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DSHS Authors: 2013 Research Articles by DSHS Staff


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

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mrl-diamond2013 Articles (in date order with most recent first)

Applying quantitative approaches to the formative evaluation of antismoking campaign messages.
Parvanta S, Gibson L, Forquer H, Moldovan-Johnson M, et al. Soc Mar Q. 2013 Dec;19(4):242-264.
This article shares an in-depth summary of a formative evaluation that used quantitative data to inform the development and selection of promotional ads for the antismoking communication component of a social marketing campaign. A foundational survey provided cross-sectional data to identify beliefs about quitting smoking that campaign messages should target, as well as beliefs to avoid. Pretesting draft ads against quantitative indicators of message effectiveness further facilitated the selection and rejection of final campaign ads. Finally, we consider lessons learned from the process of balancing quantitative methods and judgment to make formative decisions about more and less promising persuasive messages for campaigns.

Body mass index and birth defects: Texas, 2005-2008.
Marengo L, Farag NH, Canfield M. Matern Child Health J. 2013 Dec;17(10):1898-907. doi: 10.1007/s10995-012-1214-5.
Texas ranks 12th nationally in the proportion of adult residents who are obese; approximately 67 % of Texans are overweight or obese. Studies indicate that obesity is related to an increased risk for birth defects; however, small sample sizes have limited the scope of birth defects investigated, and only four levels of body mass index (BMI) are typically explored. Using six BMI levels, we evaluated the association between maternal BMI and birth defects in a population-based registry covering ~1.6 million births. Texas birth defect cases were linked to 2005-2008 vital records. Maternal BMI was calculated using self-reported prepregnancy weight and height from the vital record and categorized as follows: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), class I obese (BMI 30-34.9), class II obese (BMI 35-39.9) and class III obese (BMI ≥40). Prevalence ratios for specific birth defects for maternal BMI categories were estimated by using normal weight as the referent, adjusted for maternal age and race/ethnicity, and stratified by maternal diabetes status. Risk for certain birth defects increased with increasing BMI (i.e., atrial and ventricular septal defects, pulmonary valve atresia, patent ductus arteriosus, and clubfoot). Risk for birth defects was substantially increased among some obese mothers (BMI ≥30) (e.g., spina bifida, tetralogy of Fallot, cleft lip with or without cleft palate, hypospadias, and epispadias). Conversely, mothers with higher BMI had a lower risk for having an infant or fetus with gastroschisis (aPR = 0.35; 95 % CI = 0.12, 0.80). Given the increased risk for birth defects associated with obesity, preconception counseling should emphasize the importance of maintaining normal weight.

Epidemiologic investigation of tuberculosis in a Mexican population from Chihuahua State, Mexico: a pilot study.
Chittoor G, Arya R, Farook VS, Gonzalez L, et al. Tuberculosis (Edinb). 2013 Dec;93 Suppl:S71-7. doi: 10.1016/S1472-9792(13)70014-3.
Tuberculosis (TB) and its co-morbid conditions have become a burden on global health economies. It is well understood that susceptibility of the host to TB infection/disease is influenced by both genetic and environmental factors and their interactions. The aims of this pilot case-control study are to characterize the sociodemographic and environmental factors related to active TB disease (TB/case) and latent TB infection (LTBI/control) status, and to identify risk factors associated with progression from LTBI to TB. We recruited 75 cases with TB (mean age=46.3y; females=41%) and 75 controls with LTBI (mean age=39.0y; females=37%), from the Mestizo population of Cuidad Juárez, Mexico. In addition to the determination of case/control status, information on environmental variables was collected (e.g., socioeconomic status, smoking, alcohol consumption, substance abuse, nutritional status, household demographics, medical histories and presence of type 2 diabetes [T2DM]). The data were analyzed to identify the environmental correlates of TB and LTBI using univariate and multivariate statistical approaches. Following multivariate logistic regression analysis, TB was associated with poor nutrition, T2DM, family history of TB, and non-Chihuahua state of birth. These preliminary findings have relevance to TB control at the Mexico-United States border, and contribute to our future genetic study of TB in Mexicans.

