conception among case (n=11,050) and control (n=4723) mothers. We assessed the association between spermicide use and 27 types of birth defects and that between condom use and 32 types of birth defects. RESULTS: Maternal spermicide use during the first 3 months following conception was associated with a significant increase in the occurrence of only 1 of 27 birth defects, perimembranous ventricular septal defects (adjusted odds ratio=2.40, 95% confidence interval=1.25-4.62). There was no significant association between maternal use of male condoms during the first 3 months following conception and any of 32 types of birth defects. CONCLUSIONS: The increased occurrence of perimembranous ventricular septal defects among spermicide users may be real or may be a chance finding. Overall, the findings are consistent with those of most previous studies that observed no increased risk for birth defects among spermicide users.

Impact of Hurricane Ike on Texas Poison Center Calls.
Forrester MB.
Disaster Med Public Health Prep 2009;3:151-7.
On September 13, 2008, Hurricane Ike made landfall in Texas, resulting in the mandatory evacuation of 8 counties before landfall and the declaration of disaster areas in 29 counties afterward. This study evaluated whether Hurricane Ike affected the pattern of Texas poison center calls. Texas poison center calls received from the disaster area counties were identified for 3 time periods: August 12 to September 10, 2008 (preevacuation), September 11 to 13, 2008 (evacuation and hurricane landfall), and September 14 to 30, 2008 (postevacuation). For selected types of calls, the mean daily call volume during time periods 2 and 3 was compared with a baseline range (BR) derived from the mean daily call volume during time period 1. During the evacuation and landfall period, gasoline exposure calls were higher than expected (mean 3, BR –1 to 2). During the postevacuation period, higher than expected numbers of calls were observed for gasoline exposures (mean 5, BR –1 to 2) and carbon monoxide exposures (mean 3, BR –1–1). During an evacuation, certain calls such as those involving gasoline exposures may increase. After a hurricane, calls such as those involving carbon monoxide and gasoline exposures may increase.

Pattern of Orlistat Exposures in Children Aged 5 Years or Less.
Forrester MB.
J Emerg Med. 2009 Nov;37(4):396-9.
On February 7, 2007, orlistat became the first weight-loss drug approved by the United States Food and Drug Administration for over-the-counter sales. However, information on exposures among young children is limited. The objective of this study was to describe the pattern of orlistat exposures among young children reported to poison control centers. The pattern of all exposures to orlistat alone among patients </= 5 years old reported to six poison control centers during 1999-2005 was identified with respect to various factors. There were 107 cases. The average age was 21.4 months. There were 55 males, 51 females, and 1 unknown. The dose was identified for 76 cases. The mean dose was 155 mg. Patients were managed on site in 88% of the cases, were already at a health care facility in 8%, and were referred to a health care facility in 5%. Of the 45 patients with a known medical outcome, the outcome was no effect for 91% and minor effect for 9% of the patients. Of the 92 cases reported during 2000-2005, the listed adverse clinical effects were diarrhea (n = 4) and vomiting (n = 1), and the listed treatments were decontamination by dilution (n = 62), food (n = 8), activated charcoal (n = 5), other emetic (n = 2), cathartic (n = 1), and ipecac (n = 1). Orlistat exposures among young children involving small doses encountered by poison control centers can usually be managed on site through decontamination, and have favorable outcomes with few adverse clinical effects, mainly gastrointestinal in nature.

Control Selection and Participation in an Ongoing, Population-based, Case-control Study of Birth Defects: The National Birth Defects Prevention Study.
Cogswell ME, Bitsko RH, Anderka M, Caton AR, Feldkamp ML, Hockett Sherlock SM, Meyer RE, Ramadhani T, Robbins JM, Shaw GM, Mathews TJ, Royle M, Reefhuis J.
Am J Epidemiol. 2009 Oct 15;170(8):975-85.
To evaluate the representativeness of controls in an ongoing, population-based, case-control study of birth defects in 10 centers across the United States, researchers compared 1997-2003 birth certificate data linked to selected controls (n = 6,681) and control participants (n = 4,395) with those from their base populations (n = 2,468,697). Researchers analyzed differences in population characteristics (e.g., percentage of births at > or =2,500 g) for each group. Compared with their base populations, control participants did not differ in distributions of maternal or paternal age, previous livebirths, maternal smoking, or diabetes, but they did differ in other maternal (i.e., race/ethnicity, education, entry into prenatal care) and infant (i.e., birth weight, gestational age, and plurality) characteristics. Differences in distributions of maternal, but not infant, characteristics were associated with participation by selected controls. Absolute differences in infant characteristics for the base population versus control participants were < or =1.3 percentage points. Differences in infant characteristics were greater at centers that selected controls from hospitals compared with centers that selected controls from electronic birth certificates. These findings suggest that control participants in the National Birth Defects Prevention Study generally are representative of their base populations. Hospital-based control selection may slightly underascertain infants affected by certain adverse birth outcomes.

Multistate Outbreak of Serratia Marcescens Bloodstream Infections Caused by Contamination of Prefilled Heparin and Isotonic Sodium Chloride Solution Syringes.
Blossom D, Noble-Wang J, Su J, Pur S, Chemaly R, Shams A, Jensen B, Pascoe N, Gullion J, Casey E, Hayden M, Arduino M, Budnitz DS, Raad I, Trenholme G, Srinivasan A; Serratia in Prefilled Syringes Investigation Team Group.
Arch Intern Med. 2009 Oct 12;169(18):1705-11.
BACKGROUND: To investigate clusters of Serratia marcescens (SM) bloodstream infections (BSIs) at health care facilities in several states and determine whether contaminated prefilled heparin and isotonic sodium chloride solution (hereinafter, saline) syringes from a single manufacturer (company X) were the likely cause, we performed an outbreak investigation of inpatient and outpatient health care facilities from October 2007 through February 2008. METHODS: Active case finding for clusters of SM BSIs. Information on SM BSIs was obtained, and SM blood isolates were sent to the Centers for Disease Control and Prevention (CDC). Culture specimens were taken from various lots of prefilled heparin and saline syringes by health care facilities and the CDC to test for the presence of SM. The SM isolates from syringes and blood were compared by pulsed-field gel electrophoresis. RESULTS: A total of 162 SM BSIs in 9 states were reported among patients at facilities using prefilled heparin and/or saline syringes made by company X. Cultures of unopened prefilled heparin and saline syringes manufactured by company X grew SM. Of 83 SM blood isolates submitted to the CDC from 7 states, 70 (84%) were genetically related to the SM strain isolated from prefilled syringes. A US Food and Drug Administration inspection revealed that company X was not in compliance with quality system regulations. CONCLUSIONS: A multistate outbreak of SM BSIs was associated with intrinsic contamination of prefilled syringes. Our investigation highlights important issues in medication safety, including (1) the importance of pursuing possible product-associated outbreaks suggested by strong epidemiologic data even when initial cultures of the suspected product show no contamination and (2) the challenges of medical product recalls when production has been outsourced from one company to another.

Lessons Learned from the Deadly Sisters: Drug and Alcohol Treatment Disruption, and Consequences from Hurricanes Katrina and Rita.
Carlisle Maxwell J, Podus D, Walsh D.
Substance Use & Misuse. 2009 Oct;44(12):1681-1694.
This paper reports on the effects of Hurricanes Katrina and Rita on drug and alcohol treatment in Texas in 2005-2006. Findings are based on a secondary analysis of administrative data on 567 hurricane-related admissions and on interview data from a sample of 20 staff in 11 treatment programs. Katrina evacuees differed from Rita clients in terms of demographics and primary problem substances and treatment needs, while the experiences of program staff and needed changes to improve disaster readiness were more similar. Additional systematic research is needed to document the intermediate and long-term impacts of the storms in these and other affected areas.

Ethnic Disparities in Cervical Cancer Survival among Texas Women.
Coker AL, Desimone CP, Eggleston KS, White AL, Williams M.
J Womens Health. 2009 Oct;18(10):1577-83.
OBJECTIVE: The aim of this work was to determine whether minority women are more likely to die of cervical cancer. A population-based cohort study was performed using Texas Cancer Registry (TCR) data from 1998 to 2002. METHODS: A total of 5,166 women with cervical cancer were identified during 1998-2002 through the TCR. Measures of socioeconomic status (SES) and urbanization were created using census block group-level data. Multilevel logistic regression was used to calculate the odds of dying from cervical cancer by race, and Cox proportional hazards modeling was used for cervical cancer-specific survival analysis. RESULTS: After adjusting for age, SES, urbanization, stage, cell type, and treatment, Hispanic women were significantly less likely than non-Hispanic White women to die from cervical cancer (adjusted hazard ratio [aHR] = 0.69; 95% CI [confidence interval] = 0.59-0.80), whereas Black women were more likely to die (aHR = 1.26; 95% CI = 1.06-1.50). Black and Hispanic women were more likely to be diagnosed at a later stage than White women. Black women were significantly less likely to receive surgery among those diagnosed with localized disease (p = 0.001) relative to both White and Hispanic women. CONCLUSIONS: Relative to non-Hispanic White women, Black women were more likely to die of cervical cancer while Hispanic women were less likely to die; these survival differences were not explained by SES, urbanization, age, cell type, stage at diagnosis, or treatment.

Detection of Staphylococcus aureus Including MRSA on Environmental Surfaces in a Jail Setting.
Felkner M, Andrews K, Field LH, Taylor JP, Baldwin T, Valle-Rivera AM, Presley J, Newsome S, Casey E.
J Correct Health Care. 2009 Oct;15(4):310-7.
We examined jail environmental surfaces to explore whether they might serve as reservoirs of viable methicillin-resistant Staphylococcus aureus (MRSA). We swabbed 132 surfaces, inoculated primary and secondary mannitol salts and oxacillin-resistant screening agar, and used API tests to identify S. aureus and E-tests to determine methicillin/oxacillin resistance. We recovered S. aureus from 10 (7.6%) surfaces; eight (6.1%) isolates were MRSA. We ran pulsed-field gel electrophoresis on six resistant isolates and observed three patterns, one of which was identical to that identified in a previous study of inmates' nasal specimens. Finding MRSA-contaminated surfaces on a variety of environmental surfaces in the absence of an overt outbreak emphasizes that correctional facilities should have protocols for environmental cleaning as a component of MRSA prevention.

Change in Glow Product Exposures Reported to Poison Control Centers on Halloween.
Forrester MB, Jaramillo JE.
Texas Public Health Journal. 2009;61:9-11.
Although considered to be minimally toxic or nontoxic, glow product exposures are reported to poison control centers each year. Various poison control centers in the US had reported an apparent increase in such exposures during Halloween 2007 as compared to previous Halloweens. Glow product exposures reported to the six Texas poison control centers during Halloween (October 31-November 1) 2003-2008 were extracted for the poison control centers’ database. The distribution of cases with respect to various demographic and clinical factors was determined for 2003-2006 and for 2007-2008. Comparisons were made between the two subgroups. The number of exposures reported during Halloween was 111 in 2003, 117 in 2004, 101 in 2005, 105 in 2006, 156 in 2007, and 176 in 2008. Reported Halloween glow product exposures increased in 2007 and 2008. The Halloween 2007-2008 and 2003-2006 exposures were similar with respect to product type, exposure route, patient gender, exposure reason, and management site. However, the Halloween 2007-2008 exposures tended to involve younger children and more frequently occurred at school and involved no effect. The reason for the change in Halloween exposures in 2007 and 2008 may be due to increased use of the glow products as homeowners give them out instead of candy and police departments and other organizations distribute them in an effort to make children more visible at night.

Association of Bacterial Colonization at the Time of Presentation to a Combat Support Hospital in a Combat Zone with Subsequent 30-Day Colonization or Infection.
Kaspar RL, Griffith ME, Mann PB, Lehman DJ, Conger NG, Hospenthal DR, Murray CK.
Mil Med. 2009 Sep;174(9):899-903.
U.S. casualties have developed multidrug-resistant (MDR) bacterial infections. A surveillance project to evaluate U.S. military patients for the presence of MDR pathogens from wounding through the first 30 days of care in the military healthcare system (MHS) was performed. U.S. military patients admitted to a single combat support hospital in Iraq during June-July of 2007 had screening swabs obtained for the detection of MDR bacteria and a subsequent retrospective electronic medical records review for presence of colonization or infection in the subsequent 30 days. Screening of 74 U.S. military patients in Iraq found one colonized with methicillin-resistant Staphylococcus aureus. Fifty-six patients of these were screened for Acinetobacter in Germany and one found colonized. Of patients evacuated to the U.S., 9 developed infections. Carefully obtained screening cultures immediately after injury combined with look-back monitoring supports the role of nosocomial transmission. Consistent infection control strategies are needed for the entire MHS.

Urban versus Rural Residence and Occurrence of Septal Heart Defects in Texas.
Langlois PH, Scheuerle A, Horel SA, Carozza SE.
Birth Defects Res A Clin Mol Teratol. 2009 Sep;85(9):764-72.
BACKGROUND:: There is conflicting information on the association between urban/rural residence of mothers and atrial septal defect (ASD) or ventricular septal defect (VSD) in their offspring. Few studies have compared multiple measures of urban/rural residence. METHODS:: Data were taken from the Texas Birth Defects Registry, 1999-2003. Poisson regression was used to compare crude and adjusted birth prevalence. RESULTS:: Three broad urban/rural measures, namely, the rural urban continuum code (RUCC), urban influence code (UIC), and rural urban commuting area (RUCA), were correlated with each other, but much less correlated with percentage of land in crops. ASD showed few consistent patterns with RUCC, UIC, and RUCA but was more prevalent in counties with higher cropland percentage. For example, counties with >/=50% cropland had a prevalence ratio (PR) for isolated ASD of 3.49 (95% confidence interval [CI]: 2.85-4.24) compared to counties with <15% cropland. VSD was less prevalent in rural areas using RUCC, UIC, and RUCA. For example, for isolated VSD, small towns/rural areas had a PR of 0.64 (95% CI: 0.51-0.78) compared to urban core areas using RUCA. The pattern was seen among mild cases of VSD but not among severe cases. VSD was not associated with percentage cropland. CONCLUSIONS:: The measure of urban/rural status can greatly affect associations with certain birth defects. More prevalent ASD in areas with greater percentage cropland suggests that agricultural chemicals may be relevant. Mild cases of VSD but not severe cases were less prevalent in rural areas, suggesting that variation in detection may be largely responsible.

Are Birth Defects among Hispanics Related to Maternal Nativity or Number of Years Lived in the United States?
Ramadhani T, Short V, Canfield MA, Waller DK, Correa A, Royle M, Scheuerle A; National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2009 Sep;85(9):755-63.
BACKGROUND: Literature on the risk of birth defects among foreign- versus U.S.-born Hispanics is limited or inconsistent. We examined the association between country of birth, immigration patterns, and birth defects among Hispanic mothers. METHODS: We used data from the National Birth Defects Prevention Study and calculated odds ratios (ORs) and 95% confidence intervals and assessed the relationship between mothers' country of birth, years lived in the United States, and birth defects among 575 foreign-born compared to 539 U.S.-born Hispanic mothers. RESULTS: Hispanic mothers born in Mexico/Central America were more likely to deliver babies with spina bifida (OR = 1.53) than their U.S.-born counterparts. Also, mothers born in Mexico/Central America or who were recent United States immigrants (</=5 years) were less likely to deliver babies with all atrial septal defects combined, all septal defects combined, or atrial septal defect, secundum type. However, Hispanic foreign-born mothers who lived in the United States for >5 years were more likely to deliver babies with all neural tube defects combined (OR = 1.42), spina bifida (OR = 1.89), and longitudinal limb defects (OR = 2.34). Foreign-born mothers, regardless of their number of years lived in the United States, were more likely to deliver babies with anotia or microtia. CONCLUSIONS: Depending on the type of birth defect, foreign-born Hispanic mothers might be at higher or lower risk of delivering babies with the defects. The differences might reflect variations in predisposition, cultural norms, behavioral characteristics, and/or ascertainment of the birth defects.

Urban-Rural Residence and the Occurrence of Neural Tube Defects in Texas, 1999-2003.
Luben TJ, Messer LC, Mendola P, Carozza SE, Horel SA, Langlois PH.
Health Place. 2009 Sep;15(3):848-54.
Neural tube birth defects (NTDs) affect more than 4000 pregnancies in the US annually. The etiology of NTDs is believed to be multifactorial, but much remains unknown. We examined the pattern and magnitude of urban-rural variation in anencephaly, spina bifida without anencephaly, and encephalocele in Texas in relation with urban-rural residence for the period 1999-2003. There was no evidence that urban-rural residence was associated with changes in the rate of anencephaly or spina bifida without anencephaly in unadjusted or adjusted analyses. In contrast, rates of encephalocele were statistically significantly higher in areas classified as suburban or more rural compared to urban areas using four different urban-rural residence indicators.