Epidemiology of rabies in bats in Texas (2001-2010).
Mayes BC, Wilson PJ, Oertli EH, Hunt PR, Rohde RE. J Am Vet Med Assoc. 2013 Oct 15;243(8):1129-37. doi: 10.2460/javma.243.8.1129
Objective: To obtain epidemiological information on rabies in bats in Texas. Design: Epidemiological study. Sample: Laboratory reports of bats that had been submitted for rabies testing in Texas from 2001 through 2010. Procedures: Laboratory reports were reviewed to obtain information on seasonality of rabies in bats; distribution, species, and rabies virus variants of rabid bats; and human and domestic animal exposures to rabid bats. Results: The number of rabid bats during the first 5 years of the study period remained static until a > 2-fold increase in 2006; during the subsequent 4 years, the annual number of rabid bats remained at this higher level, including a peak in 2008. The highest proportions of rabid bats were seen in late summer and early fall. The Brazilian free-tailed bat (Tadarida brasiliensis) was the most often affected species. Additionally, the rabies virus variant associated with the Brazilian free-tailed bat was the most prevalent. The percentage of rabid bats from urban areas was greater than that from rural areas. Dogs and cats were the domestic animals most frequently exposed to rabid bats. Most humans exposed to rabid bats did not report a known bite or scratch. The highest numbers of humans exposed to rabid bats were males between 11 to 15 years old. Conclusions and Clinical Relevance: Information on the epidemiology of rabies in bats and the epidemiology of exposures to rabid bats may be useful in planning and implementing local, state, and national rabies control and prevention campaigns and in encouraging rabies vaccination of domestic animals.

Factor structure of the Mental Health Statistics Improvement Program (MHSIP) Family and Youth satisfaction surveys.
Shafer AB, Temple JM. J Behav Health Serv Res. 2013 Jul;40(3):306-16. doi: 10.1007/s11414-013-9332-4.
Two studies of the Mental Health Statics Improvement Project (MHSIP) Family and Youth consumer satisfaction surveys factor structure and psychometrics were conducted. In study 1, the 2002-2006 Youth Services Survey for Families (N = 6,007) was administered to parents of children receiving services, and in study 2, the 2002-2004 Youth Services Survey (N = 1,718) was administered to children age 12-18 receiving services. Factor analyses across both studies found five factors that strongly supported the hypothesized scale domains of outcomes, satisfaction, cultural sensitivity, participation, and access. Scales based on these factors had good reliability with an average coefficient alpha of 0.85. The average convergent validity correlation between scale scores from the parent and child surveys was r = 0.62. Overall, the results supported the structure, reliability, and validity of the surveys.

General medical care external hospitalizations for patients in Texas state mental health hospitals.
Shafer AB, Ray RK, Becker EA. Tex Med. 2013 Mar 1;109(3):e1.
We explored the characteristics of general medical hospital admissions for patients in state mental health hospitals. Data were extracted from a statewide database of all hospital discharges for 5 years identified as general medical hospital admissions that occurred during the stay of patients at state mental health hospitals. Across the 9 mental health hospitals in the state system, rates of admission to general medical hospitals varied significantly from 0.7% to 3.7%. On average, of the 1.9% of all state mental health inpatients who had a general hospital admission, 25% occurred within 4 days of admission to the mental hospital. The average general hospitalization lasted 5.7 days. The reported total charge for all stays was $34 million. Dehydration (15%), hypertension (10%), and diabetes (10%) were the most frequent diagnoses. Thirteen percent of diagnoses met preventable hospitalization criteria. Given the variability among hospitals in admission rates and the number of preventable conditions, improvements in patient care and health as well as reduced admissions to general medical hospitals may be possible.