Organophosphate Antidote Auto-Injectors vs. Traditional Administration: A Time Motion Study.
Rebmann T, Clements BW, Bailey JA, Evans RG.
J Emerg Med. 2009 Aug;37(2):139-43.
Organophosphates may be used as weapons in chemical attacks on civilian or military populations. Antidotes are available to counter the effects of organophosphates, but they must be administered shortly after exposure. Timing required to administer organophosphate antidotes using traditional equipment vs. auto-injectors has not been studied. This study is intended to quantify and compare the time required to administer organophosphate antidotes using traditional equipment vs. auto-injectors in different treatment conditions. The study was a randomized, un-blinded design. There were 62 participants assigned to one of three groups: Mark I, ATNAA (antidote treatment nerve agent auto-injector), and traditional needle/syringe; however, the results from only 56 participants could be analyzed. Injection trials were videotaped. Subjects also completed a 14-item survey containing demographic questions, perceived ease of injection, receipt of prior training, and preferred training format for organophosphate treatment. Injection time differentials were compared using one-way analysis of variance; post hoc evaluation was performed using the Scheffe test with Bonferroni correction. Fifty-six subjects completed this study. The ATNAA required less time to administer than the Mark I or traditional needle/syringe devices (p < .001). There was no difference in time to administer the Mark I auto-injectors vs. a traditional needle/syringe. There were no differences between injection time and occupation, receipt of prior training, wearing of personal protective equipment, or perceived ease of injection device use. The use of auto-injectors shortens response time for administering organophosphate antidote treatment. An ATNAA auto-injector can be administered in less than half the time it takes to administer a single injection using a needle and syringe or two injections using a Mark I. Mark I can be administered in approximately the same amount of time it takes to administer a single injection using a needle and syringe. The difference between injection time for the ATNAA and needle and syringe would have been even larger if two injections were given with the needle and syringe. The wearing or absence of personal protective equipment does not affect injection time.

H1N1 2009 Influenza Virus Infection during Pregnancy in the USA.
Jamieson DJ, Honein MA, Rasmussen SA, Williams JL, Swerdlow DL, Biggerstaff MS, Lindstrom S, Louie JK, Christ CM, Bohm SR, Fonseca VP, Ritger KA, Kuhles DJ, Eggers P, Bruce H, Davidson HA, Lutterloh E, Harris ML, Burke C, Cocoros N, Finelli L, MacFarlane KF, Shu B, Olsen SJ; Novel Influenza A (H1N1) Pregnancy Working Group.
Lancet. 2009 Aug 8;374(9688):451-8.
BACKGROUND: Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak. METHODS: After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness. FINDINGS: From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100 000 pregnant women, 95% CI 0.13-0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07-0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. INTERPRETATION: Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.

Immediate- and Controlled-Release Zolpidem Ingestions Reported to Texas Poison Centers.
Forrester MB.
Hum Exp Toxicol. 2009 Aug;28(8):505-9.
Zolpidem is available in immediate-release (IR) and controlled-release (CR) formulations. This investigation examined whether there were differences in zolpidem IR and CR ingestions reported to poison control centers. Zolpidem ingestions that did not involve co-ingestants reported to Texas poison control centers during 2005-2008 were identified. The ingestions were grouped by IR and CR formulations and compared with respect to demographic and clinical factors. There were 734 IR and 163 CR ingestions. The mean dose ingested was 92.9 mg and 104.6 mg, respectively. IR and CR cases were, respectively, 56.9% and 58.3% male, 54.6% and 49.7% age >19 years, 65.0% and 65.0% already at or en route to a health care facility when the poison control center was contacted, and 30.1% and 39.3% involved no effect. The most frequently reported adverse clinical effects were, for IR and CR, respectively, drowsiness (54.4% vs 42.3%), tachycardia (10.6% vs 11.7%), ataxia (6.3% vs 11.7%), slurred speech (6.3% vs 6.7%), vomiting (5.0% vs 5.5%) and hallucinations/delusions (4.9% vs 3.1%). The distribution of zolpidem IR and CR ingestions reported to Texas poison control centers were similar. However, zolpidem CR ingestions appeared less likely to result in drowsiness and hallucinations but more likely to result in ataxia.

Development, Testing, and Validation of a Patient Satisfaction Questionnaire for Use in the Clinical Genetics Setting.
Zellerino B, Milligan SA, Brooks R, Freedenberg DL, Collingridge DS, Williams MS.
Am J Med Genet C Semin Med Genet. 2009 Aug 15;151C(3):191-9.
Patient satisfaction is an important component of assessing quality of care. The purpose of this study is to develop a concise patient satisfaction tool specifically for use in the clinical genetics setting. An international survey identified two domains, "Respect Given" and "Patient Questions Answered" as being important components of satisfaction in the genetic encounter. A working group of professionals assembled a 14-question pilot questionnaire that was subsequently tested in 13 clinical sites. Nearly 400 responses were used to validate the tool and ultimately construct a 7-item questionnaire. The 7-item questionnaire was found to be reliable and valid and addresses two key components of patient satisfaction: technical aspects of care and interpersonal relations. The tool is compared to other patient satisfaction tools developed for use in the clinical genetics setting. A Spanish version is also provided.

Carbon Monoxide Exposures after Hurricane Ike -- Texas, September 2008
MMWR Morb Mortal Wkly Rep. 2009 Aug 14;58(31):845-9.
Centers for Disease Control and Prevention (CDC). DSHS Contributors: Villanacci J, Zane D, Forrester M, Hellsten J, Beal R, Beasley C.
During power outages after hurricanes, survivors can be at risk for carbon monoxide (CO) poisoning if they improperly use portable generators. On September 13, 2008, Hurricane Ike struck the coast of Texas, leaving approximately 2.3 million households in the southeastern portion of the state without electricity. Six days later, 1.3 million homes were still without electrical power. To assess the impact of storm-related CO exposures and to enhance prevention efforts, CDC analyzed data on CO exposures from five disparate surveillance sources reported during September 13-26 in southeast Texas. This report describes the results of that analysis.

Maternal Residential Proximity to Waste Sites and Industrial Facilities and Conotruncal Heart Defects in Offspring.
Langlois PH, Brender JD, Suarez L, Zhan FB, Mistry JH, Scheuerle A, Moody K.
Paediatr Perinat Epidemiol. 2009 Jul;23(4):321-31.
Most studies of the relationship between maternal residential proximity to sources of environmental pollution and congenital cardiovascular malformations have combined heart defects into one group or broad subgroups. The current case-control study examined whether risk of conotruncal heart defects, including subsets of specific defects, was associated with maternal residential proximity to hazardous waste sites and industrial facilities with recorded air emissions. Texas Birth Defects Registry cases were linked to their birth or fetal death certificate. Controls without birth defects were randomly selected from birth certificates. Distances from maternal addresses at delivery to National Priority List (NPL) waste sites, state superfund waste sites, and Toxic Release Inventory (TRI) facilities were determined for 1244 cases (89.5% of those eligible) and 4368 controls (88.0%). Living within 1 mile of a hazardous waste site was not associated with risk of conotruncal heart defects [adjusted odds ratio (aOR) = 0.83, 95% confidence interval (CI) = 0.54, 1.27]. This was true whether looking at most types of defects or waste sites. Only truncus arteriosus showed statistically elevated ORs with any waste site (crude OR: 2.80, 95% CI 1.19, 6.54) and with NPL sites (crude OR: 4.63, 95% CI 1.18, 13.15; aOR 4.99, 95% CI 1.26, 14.51), but the latter was based on only four exposed cases. There was minimal association between conotruncal heart defects and proximity to TRI facilities (aOR = 1.10, 95% CI = 0.91, 1.33). Stratification by maternal age or race/ethnic group made little difference in effect estimates for waste sites or industrial facilities. In this study population, maternal residential proximity to waste sites or industries with reported air emissions was not associated with conotruncal heart defects or its subtypes in offspring, with the exception of truncus arteriosus.

Anencephaly and Spina Bifida among Hispanics: Maternal, Sociodemographic, and Acculturation Factors in the National Birth Defects Prevention Study.
Canfield MA, Ramadhani TA, Shaw GM, Carmichael SL, Waller DK, Mosley BS, Royle MH, Olney RS; National Birth Defects Prevention Study.
Birth Defects Res A Clin Mol Teratol. 2009 Jul;85(7):637-46.
BACKGROUND: We used data from the multisite National Birth Defects Prevention Study for expected delivery dates from October 1997 through 2003, to determine whether the increased risk in anencephaly and spina bifida (neural tube defects (NTDs)) in Hispanics was explained by selected sociodemographic, acculturation, and other maternal characteristics. METHODS: For each type of defect, we examined the association with selected maternal characteristics stratified by race/ethnicity and the association with Hispanic parents' acculturation level, relative to non-Hispanic whites. We used logistic regression and calculated crude odds ratios (ORs) and their 95% confidence intervals (CIs). RESULTS: Hispanic mothers who reported the highest level of income were 80% less likely to deliver babies with spina bifida. In addition, highly educated Hispanic and white mothers had 76 and 35% lower risk, respectively. Other factors showing differing effects for spina bifida in Hispanics included maternal age, parity, and gestational diabetes. For spina bifida there was no significant elevated risk for U.S.-born Hispanics, relative to whites, but for anencephaly, corresponding ORs ranged from 1.9 to 2.3. The highest risk for spina bifida was observed for recent Hispanic immigrant parents from Mexico or Central America residing in the United States <5 years (OR = 3.28, 95% CI = 1.46-7.37). CONCLUSIONS: Less acculturated Hispanic parents seemed to be at highest risk of NTDs. For anencephaly, U.S.-born and English-speaking Hispanic parents were also at increased risk. Finally, from an etiologic standpoint, spina bifida and anencephaly appeared to be etiologically heterogeneous from these analyses.

Cancer Risk among Children with Very Low Birth Weights.
Spector LG, Puumala SE, Carozza SE, Chow EJ, Fox EE, Horel S, Johnson KJ, McLaughlin CC, Reynolds P, Behren JV, Mueller BA.
Pediatrics. 2009 Jul;124(1):96-104.
OBJECTIVE: The risk of hepatoblastoma is strongly increased among children with very low birth weight (<1500 g). Because data on very low birth weight and other childhood cancers are sparse, we examined the risk of malignancy with very low birth weight in a large data set. METHODS: We combined case-control data sets created by linking the cancer and birth registries of California, Minnesota, New York, Texas, and Washington states, which included 17672 children diagnosed as having cancer at 0 to 14 years of age and 57966 randomly selected control subjects. Unconditional logistic regression analysis was used to examine the association of cancer with very low birth weight and moderately low birth weight (1500-1999 g and 2000-2499 g, respectively), compared with moderate/high birth weight (>or=2500 g), with adjustment for gender, gestational age, birth order, plurality, maternal age, maternal race, state, and year of birth. RESULTS: Most childhood cancers were not associated with low birth weights. However, retinoblastomas and gliomas other than astrocytomas and ependymomas were possibly associated with very low birth weight. The risk of other gliomas was also increased among children weighing 1500 to 1999 g at birth. CONCLUSIONS: These data suggested no association between most cancers and very low birth weight, with the exception of the known association of hepatoblastoma and possibly moderately increased risks of other gliomas and retinoblastoma, which may warrant confirmation.

Parental Age and Risk of Childhood Cancer: A Pooled Analysis.
Johnson KJ, Carozza SE, Chow EJ, Fox EE, Horel S, McLaughlin CC, Mueller BA, Puumala SE, Reynolds P, Von Behren J, Spector LG.
Epidemiology. 2009 Jul;20(4):475-83.
BACKGROUND:: Few risk factors for childhood cancer are well-established. We investigated whether advancing parental age increases childhood cancer risk. METHODS:: We assessed the relationship between parental age and childhood cancer in a case-control study using pooled population-based data. Our pooling was based on linked cancer and birth registry records from New York, Washington, Minnesota, Texas, and California. Subjects included 17,672 cancer cases diagnosed at ages 0-14 years during 1980-2004 and 57,966 controls born during 1970-2004. Individuals with Down syndrome were excluded. Odds ratios and 95% confidence intervals were calculated by logistic regression for the association between parental age and childhood cancer after adjustment for sex, birth weight, gestational age, birth order, plurality, maternal race, birth year, and state. RESULTS:: Positive linear trends per 5-year maternal age increase were observed for childhood cancers overall (odds ratio = 1.08 [95% confidence interval = 1.06-1.10]) and 7 of the 10 most frequent diagnostic groups: leukemia (1.08 [1.05-1.11]), lymphoma (1.06 [1.01-1.12]),central nervous system tumors (1.07 [1.03-1.10]), neuroblastoma (1.09 [1.04-1.15]), Wilms' tumor (1.16 [1.09-1.22]), bone tumors (1.10 [1.00-1.20]), and soft tissue sarcomas (1.10 [1.04-1.17]). No maternal ageeffect was noted for retinoblastoma, germ cell tumors, or hepatoblastoma. Paternal age was not independently associated with most childhood cancers after adjustment for maternal age. CONCLUSIONS:: Our results suggest that older maternal age increases risk for most common childhood cancers. Investigation into possible mechanisms for this association is warranted.

Neurologic Complications Associated with Novel Influenza A (H1N1) Virus Infection in Children - Dallas, Texas, May 2009
MMWR Morb Mortal Wkly Rep. 2009 Jul 24;58(28):773-8.
Centers for Disease Control and Prevention (CDC). DSHS Contributor: Pascoe N.
Neurologic complications, including seizures, encephalitis, encephalopathy, Reye syndrome, and other neurologic disorders, have been described previously in association with respiratory tract infection with seasonal influenza A or B viruses, but not with novel influenza A (H1N1) virus. On May 28, 2009, the Dallas County Department of Health and Human Services (DCHHS) notified CDC of four children with neurologic complications associated with novel influenza A (H1N1) virus infection admitted to hospitals in Dallas County, Texas, during May 18-28. This report summarizes the clinical characteristics of those four cases. Patients were aged 7-17 years and were admitted with signs of influenza-like illness (ILI) and seizures or altered mental status. Three of the four patients had abnormal electroencephalograms (EEGs). In all four patients, novel influenza A (H1N1) viral RNA was detected in nasopharyngeal specimens but not in cerebrospinal fluid (CSF). Antiviral therapy included oseltamivir (four patients) and rimantadine (three patients). All four patients recovered fully and had no neurologic sequelae at discharge. These findings indicate that, as with seasonal influenza, neurologic complications can occur after respiratory tract infection with novel influenza A (H1N1) virus. For children who have ILI accompanied by unexplained seizures or mental status changes, clinicians should consider acute seasonal influenza or novel influenza A (H1N1) virus infection in the differential diagnosis, send respiratory specimens for appropriate diagnostic testing, and promptly initiate empirical antiviral treatment, especially in hospitalized patients.

Epidemiologic Investigation of a 2007 Outbreak of Serratia Marcescens Bloodstream Infection in Texas Caused by Contamination of Syringes Prefilled with Heparin and Saline.
Su JR, Blossom DB, Chung W, Gullion JS, Pascoe N, Heseltine G, Srinivasan A.
Infect Control Hosp Epidemiol. 2009 Jun;30(6):593-5.
This retrospective cohort study found that syringes prefilled with heparin flush solution caused an outbreak of Serratia marcescens bloodstream infection at an outpatient treatment center in Texas in 2007. The epidemiologic study supported this conclusion, despite the lack of microbiologic evidence of contamination from environmental and product testing. This report underscores the crucial contributions that epidemiologic studies can make to investigations of outbreaks that are possibly product related.