Texas poison centers’ involvement in the public health response to the West Nile virus outbreak in 2012.
Forrester MB, Gardner M. TX Public Health J. 2013;65(4):16-20.
Context: The largest West Nile virus outbreak in Texas occurred in 2012, with Dallas County particularly affected. Aerial insecticide spraying was conducted in Dallas County during August 16-23. On August 14, the North Texas Poison Center issued a press release indicating that the public could call the Texas Poison Center Network (TPCN) if they have questions about West Nile virus or the spraying. The TPCN also activated it s interactive voice response (IVR) system during August 15-27 to provide messages about West Nile virus and the aerial spraying. Objective: This investigation was to determine whether the West Nile virus outbreak affected the pattern of calls the TPCN received. Methods: The daily number of total calls handled by TPCN agents in August was determined and examined for any trends in relation to the aerial spraying. All West Nile virus-related calls handled by TPCN agents during August were identified and the call date, caller county, and call topic determined. The number of times the IVR message was accessed each day was identified. Results: The number of total calls handled by TPCN agents on August 16 (1,256) was the highest daily number of calls received in 2012. Of 988 West Nile virus-related calls handled by TPCN agents, 78% were about the aerial spraying, 19% were about West Nile virus, and 3% were unknown; 94% were information calls. Seventy-two percent of the calls originated in Dallas County. The IVR message was accessed by 1,516 callers. Discussion: The 2012 West Nile virus outbreak resulted in a surge in calls to the TPCN on August 16. The IVR system was utilized to answer a number of calls. Most of the West Nile virus-related calls handled by TPCN agents were about the aerial spraying, were requests for information, and came from Dallas County.

Kratom exposures reported to Texas poison centers.
Forrester MB. J Addict Dis. 2013;32(4):396-400.
Kratom use is a growing problem in the United States. Kratom exposures reported to Texas poison centers between January 1998 and September 2013 were identified. No kratom exposures were reported from 1998 to 2008 and 14 exposures were reported from 2009 to September 2013. Eleven patients were male, and 11 patients were in their 20s. The kratom was ingested in 12 patients, inhaled in 1, and both ingested and inhaled in 1. Twelve patients were managed at a healthcare facility and the remaining 2 were managed at home.

Poisson versus logistic regression in a descriptive epidemiologic analysis of data from a Birth Defects Registry.
Langlois PH, Canfield MA, Swartz MD. Birth Defects Res A Clin Mol Teratol. 2013 Oct;97(10):702-7.
BACKGROUND: The objective of this study was to compare results from four statistical approaches to describe the epidemiology of a birth defect. METHODS: Cases of tracheoesophageal fistula and/or esophageal atresia were selected from the Texas Birth Defects Registry, and live births from Texas birth certificate data. All were delivered in 1999 through 2009. Data on infant and maternal characteristics were taken from the vital record. Four approaches were compared: a cohort design using Poisson regression (PR) and three case-control analyses using logistic regression (LR) with 10 controls per case (LR10), four controls per case (LR4), or affected controls having other birth defects. Analyses were conducted for all 11 years and for just 1 year (2009). RESULTS: Using all 11 years, there were 869 cases of tracheoesophageal fistula and/or esophageal atresia, and results for PR, LR10, and LR4 were similar. Results using only 2009 were more divergent: PR yielded more statistically significant global tests (type III analyses) and narrower 95% confidence intervals, followed closely by LR10. For both time periods, results using affected controls were different from those using PR and LR. CONCLUSION: For these descriptive epidemiologic analyses, PR yielded the most precise estimates. However, LR provided similar estimates, and using 10 controls per case yielded precision almost as good as PR.

Management of Seizure Disorders in the Deployed Environment: A Treatment Guide for the Non-Neurologist in Theater. 
Kaspar R, Buckner RE II, McMahon JP, Etienne M, Larsen AA Jr, Duckworth J. Mil Med. 2013;178(8):907-913.
Patients with seizures can present a common and challenging problem for medical providers in the deployed environment. Unfortunately, there is a paucity of controlled clinical trial data that can be used to formulate evidence-based guidelines for management. In an attempt to aid the non-neurologist deployed provider in the care of patients presenting with seizures, the authors describe two cases illustrative of common presentations. Thereafter, the authors address many facets of the management questions commonly raised by such cases and offer suggestions regarding such issues as initial pharmacologic management, the need for admission and evacuation, seizure precautions, differentiation from syncope and nonepileptic seizures, addressing patient and command concerns regarding evaluation and duty restrictions, and obtaining online management assistance.