Maternal Serum Homocysteine and Risk for Neural Tube Defects in a Texas-Mexico Border Population.
Felkner M, Suarez L, Canfield MA, Brender JD, Sun Q.
Birth Defects Res A Clin Mol Teratol. 2009 Jun;85(6):574-81.
BACKGROUND:: To better understand the neural tube defect (NTD) causal pathway, the authors measured homocysteine, an indicator of tissue micronutrient deficiencies. The authors examined independent and joint associations of serum homocysteine, B(12,) and folate and red blood cell (RBC) folate with NTD-affected pregnancies. METHODS:: Case women in this population-based study had NTD-affected pregnancies 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. The authors measured homocysteine levels using tandem mass spectroscopy; competitive binding was used for other biomarkers. RESULTS:: Homocysteine testing was done on 103 cases and 139 controls. Odds ratios (ORs) were increased in all upper homocysteine quintiles compared to the lowest quintile (1.7, 1.3, 2.8, 2.4). Women with high homocysteine values had increased ORs regardless of high versus low levels for B(12) (OR = 3.5, 4.8, respectively) or RBC folate (OR = 2.9, 3.5, respectively). CONCLUSIONS:: High serum homocysteine levels are associated with NTD-affected pregnancies. Moreover, high homocysteine levels have a detrimental effect on NTD-risk even when serum B(12) or RBC folate levels are high. Excess homocysteine might play an independent role in the development of NTDs.

Triple-Reassortant Swine Influenza A (H1) in Humans in the United States, 2005–2009.
Shinde V, Bridges CB, Uyeki TM, Shu B, Balish A, Xu X, Lindstrom S, Gubareva LV, Deyde V, Garten RJ, Harris M, Gerber S, Vagasky S, Smith F, Pascoe N, Martin K, Dufficy D, Ritger K, Conover C, Quinlisk P, Klimov A, Bresee JS, Finelli L.
N Engl J Med. 2009 June 18;360(25):2616-25.
Background: Triple-reassortant swine influenza A (H1) viruses, containing genes from avian, human, and swine influenza viruses, emerged and became enzootic among pig herds in North America during the late 1990s. Methods: We report the clinical features of the first 11 sporadic cases of infection of humans with triple-reassortant swine influenza A (H1) viruses reported to the Centers for Disease Control and Prevention, occurring from December 2005 through February 2009, until just before the current epidemic of swine-origin influenza A (H1N1) among humans. These data were obtained from routine national influenza surveillance reports and from joint case investigations by public and animal health agencies. Results: The median age of the 11 patients was 10 years (range, 16 months to 48 years), and 4 had underlying health conditions. Nine of the patients had had exposure to pigs, five through direct contact and four through visits to a location where pigs were present but without contact. In another patient, human-to-human transmission was suspected. The range of the incubation period, from the last known exposure to the onset of symptoms, was 3 to 9 days. Among the 10 patients with known clinical symptoms, symptoms included fever (in 90%), cough (in 100%), headache (in 60%), and diarrhea (in 30%). Complete blood counts were available for four patients, revealing leukopenia in two, lymphopenia in one, and thrombocytopenia in another. Four patients were hospitalized, two of whom underwent invasive mechanical ventilation. Four patients received oseltamivir, and all 11 recovered from their illness. Conclusions: From December 2005 until just before the current human epidemic of swine-origin influenza viruses, there was sporadic infection with triple-reassortant swine influenza A (H1) viruses in persons with exposure to pigs in the United States. Although all the patients recovered, severe illness of the lower respiratory tract and unusual influenza signs such as diarrhea were observed in some patients, including those who had been previously healthy.

Updated prevalence estimates of multiple sclerosis in Texas, 1998 to 2003.
Wagner LB, Archer NP, Williamson DM, Henry JP, Schiffer R.
Tex Med. 2009 Jun 1;105(6):e1.
The Texas Department of State Health Services extended a prevalence study of multiple sclerosis (MS) in a 19-county area in North Texas to include 3 additional years of data and included a new geographic area with a predominantly Hispanic population (El Paso County). Patients in whom MS was diagnosed by a neurologist, who resided in the study areas, and who had an office visit between 1998 and 2003 were included in the study.

Comparison of Immediate-Release and Controlled-Release Paroxetine Ingestions Reported to Texas Poison Control Centers between 2002 and 2008.
Forrester MB.
J Pharm Technol 2009;25:169-175.
Abstract: Background: Controlled-release (CR) paroxetine was created to improve the tolerability while maintaining the therapeutic benefits of immediate-release (IR) paroxetine. There is limited information comparing the toxicity of the two paroxetine formulations. Objective: The objective of this investigation was to compare paroxetine IR and paroxetine CR ingestions reported to poison control centers. Methods: Cases were ingestions of paroxetine alone reported to Texas poison control centers during 2002-2008 where the final medical outcome and reported dose ingested were known. The rates for selected variables were determined for paroxetine IR and paroxetine CR and comparisons between the two made by calculating the ratio of the paroxetine CR rate to the paroxetine IR rate and 95% confidence interval (CI). Compliance with simplified algorithms of triage management guidelines was determined for both formulations. Results: There were 405 cases of paroxetine IR and 169 of paroxetine CR. There was no statistically significant difference between the formulations with respect to the rates of serious medical outcome (ratio 0.69, 95% CI 0.34-1.31), self-harm or malicious intent (ratio 0.82, 95% CI 0.60-1.12) or referral to a healthcare facility (ratio 1.18, 95% CI 0.76-1.83). The rate of compliance with the triage algorithm for cases not already at or en route to a healthcare facility when the poison control center was contacted was 87% for paroxetine IR and 89% for paroxetine CR. Conclusions: The toxicity and management of paroxetine IR and paroxetine CR ingestions reported to Texas poison control centers were similar.

Mass Prophylaxis: The Brass Ring of Public Health Preparedness.
Bruce Clements
DomPrep Journal, 2009 May; 5(5):22,24.

Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women – United States, April-May 2009
MMWR Morb Mortal Wkly Rep. 2009 May 15;58(18):497-500.
Centers for Disease Control and Prevention (CDC). DSHS contributors: Fonseca V, Davis M, and Wing R.
CDC first identified cases of respiratory infection with a novel influenza A (H1N1) virus in the United States on April 15 and 17, 2009. During seasonal influenza epidemics and previous pandemics, pregnant women have been at increased risk for complications related to influenza infection. In addition, maternal influenza virus infection and accompanying hyperthermia place fetuses at risk for complications such as birth defects and preterm birth. As part of surveillance for infection with the novel influenza A (H1N1) virus, CDC initiated surveillance for pregnant women who were infected with the novel virus. As of May 10, a total of 20 cases of novel influenza A (H1N1) virus infection had been reported among pregnant women in the United States, including 15 confirmed cases and five probable cases. Among the 13 women from seven states for whom data are available, the median age was 26 years (range: 15-39 years); three women were hospitalized, one of whom died. This report provides preliminary details of three cases of novel influenza A (H1N1) virus infection in pregnant women. Pregnant women with confirmed, probable, or suspected novel influenza A (H1N1) virus infection should receive antiviral treatment for 5 days. Oseltamivir is the preferred treatment for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of chemoprophylaxis with zanamivir or oseltamivir.

Outbreak of Severe Respiratory Disease Associated with Emergent Human Adenovirus Serotype 14 at a US Air Force Training Facility in 2007.
Tate JE, Bunning ML, Lott L, Lu X, Su J, Metzgar D, Brosch L, Panozzo CA, Marconi VC, Faix DJ, Prill M, Johnson B, Erdman DD, Fonseca V, Anderson LJ, Widdowson MA.
J Infect Dis. 2009 May 15;199(10):1419-26.
Background. In 2007, a US Air Force training facility reported a cluster of severe respiratory illnesses associated with a rare human adenovirus (Ad) serotype, Ad14. We investigated this outbreak to better understand its epidemiology, clinical spectrum, and associated risk factors. Methods. Data were collected from ongoing febrile respiratory illness (FRI) surveillance and from a retrospective cohort investigation. Because an Ad7 vaccine is in development, Ad7 antibody titers in pretraining serum samples from trainees with mild and those with severe Ad14 illness were compared. Results. During 2007, an estimated 551 (48%) of 1147 trainees with FRI were infected with Ad14; 23 were hospitalized with pneumonia, 4 required admission to an intensive care unit, and 1 died. Among cohort members ([Formula: see text]), the Ad14 infection rate was high (50%). Of those infected, 40% experienced FRI. No cohort members were hospitalized. Male sex (risk ratio [RR], 4.7 [95% confidence interval {CI}, 2.2-10.1]) and an ill close contact (RR, 1.6 [95% CI, 1.2-2.2]) were associated with infection. Preexisting Ad7 neutralizing antibodies were found in 7 (37%) of 19 Ad14-positive trainees with mild illness but in 0 of 16 trainees with Ad14 pneumonia. Conclusions. Emergence of Ad14, a rare Ad serotype, caused a protracted outbreak of respiratory illness among military recruits. Most infected recruits experienced FRI or milder illnesses. Some required hospitalization, and 1 died. Natural Ad7 infection may protect against severe Ad14 illness.

SSRI Use and Behavioral Disruption among Children and Adolescents at Austin State Hospital.
Becker EA, Crismon ML, Shafer A, Hayat J.
Tex Med. 2009 May 1;105(5):e1-5.
This study examined the effect of selective serotonin reuptake inhibitors on children and adolescents' disruptive behavior. Measures of disruptive behavior were operationally defined as the use of mechanical restraints and emergency medication. No significant relationship between SSRI use and increased agitation, hostility, or self-harm as manifested by the number of mechanical restraints or emergency medications at any time during hospitalization was found.

Update: Swine Influenza A (H1N1) Infections--California and Texas, April 2009
MMWR Morb Mortal Wkly Rep. 2009 May 1;58(16):435-7.
Centers for Disease Control and Prevention (CDC). DSHS staff contributed.
On April 21, 2009, CDC reported that two recent cases of febrile respiratory illness in children in southern California had been caused by infection with genetically similar swine influenza A (H1N1) viruses. The viruses contained a unique combination of gene segments that had not been reported previously among swine or human influenza viruses in the United States or elsewhere. Neither child had known contact with pigs, resulting in concern that human-to-human transmission might have occurred. The seasonal influenza vaccine H1N1 strain is thought to be unlikely to provide protection. This report updates the status of the ongoing investigation and provides preliminary details about six additional persons infected by the same strain of swine influenza A (H1N1) virus identified in the previous cases, as of April 24. The six additional cases were reported in San Diego County, California (three cases), Imperial County, California (one case), and Guadalupe County, Texas (two cases). CDC, the California Department of Public Health, and the Texas Department of Health and Human Services are conducting case investigations, monitoring for illness in contacts of the eight patients, and enhancing surveillance to determine the extent of spread of the virus. CDC continues to recommend that any influenza A viruses that cannot be subtyped be sent promptly for testing to CDC. In addition, swine influenza A (H1N1) viruses of the same strain as those in the U.S. patients have been confirmed by CDC among specimens from patients in Mexico. Clinicians should consider swine influenza as well as seasonal influenza virus infections in the differential diagnosis for patients who have febrile respiratory illness and who 1) live in San Diego and Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset.

Assessment of a Commercial Searchable Population Directory as a Means of Selecting Controls for Case-Control Studies.
Chintapalli S, Goodman M, Allen M, Ward K, Liff J, Young J, Terry P.
Public Health Rep. 2009 May-Jun;124(3):378-83.
We explored the feasibility of using SalesGenie, a commercially available database, as a potential alternative to traditional methods of selecting controls for population-based case-control studies. An attractive feature of this particular database is that it permits a search within specific age ranges, geographic locations, and household income. Information on 1,068 cases reported to the California Cancer Registry between 2001 and 2005 was entered manually into the SalesGenie Web-based search engine. The frequency of Registry-to-SalesGenie matches was then compared with the frequency of matching the registry data to the California Department of Motor Vehicles (DMV) records. Our findings indicate that the SalesGenie database is currently less comprehensive than DMV records. Nevertheless, Web-based population data sources may provide a potential alternative for population-based studies when used in conjunction with other methods, particularly in states where DMV records are not accessible to researchers.

Blood Lead Levels and Growth Status among African-American and Hispanic Children in Dallas, Texas--1980 and 2002: Dallas Lead Project II.
Little BB, Spalding S, Walsh B, Keyes DC, Wainer J, Pickens S, Royster M, Villanacci J, Gratton T.
Ann Hum Biol. 2009 May-Jun;36(3):331-41.
OBJECTIVE: The purpose of this investigation is to analyze childhood blood lead levels and growth status (ages 2-12) in Dallas, Texas lead smelter communities in the 1980s and 2002, where smelters operated from 1936 to 1990. METHODS AND MATERIALS: A sample of convenience study design was used in two cohorts (n=360): 1980-1989 (n=191) and 2002 (n=169). Multivariate analysis of variance and covariance and tandem multiple regressions were used to evaluate the association between stature and blood lead level in two time periods. RESULTS: In 2002 average child blood lead level (1.6 microg/dL+/-0.2 SE) was significantly (p<0.001) lower compared to the 1980 cohort mean level (23.6 microg/dL+/-1.3 SE). Average height and weight in 2002 were 4.5 cm and 4.0 kg greater, respectively, than in 1980. Lowered blood lead level was associated with 3.9 cm, 3.5 kg and 1.1 units greater height, weight and body mass index (BMI), respectively. Cohort effect was associated with greater height (0.6 cm), weight (0.5 kg) and BMI (0.1). CONCLUSION: This investigation reports on child growth in a community before and after the transition from high to low blood lead levels over several decades. Using child growth as a proxy, health status of Dallas's lead smelter communities increased markedly over the past two decades, primarily because of lower blood lead levels, while the poverty rate was only marginally lower.

Exposures to Lipid-Lowering Agents Reported to Texas Poison Control Centers during 2002-2007.
Forrester MB.
Texas Public Health Journal. 2009;61:26-8.
Abstract: The pattern of lipid-lowering agent prescriptions in the United States has changed over the last few years. The proportion represented by statins, the most frequently reported drug class, declined and the proportion represented by ezetimibe increased. The intent of this investigation was to determine whether the pattern of exposures to these drugs reported to poison control centers also changed. All exposures involving statins, fibrates, ezetimibe, and bile acid sequestrants reported to Texas poison control centers during 2002-2007 were identified. The distribution of total exposures among the four drug classes was determined for each year and compared to the distribution of prescriptions. Statins were involved in over 80% of exposures every year; however, the proportion of total exposures comprised by statins was lower in 2007 (83.5%) than in 2002 (86.4%). Fibrates were the second most frequently reported drug class involved in the exposures during the early part of this time period. The proportion of total exposures represented by ezetimibe increased each year of the investigation from 0.0% to 18.1%, surpassing fibrates in 2007. Approximately 1% of the exposures each year involved bile acid sequestrants. The pattern of lipid-lowering agent exposures reported to Texas poison control centers changed during 2002-2007. The changes were similar to those observed among lipid-lowering agent prescriptions nationwide. Exposures reported to poison control centers may be used as a surrogate for evaluating trends in total use of drugs in populations, at least for lipid-lowering agent drugs. This may be useful because of recent studies examining the effectiveness of ezetimibe.

Cases of Pediatric Ingestion of Celecoxib Reported to Texas Poison Control Centers in 2000-2007.
Forrester MB.
Hum Exp Toxicol. 2009 Apr;28(4):191-4.
Little data exist regarding pediatric celecoxib ingestions. This study described the pattern of pediatric celecoxib ingestions reported to poison control centers. Cases were isolated celecoxib ingestions by patients aged 0-5 years during 2000-2007 reported to Texas poison control centers. The distribution of cases was described with respect to demographic and clinical factors. Of the 177 total patients, dose ingested in milligrams was reported for 92 patients. Mean reported dose was 305.5 mg (range 10-2300 mg). Of those 92 cases, distribution by management site was 89.1% on site, 6.5% already at/en route to healthcare facility and 4.3% referred to healthcare facility. Final medical outcome was no effect for 95.7% cases and minor effect for 4.3% cases. Specific clinical effects reported (in only one case each) were rash, abdominal pain, vomiting, agitation/irritability, and drowsiness. All of the pediatric celecoxib ingestions reported to Texas poison control centers resulted in no or minor effect.

Acute Stress Cardiomyopathy and Deaths Associated with Electronic Weapons.
Cevik C, Otahbachi M, Miller E, Bagdure S, Nugent KM.
Int J Cardiol. 2009 Mar 6;132(3):312-7.
Deaths associated with the use of electronic weapons almost always occur in young men involved in either civil disturbances or criminal activity. These situations are associated with high levels of circulating catecholamines and frequently associated with drug intoxication. The mechanism for these deaths is unclear. Clinical studies indicate that these high voltage electrical pulses do not cause cardiac arrhythmia. Acute stress cardiomyopathy provides an alternative explanation for deaths associated with electronic weapons and may provide a better explanation for the usual time course associated with taser deaths. Patients with acute stress cardiomyopathy usually have had an emotional or physical stress, have high circulating levels of catecholamines, present with an acute coronary syndrome but have normal coronary vessels without significant thrombus formation. They have unusual left ventricular dysfunction with so-called apical ballooning. This presentation has been attributed to the direct effects of catecholamines on myocardial cell function. Alternative explanations include vasospasm in the coronary microcirculation and/or acute thrombosis followed by rapid thrombolysis. Similar events could occur during the high stress situations associated with the use of electronic weapons. These events also likely explain restraint-related deaths which occur in independent of any use of electronic weapons. Forensic pathologists have the opportunity to provide important details about the pathogenesis of these deaths through histological studies and careful evaluation of coronary vessels.