Feasibility of matching Vaccine Adverse Event Reporting System and poison center records.
Forrester MB. J Registry Manage 2013;40:93-97.
Background: The Vaccine Adverse Event Reporting System (VAERS) is a US surveillance program that collects information on adverse events that occur after the use of vaccines. Poison centers also receive calls about potentially adverse exposures to vaccines. Since the same vaccine exposure might be reported to both VAERS and a poison center, this study examined the feasibility of matching publicly available VAERS records to poison center records. Methods: All VAERS records reported from Texas during 2000 2011 were downloaded from the VAERS database. All vaccine exposures reported to Texas poison centers during 2000 2011 were identified. Since no unique identifiers (eg, names, dates of birth, etc) were available in the public VAERS database, matches had to be made using other, non unique data fields that both databases had in common. Matches were made using the following 4 data fields: vaccine, sex or gender, age, and date. The match rate was determined for total poison center records and for selected poison center variables. Results: There were 13,630 VAERS and 738 poison center records in the investigation. Twenty nine percent (213) of the poison center records were matched to VAERS records. The match rate by 3 year period was 2000 2002 (21%), 2003 2005 (27%), 2006 2008 (20%), and 2009 2011 (41%). The rate for the most common vaccines was influenza (42%), pneumococcal (39%), diphtheria pertussis tetanus (49%), hepatitis B (14%), and diphtheria tetanus (29%). The match rate was 35% for adverse reactions and 32% for therapeutic errors. The rate was 28% for non-serious outcomes and 33% for serious outcomes. The match rate was 29% for patients managed on site and 28% for patients already at or referred to a health-care facility. Conclusion: Matching between public VAERS and poison center records can be performed. However, these matches might be considered tentative because unique identifiers are not available. The match rate was highest during the most recent 3 year period. The match rate varied by vaccine but not by the exposure reason, management site, or medical outcome.

Prevalence and Correlates of Gastroschisis in 15 States, 1995 to 2005.
Kirby, Russell S. PhD, MS; Marshall, Jennifer MPH; Tanner, Jean Paul MPH; Salemi, Jason L. MPH; Feldkamp, Marcia L. PhD, PA; Marengo, Lisa MS; Meyer, Robert E. PhD; Druschel, Charlotte M. MD, MPH; Rickard, Russel MS; Kucik, James E. PhD, MPH; for the National Birth Defects Prevention Network
Obstetrics & Gynecology: epub 8 July 2013
Objective: To identify trends in the prevalence and epidemiologic correlates of gastroschisis using a large population-based sample with cases identified by the National Birth Defects Prevention Network over the course of an 11-year period. Methods: This study examined 4,713 cases of gastroschisis occurring in 15 states during 1995-2005, using public use natality data sets for denominators. Multivariable Poisson regression was used to identify statistically significant risk factors, and Joinpoint regression analyses were conducted to assess temporal trends in gastroschisis prevalence by maternal age and race and ethnicity. Results: Results show an increasing temporal trend for gastroschisis (from 2.32 per 10,000 to 4.42 per 10,000 live births). Increasing prevalence of gastroschisis has occurred primarily among younger mothers (11.45 per 10,000 live births among mothers younger than age 20 years compared with 5.35 per 10,000 among women aged 20 to 24 years). In the multivariable analysis, using non-Hispanic whites as the referent group, non-Hispanic black women had the lowest risk of having a gastroschisis-affected pregnancy (prevalence ratio 0.42, 95% confidence interval [CI] 0.37-0.48), followed by Hispanics (prevalence ratio 0.86, 95% CI 0.81-0.92). Gastroschisis prevalence did not differ by newborn sex. Conclusions: Our findings demonstrate that the prevalence of gastroschisis has been increasing since 1995 among 15 states in the United States, and that higher rates of gastroschisis are associated with non-Hispanic white maternal race and ethnicity, and maternal age younger than 25 years (particularly younger than 20 years of age).

The less than glorious side of morning glories.
Forrester MB. 
Texas Public Health Journal 2013;65(3):5.

Pediatric ingestions of dissolvable nicotine products.
Forrester MB. 
Texas Public Health Journal 2013;65(3):5-6.

Ask-Advise-Connect: A New Approach to Smoking Treatment Delivery in Health Care Settings.
Vidrine JI, Shete S, Cao Y, Greisinger A, Harmonson P, Sharp B, Miles L, Zbikowski SM, Wetter DW.
JAMA Intern Med. 2013 Mar 25; 173(6):458-64.
Importance: Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance. Objective: To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment.  Design: A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011.  Setting: Ten clinics in Houston, Texas. Participants: Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics. Interventions: Linking smokers with quitline-delivered treatment. Main Outcome Measure: Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. Results: In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. Conclusions And Relevance: The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.

Eliminating Tuberculosis One Neighborhood at a Time.
Cegielski JP, Griffith DE, McGaha PK, Wolfgang M, Robinson CB, Clark PA, Hassell WL, Robison VA, Walker KP, Wallace C.
Am J Public Health. 2013;103:1292–1300
Objectives. We evaluated a strategy for preventing tuberculosis (TB) in communities most affected by it. Methods. In 1996, we mapped reported TB cases (1985–1995) and positive tuberculin skin test (TST) reactors (1993–1995) in Smith County, Texas. We delineated the 2 largest, densest clusters, identifying 2 highest-incidence neighborhoods (180 square blocks, 3153 residents). After extensive community preparation, trained health care workers went door-to-door offering TST to all residents unless contraindicated. TST-positive individuals were escorted to a mobile clinic for radiography, clinical evaluation, and isoniazid preventive treatment (IPT) as indicated. To assess long-term impact, we mapped all TB cases in Smith County during the equivalent time period after the project. Results. Of 2258 eligible individuals, 1291 (57.1%) were tested, 229 (17.7%) were TST positive, and 147 were treated. From 1996 to 2006, there were no TB cases in either project neighborhood, in contrast with the preintervention decade and the continued occurrence of TB in the rest of Smith County. Conclusions. Targeting high-incidence neighborhoods for active, communitybased screening and IPT may hasten TB elimination in the United States.

Investigation of a Chlamydia pneumoniae Outbreak in a Federal Correctional Facility in Texas.
Conklin L, Adjemian J, Loo J, Mandal S, Davis C, Parks S, Parsons T, McDonough B, Partida J, Thurman K, Diaz MH, Benitez A, Pondo T, Whitney CG, Winchell JM, Kendig N, Van Beneden C.
Clin Infect Dis. 2013 May 30. [Epub ahead of print]
Background.  Chlamydia pneumoniae illness is poorly characterized, particularly as a sole causative pathogen. We investigated a C. pneumoniae outbreak at a federal correctional facility. Methods.  We identified inmates with acute respiratory illness (ARI) from November 1, 2009 - February 24, 2010 through clinic self-referral and active case-finding. We tested oropharyngeal and/or nasopharyngeal swabs for C. pneumoniae by quantitative polymerase chain reaction (qPCR) and sera by microimmunofluorescence. Cases were inmates with ARI and radiologically-confirmed pneumonia, positive qPCR, or serological evidence of recent infection. Swabs from 7 acutely ill inmates were tested for 18 respiratory pathogens using qPCR TaqMan array cards (TAC). Follow-up swabs from case-patients were collected for up to 8 weeks. Results.  Among 33 self-referred and 226 randomly selected inmates, 52 (20.1%) met case definition; 4 were confirmed by radiologically-confirmed pneumonia only, 9 by qPCR only, 17 by serology only, and 22 by both qPCR and serology. The prison attack rate was 10.4% (95% CI: 7.0, 13.8%). White inmates and residents of housing unit Y were at highest risk. TAC testing detected C. pneumoniae in 4 (57%) inmates; no other causative pathogens were identified. Among 40 inmates followed prospectively, C. pneumoniae was detected for up to 8 weeks. Thirteen (52%) of 25 inmates treated with azithromycin continued to be qPCR positive >2 weeks after treatment. Conclusions.  C. pneumoniae was the causative pathogen of this outbreak. Higher risk among certain groups suggests social interaction contributed to transmission. Persistence of C. pneumoniae in the oropharynx creates challenges for outbreak control measures.

Impact of 2012 West Nile virus outbreak on pesticide exposures reported to Texas poison centers. (No abstract available.)
Forrester MB, Gardner M. 
Texas Public Health Journal 2013;65(2):11-13.

Cancer Screenings throughout Texas, 2008 and 2010 Behavioral Risk Factor Surveillance System.
Cook M, Maynard W, Wyatt S, Garcia B.
Texas Public Health Journal. Winter 2013;65(1):8-13.
The article presents a study on the monitoring and screening of cancer in Texas in 2008 and 2010. It looks into the establishment of the Cancer Prevention Research Institute of Texas (CPRIT) and its effort to increase evidence-based screening for cancers of the breast, cervix, and colon and rectum. It explores the estimates of screening rates in the state.