Epidemiology of Rabies in Skunks in Texas.
Oertli EH, Wilson PJ, Hunt PR, Sidwa TJ, Rohde RE.
J Am Vet Med Assoc. 2009 Mar 1;234(5):616-20.
Objective: To obtain epidemiologic information on rabies in skunks in Texas. Design: Epidemiologic study. Sample Population: Reports of skunks that had been submitted for rabies testing in Texas from 1953 through 2007. Procedures: Reports were reviewed to obtain information on seasonality of rabies in skunks, seasonality of human and domestic animal exposure to rabid skunks, commonly reported clinical signs of rabies in skunks, domestic animals frequently exposed to rabid skunks, common scenarios for exposure of domestic animals to rabid skunks, disposition of domestic animals exposed to rabid skunks, age and gender of humans exposed to rabid skunks, and usual routes of exposure of humans to rabid skunks. Results: On a yearly basis, the number of rabid skunks peaked in 1961, 1979, and 2001. On a monthly basis, the number of rabid skunks peaked in March and April. Over the study period, the percentage of rabid skunks from urban areas increased and the percentage from rural areas decreased. Striped skunks were the most common species. Dogs and cats were the domestic animals most frequently exposed to rabid skunks. On average, the highest numbers of humans exposed to rabid skunks were between 36 and 50 years old. Most humans were exposed through means other than a bite. Typical behaviors of rabid skunks were entering a dog pen, appearing outside during daytime, and attacking pets. Conclusions and Clinical Relevance: Information on the epidemiology of rabies in skunks may be useful in planning and implementing local, state, and national rabies control and prevention campaigns.

A Delphi Clinical Practice Protocol for the Management of Very Long Chain Acyl-Coa Dehydrogenase Deficiency.
Arnold GL, Van Hove J, Freedenberg D, Strauss A, Longo N, Burton B, Garganta C, Ficicioglu C, Cederbaum S, Harding C, Boles RG, Matern D, Chakraborty P, Feigenbaum A.
Mol Genet Metab. 2009 Mar;96(3):85-90.
Introduction: Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency is a disorder of oxidation of long chain fat, and can present as cardiomyopathy or fasting intolerance in the first months to years of life, or as myopathy in later childhood to adulthood. Expanded newborn screening has identified a relatively high incidence of this disorder (1:31,500), but there is a dearth of evidence-based outcomes data to guide the development of clinical practice protocols. This consensus protocol is intended to assist clinicians in the diagnosis and management of screen-positive newborns for VLCAD deficiency until evidence-based guidelines are available. Method: The Oxford Centre for Evidence-based Medicine system was used to grade the literature review and create recommendations graded from A (evidence level of randomized clinical trials) to D (expert opinion). Delphi was used as the consensus tool. A panel of 14 experts (including clinicians, diagnostic laboratory directors and researchers) completed three rounds of survey questions and had a face-to-face meeting. Result: Panelists reviewed the initial evaluation of the screen-positive infant, diagnostic testing and management of diagnosed patients. Grade C and D consensus recommendations were made in each of these three areas. The panel did not reach consensus on all issues, particularly in the dietary management of asymptomatic infants diagnosed by newborn screening.

Kounis Syndrome Following Beta-Lactam Antibiotic Use: Review of Literature.
Ridella M, Bagdure S, Nugent K, Cevik C.
Inflamm Allergy Drug Targets. 2009 Mar;8(1):11-6.
Background: Patients with anaphylaxis can have acute coronary syndromes secondary to allergic mediator effects on coronary vessels. Information about these cases is restricted to isolated case reports. Methods: To review this topic we identified all cases in the PubMed database in English with searches using beta-lactams\adverse effects and several coronary disease MeSH terms. Results: We analyzed 17 cases with a median age of 60 (range 13 to 72). Seventy-six percent of the patients were men. The beta-lactam antibiotic was administered by oral, IV, and intramuscular routes. Thirteen patients had cutaneous reactions, seven had respiratory symptoms, two had GI symptoms, 11 had chest pain, and 12 had hypotension. All reactions except one developed within 30 minutes. Ten patients had an elevated troponin levels. ECG revealed ST segment elevation in all patients except one. Cardiac catheterization was normal in 10 patients and abnormal in five patients. Allergy testing identified four patients with positive skin tests to antibiotics, four with increased IgE levels, three with increased histamine and tryptase levels, and one with a positive leukocyte transformation test. Treatment included drugs for anaphylaxis and acute coronary syndrome. All patients survived. Conclusions: Patients with anaphylaxis can present with acute coronary syndrome secondary to either vasospasm or acute plaque rupture and thrombus formation. The typical patient is a man with cutaneous, respiratory and cardiac symptoms and with ST segment elevation in inferior leads. The pathogenesis involves histamine and other mast cell mediators. Management should include therapy for anaphylaxis and vasospasmolytics. The use of epinephrine requires caution.

Binge Drinking among U.S. Active-Duty Military Personnel.
Stahre MA, Brewer RD, Fonseca VP, Naimi TS.
Am J Prev Med. 2009 Mar;36(3):208-17.
BACKGROUND: Binge drinking (drinking on a single occasion >or=5 drinks for men or >or=4 drinks for women) is a common risk behavior among U.S. adults that is associated with many adverse health and social consequences. However, little is known about binge drinking among active-duty military personnel (ADMP). The objectives of this study were to quantify episodes of binge drinking, to characterize ADMP who binge-drink, and to examine the relationship between binge drinking and related harms. METHODS: The prevalence of binge drinking and related harms was assessed from responses to the 2005 Department of Defense Survey of Health Related Behaviors Among Military Personnel (n=16,037), an anonymous, self-administered survey. The data were analyzed in 2007 after the release of the public-use data. RESULTS: In 2005, a total of 43.2% of ADMP reported past-month binge drinking, resulting in 29.7 episodes per person per year. In all, 67.1% of binge episodes were reported by personnel aged 17-25 years (46.7% of ADMP), and 25.1% of these episodes were reported by underage youth (aged 17-20 years). Heavy drinkers (19.8% of ADMP) were responsible for 71.5% of the binge-drinking episodes and had the highest number of annual per-capita episodes of binge drinking (112.6 episodes). Compared to nonbinge drinkers, binge drinkers were more likely to report alcohol-related harms, including job performance problems (AOR=6.5; 95% CI=4.65, 9.15); alcohol-impaired driving (AOR=4.9; 95% CI=3.68, 6.49); and criminal justice problems (AOR=6.2; 95% CI=4.00, 9.72). CONCLUSIONS: Binge drinking is common among ADMP and is strongly associated with adverse health and social consequences. Effective interventions (e.g., the enforcement and retainment of the minimum legal drinking age) to prevent binge drinking should be implemented across the military and in conjunction with military communities to discourage binge drinking.

Alcohol Consumption by Women Before and During Pregnancy.
Ethen MK, Ramadhani TA, Scheuerle AE, Canfield MA, Wyszynski DF, Druschel CM, Romitti PA.
Matern Child Health J. 2009 Mar;13(2):274-85.
Objectives: To determine the prevalence, patterns, and predictors of alcohol consumption prior to and during various intervals of pregnancy in the U.S. Methods: Alcohol-related, pregnancy-related, and demographic data were derived from computer-assisted telephone interviews with 4,088 randomly selected control mothers from the National Birth Defects Prevention Study who delivered live born infants without birth defects during 1997-2002. Alcohol consumption rates and crude and adjusted odds ratios (OR) were calculated. Results: 30.3% of all women reported drinking alcohol at some time during pregnancy, of which 8.3% reported binge drinking (4+ drinks on one occasion). Drinking rates declined considerably after the first month of pregnancy, during which 22.5% of women reported drinking, although 2.7% of women reported drinking during all trimesters of pregnancy and 7.9% reported drinking during the 3rd trimester. Pre-pregnancy binge drinking was a strong predictor of both drinking during pregnancy (adjusted OR = 8.52, 95% CI = 6.67-10.88) and binge drinking during pregnancy (adjusted OR = 36.02, 95% CI = 24.63-52.69). Other characteristics associated with both any drinking and binge drinking during pregnancy were non-Hispanic white race/ethnicity, cigarette smoking during pregnancy, and having an unintended pregnancy. Conclusions: Our study revealed that drinking during pregnancy is fairly common, three times the levels reported in surveys that ask only about drinking during the month before the survey. Women who binge drink before pregnancy are at particular risk for drinking after becoming pregnant. Sexually active women of childbearing ages who drink alcohol should be advised to use reliable methods to prevent pregnancy, plan their pregnancies, and stop drinking before becoming pregnant.