Comparison of Pediatric Exposures to Concentrated "Pack" and Traditional Laundry Detergents.
Forrester MB.
Pediatr Emerg Care 2013;29:482-486.
Objectives: Pediatric exposures to concentrated laundry detergent packs may result in serious adverse effects. This study compared pediatric exposures to laundry detergent packs and traditional laundry detergents. Methods: Cases were exposures among patients 5 years or younger to laundry detergent packs during January to June 2012 and traditional laundry detergents during January to December 2011 reported to Texas poison centers. Comparisons between the 2 types of products were made for various variables. Results: Of 187 laundry detergent pack and 452 traditional laundry detergent exposures, the patient was already at or en route to a health care facility in 21.4% of the laundry detergent pack and 9.3% of the traditional laundry detergent exposures. Of those exposures where the poison center could potentially influence where the patient was managed, 23.8% of laundry detergent pack and 3.7% of traditional laundry detergent exposures were referred to health care facilities. Potentially serious outcomes were reported in 12.3% of laundry detergent pack and 2.4% of traditional laundry detergent exposures. The most commonly reported clinical effects in laundry detergent pack and traditional laundry detergent exposures were vomiting (54.5% vs 17.0%), cough (11.2% vs 2.2%), ocular irritation (7.0% vs 6.4%), red eye (7.0% vs 5.3%), nausea (7.0% vs 2.7%), and oral irritation (7.0% vs 2.2%). Conclusions: Pediatric exposures to laundry detergent packs were more likely to be managed at a health care facility. Moreover, the laundry detergent pack exposures were more likely to result in serious outcomes and involve the most common clinical effects.

National Outbreak of Type A Foodborne Botulism Associated with a Widely Distributed Commercially Canned Hot Dog Chili Sauce.
Juliao PC, Maslanka S, Dykes J, Gaul L, Bagdure S, Granzow-Kibiger L, Salehi E, Zink D, Neligan RP, Barton-Behravesh C, Lúquez C, Biggerstaff M, Lynch M, Olson C, Williams I, Barzilay EJ.
Clin Infect Dis. 2013 Feb;56(3):376-82.
A type A botulism outbreak was associated with commercially canned food; it is the first botulism outbreak in the United States involving a commercial cannery in >30 years. Because of possible widespread distribution of the implicated product, this outbreak was a major public health concern. Background: On 7 and 11 July 2007, health officials in Texas and Indiana, respectively, reported 4 possible cases of type A foodborne botulism to the US Centers for Disease Control and Prevention. Foodborne botulism is a rare and sometimes fatal illness caused by consuming foods containing botulinum neurotoxin. Methods: Investigators reviewed patients’ medical charts and food histories. Clinical specimens and food samples were tested for botulinum toxin and neurotoxin-producing Clostridium species. Investigators conducted inspections of the cannery that produced the implicated product. Results: Eight confirmed outbreak associated cases were identified from Indiana (n = 2), Texas (n = 3), and Ohio (n = 3). Botulinum toxin type A was identified in leftover chili sauce consumed by the Indiana patients and 1 of the Ohio patients. Cannery inspectors found violations of federal canned-food regulations that could have led to survival of Clostridium botulinum spores during sterilization. The company recalled 39 million cans of chili. Following the outbreak, the US Food and Drug Administration inspected other canneries with similar canning systems and issued warnings to the industry about the danger of C. botulinum and the importance of compliance with canned food manufacturing regulations. Conclusions: Commercially produced hot dog chili sauce caused these cases of type A botulism. This is the first US foodborne botulism outbreak involving a commercial cannery in >30 years. Sharing of epidemiologic and laboratory findings allowed for the rapid identification of implicated food items and swift removal of potentially deadly products from the market by US food regulatory authorities.