The Association between Major Birth Defects and Preterm Birth.
Honein MA, Kirby RS, Meyer RE, Xing J, Skerrette NI, Yuskiv N, Marengo L, Petrini JR, Davidoff MJ, Mai CT, Druschel CM, Viner-Brown S, Sever LE; for the National Birth Defects Prevention Network.
Matern Child Health J. 2009 Mar;13(2):164-175.
Objective To evaluate the association between preterm birth and major birth defects by maternal and infant characteristics and specific types of birth defects. Study Design We pooled data for 1995-2000 from 13 states with population-based birth defects surveillance systems, representing about 30% of all U.S. births. Analyses were limited to singleton, live births from 24-44 weeks gestational age. Results Overall, birth defects were more than twice as common among preterm births (24-36 weeks) compared with term births (37-41 weeks gestation) (prevalence ratio [PR] = 2.65, 95% confidence interval [CI] 2.62-2.68), and approximately 8% of preterm births had a birth defect. Birth defects were over five times more likely among very preterm births (24-31 weeks gestation) compared with term births (PR = 5.25, 95% CI 5.15-5.35), with about 16% of very preterm births having a birth defect. Defects most strongly associated with very preterm birth included central nervous system defects (PR = 16.23, 95% CI 15.49-17.00) and cardiovascular defects (PR = 9.29, 95% CI 9.03-9.56). Conclusions Birth defects contribute to the occurrence of preterm birth. Research to identify shared causal pathways and risk factors could suggest appropriate interventions to reduce both preterm birth and birth defects.

Birth Defects and Military Service since 1990.
Langlois PH, Ramadhani TA, Royle MH, Robbins JM, Scheuerle AE, Wyszynski DF.
Mil Med. 2009 Feb;174(2):170-6.
The National Birth Defects Prevention Study is an ongoing, multicenter, case-control study of over 30 major birth defects, and is one of the largest studies of the causes of birth defects to date. Data from it were examined to determine if maternal or paternal military service since 1990 as reported during the interview was associated with birth defects among offspring. Logistic regression was used to produce odds ratios (ORs) adjusted for major confounders. Overall, the results indicated no statistically significant association between parental military service since 1990 and increased risk of birth defects.

Hantavirus Pulmonary Syndrome in Texas: 1993-2006.
Rivers MN, Alexander JL, Rohde RE, Pierce JR Jr.
South Med J. 2009 Jan;102(1):36-41.
BACKGROUND: Hantavirus pulmonary syndrome (HPS) is a rare cardiopulmonary disease that was first described after a 1993 epidemic in the southwestern United States. This study reviewed all cases reported in Texas to date. METHODS: We reviewed case report forms submitted to the Texas Department of State Health Services and medical records (when available) to determine demographic and clinical features of Texas HPS cases. CONCLUSIONS: Middle-aged adults were more commonly affected. Respiratory symptoms were often accompanied by fever, gastrointestinal symptoms, and headache. Hypoxemia was observed in all cases. Common laboratory features included thrombocytopenia (92% of patients), elevated creatinine (61% of patients), increased polymorphonuclear leukocyte band forms (52% of patients), and hematocrit more than 55% (32% of patients). Most cases were associated with seeing rodents or rodent excreta at home. HPS was frequently misdiagnosed on initial presentation. Mortality was over 46%, higher for infection with the Sin Nombre virus (50%) than with the Bayou virus (0%). In Texas, the distribution of HPS is mainly along the coast and in west Texas.

The Prevalence and Predictors of Anencephaly and Spina Bifida in Texas.
Canfield MA, Marengo L, Ramadhani TA, Suarez L, Brender JD, Scheuerle A.
Paediatr Perinat Epidemiol. 2009 Jan;23(1):41-50.
Texas shares a 1255-mile border with Mexico and encompasses a variety of ecosystems, industries and other potential environmental exposures. The Texas Birth Defects Registry is an active surveillance system which covers all pregnancy outcomes (livebirths, fetal deaths and elective pregnancy terminations). This study describes the occurrence and the predictors of neural tube defects (anencephaly and spina bifida) in Texas between 1999 and 2003. Birth prevalence, crude and adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression, for each defect, by fetal/infant sex, delivery year and maternal sociodemographic characteristics. Among approximately 1.8 million livebirths, a total of 1157 neural tube defects cases were ascertained by the Registry, resulting in an overall prevalence of 6.33 cases per 10 000 livebirths. The prevalences of anencephaly and spina bifida were 2.81 and 3.52 per 10 000 livebirths respectively. Prevalences of both defects were highest in Hispanics, among mothers living along the border with Mexico, among women of higher parity and among mothers who were 40+ years of age. In addition, the prevalence of each defect was higher among women with no record of prenatal care and among women with less than 7 years of education. Hispanic ethnicity was an important predictor for anencephaly, along with sex, maternal age, parity and border residence. However, only border residence and delivery year were significant predictors for spina bifida.

Pattern of Lisdexamfetamine Ingestions Reported to Texas Poison Centers.
Forrester MB
J Pharm Technol. 2009;25:10-3.
BACKGROUND: Little information exists on lisdexamfetamine ingestions reported to poison centers. OBJECTIVE: To describe the pattern of lisdexamfetamine ingestions reported during the first year of their approved use to Texas poison centers. METHODS: The distribution of total cases of lisdexamfetamine ingestions with and without coingestants reported to Texas poison centers from July 2007–June 2008 was determined for the following selected variables: drug formulation, reported total dose ingested, patient sex and age, exposure site, and circumstances of the exposure. RESULTS: Of 187 total ingestions, the total dose ingested was reported for 59% (mean 221.4 mg; range 5–3,080). Fifty-eight percent of the patients were male and 38% were aged 6–12 years. Thirty-eight percent of the ingestions occurred as a result of therapeutic error, 26% were due to general unintentional reasons, and 12% were suspected attempted suicide; 11% of the patients called the poison center due to an adverse reaction to lisdexamfetamine. Of the 133 (71%) cases without coingestants, 53% were managed on site (ie, not a healthcare facility) and 79% resulted in or were expected to result in, at most, minor effects or minimal toxicity. The most frequently reported adverse clinical effects among cases without coingestants were tachycardia (14%), agitation (14%), vomiting (6%), and nausea (5%). CONCLUSIONS: The majority of lisdexamfetamine ingestions reported to Texas poison centers did not involve coingestants. Of those without coingestants, most were managed on site and did not result in serious medical outcomes.

Pattern of Pediatric Zolpidem Ingestions Reported to Texas Poison Control Centers, 2000 to 2006.
Forrester MB.
Pediatr Emerg Care 2009;25:26-30.
OBJECTIVES: The purpose of this study was to describe the pattern of zolpidem ingestions by young children reported to poison control centers. METHODS: Cases were all zolpidem ingestions by children 0 to 5 years old reported to Texas poison control centers during 2000 to 2006. Multiple substance ingestions were excluded. The distribution of cases was described with respect to such demographic and clinical factors as patient gender, ingestion reason, ingestion site, management site, and medical outcome. RESULTS: There were a total of 463 cases, all unintentional exposures. The patient was male in 52.2% of the cases, and the exposure occurred at the patient's own home in 92.8% of the cases. The patient was managed on-site in 54.4% cases, already at or en route to a health care facility in 29.6% cases, and referred to a health care facility in 16.0% cases. Of the 322 cases with a known final medical outcome, 59.0% had no effect, 35.1% had minor effects, and 5.9% had moderate effects. CONCLUSIONS: Pediatric ingestions of zolpidem alone reported to Texas poison control centers most frequently resulted in at most minor effects and were often managed at home.

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Last updated February 28, 2014