Emergence of Autochthonous Cutaneous Leishmaniasis in Northeastern Texas and Southeastern Oklahoma.
Clarke CF, Bradley KK, Wright JH, Glowicz J.
Am J Trop Med Hyg. 2013 Jan;88(1):157-61.
Autochthonous human cases of leishmaniasis in the United States are uncommon. We report three new cases of cutaneous leishmaniasis and details of a previously reported case, all outside the known endemic range in Texas. Surveys for enzootic rodent reservoirs and sand fly vectors were conducted around the residences of three of the case-patient during the summer of 2006; female Lutzomyia anthophora sand flies were collected at a north Texas and southeast Oklahoma residence of a case-patient, indicating proximity of a suitable vector. Urban sprawl, climatologic variability, or natural expansion of Leishmania mexicana are possible explanations for the apparent spread to the north and east. Enhanced awareness among healthcare providers in the south central region of the United States is important to ensure clinical suspicion of leishmaniasis, diagnosis, and appropriate patient management.

Disparities in the Treatment and Outcomes of Lung Cancer among HIV-infected People in Texas.
Suneja G, Shiels MS, Melville SK, Williams MA, Rengan R, Engels EA.
AIDS. 2013 Jan 28;27(3):459-68.
Objectives:: HIV-infected people have elevated risk for lung cancer and higher mortality following cancer diagnosis than HIV-uninfected individuals. It is unclear whether HIV-infected people with lung cancer receive similar cancer treatment as HIV-uninfected people. Design/Methods: We studied adults 18+ years old with lung cancer reported to the Texas Cancer Registry (N = 156,930) from 1995-2009. HIV status was determined by linkage with the Texas enhanced HIV/AIDS Reporting System. For non-small cell lung cancer (NSCLC) cases, we identified predictors of cancer treatment using logistic regression. We used Cox regression to evaluate effects of HIV and cancer treatment on mortality. Results: Compared with HIV-uninfected lung cancer cases (N = 156,593), HIV-infected lung cancer cases (N = 337) were more frequently young, non-Hispanic black, male, and with distant stage disease. HIV-infected NSCLC cases less frequently received cancer treatment than HIV-uninfected cases (60.3% vs. 77.5%; odds ratio 0.39, 95% confidence interval [CI] 0.30-0.52, after adjustment for diagnosis year, age, sex, race, stage, and histologic subtype). HIV infection was associated with higher lung cancer-specific mortality (hazard ratio [HR] 1.34, 95%CI 1.15-1.56, adjusted for demographics and tumor characteristics). Inclusion of cancer treatment in adjusted models slightly attenuated the effect of HIV on lung cancer-specific mortality (HR 1.25; 95%CI 1.06-1.47). Also, there was a suggestion that HIV was more strongly associated with mortality among untreated than among treated cases (adjusted HR 1.32 vs. 1.16, p-interaction = 0.34). Conclusion: HIV-infected NSCLC cases were less frequently treated for lung cancer than HIV-uninfected cases, which may have affected survival.

From Model to Action: Using a System Dynamics Model of Chronic Disease Risks to Align Community Action.
Loyo HK, Batcher C, Wile K, Huang P, Orenstein D, Milstein B.
Health Promot Pract. 2013 Jan;14(1):53-61.
Health planners in Austin, Texas, are using a System Dynamics Model of Cardiovascular Disease Risks (SD model) to align prevention efforts and maximize the effect of limited resources. The SD model was developed using available evidence of disease prevalence, risk factors, local contextual factors, resulting health conditions, and their impact on population health. Given an interest in understanding opportunities for upstream health protection, the SD model focused on the portion of the population that has never had a cardiovascular event. Leaders in Austin used this interactive simulation model as a catalyst for convening diverse stakeholders in thinking about their strategic directions and policy priorities. Health officials shared insights from the model with a range of organizations in an effort to align actions and leverage assets in the community to promote healthier conditions for all. This article summarizes the results from several simulated intervention scenarios focusing specifically on conditions in East Travis County, an area marked by higher prevalence of adverse living conditions and related chronic diseases. The article also describes the formation of a new Chronic Disease Prevention Coalition in Austin, along with shifts in its members perceived priorities for intervention both before and after interactions with the SD model.

West Nile Virus Infection among Humans, Texas, USA, 2002-2011.
Nolan M, Schuermann J, Murray K.
Emerg Infect Dis. 2013 Jan;19(1):137-9.
We conducted an epidemiologic analysis to document West Nile virus infections among humans in Texas, USA, during 2002-2011. West Nile virus has become endemic to Texas; the number of reported cases increased every 3 years. Risk for infection was greatest in rural northwestern Texas, where Culex tarsalis mosquitoes are the predominant mosquito species.

Pediatric Insecticide Chalk Exposures Reported to Texas Poison Centers.
Forrester MB.
Hum Exp Toxicol 2013;32:554-8.
The pesticide Miraculous Insecticide Chalk is illegal in the United States but can be obtained through a variety of sources. Because it is a stick similar in appearance to common blackboard chalk, children might play with it and put it in their mouths. All Miraculous Insecticide Chalk exposures involving children 5 years or younger reported to Texas poison centers during 2000-2010 were identified. The distribution by selected demographic and clinical factors was calculated. Of the total 188 exposures, the mean age was 1.5 years (range 6 months-5 years) and 60.6% were male. Ingestions were reported in 97.3% of the exposures, and these were reported to involve at most one stick of the chalk. The lowest exposure rates per 100,000 population of 5 years or younger were reported in the Public Health Regions in northern and eastern Texas (0.00-2.30) and the highest rates in the Public Health Regions in southern and western Texas (19.08-39.50). Of the 187 exposures not involving other substances, 96.8% were known or expected to result in at most minor effects, and 71.1% were managed on site (at residence).

Reporting of Bedbug Treatment Exposures to Texas Poison Centres
Forrester MB, Prosperie S.
Public Health. 2013 Mar 12. [Epub ahead of print] (No abstract available.)

Adolescent Synthetic Cathinone Exposures Reported to Texas Poison Centers.
Forrester MB.
Pediatr Emerg Care 2013 [Epub ahead of print]
Objectives: This study describes the pattern of adolescent synthetic cathinone exposures reported to a large, statewide poison center system. Methods: Synthetic cathinone exposures among patients younger than 20 years reported to Texas poison centers during 2010 to 2011 were identified. The distribution of exposures by various demographic and clinical factors was determined. Results: For 51 adolescent exposures, the mean age was 17.5 years (range, 12-19 years). The exposure was by inhalation in 66.7% of the cases and 60.8% involved male patients. The exposure site was the patient's own or another residence in 58.8% of the cases. The patient was already at or en route to a health care facility in 76.5% of the cases, and the medical outcome was known or suspected to be serious in 74.5%. The most frequently reported adverse clinical effects were agitation/irritability (43.1%), tachycardia (37.3%), drowsiness/lethargy (13.7%), hallucinations (9.8%), fever (9.8%), vomiting (9.8%), and hypertension (7.8%). Conclusions: Adolescent synthetic cathinone exposures reported to Texas poison centers were more likely to have occurred by inhalation. The adolescents were more likely to be male. The exposures more often occurred at the patient's own residence and were managed at a health care facility with a serious outcome. This pattern of exposures was similar to that observed among adults.

Hospital-Acquired Listeriosis Outbreak Caused by Contaminated Diced Celery--Texas, 2010.
Gaul LK, Farag NH, Shim T, Kingsley MA, Silk BJ, Hyytia-Trees E.
Clin Infect Dis. 2013 Jan;56(1):20-6.
Background: Listeria monocytogenes causes often-fatal infections affecting mainly immunocompromised persons. Sources of hospital-acquired listeriosis outbreaks can be difficult to identify. We investigated a listeriosis outbreak spanning 7 months and involving 5 hospitals. Methods: Outbreak-related cases were identified by pulsed-field gel electrophoresis (PFGE) and confirmed by multiple-locus variable-number tandem-repeat analysis (MLVA). We conducted patient interviews, medical records reviews, and hospital food source evaluations. Food and environmental specimens were collected at a hospital (hospital A) where 6 patients had been admitted before listeriosis onset; these specimens were tested by culture, polymerase chain reaction (PCR), and PFGE. We collected and tested food and environmental samples at the implicated processing facility. Results: Ten outbreak-related patients were immunocompromised by ≥1 underlying conditions or treatments; 5 died. All patients had been admitted to or visited an acute-care hospital during their possible incubation periods. The outbreak strain of L. monocytogenes was isolated from chicken salad and its diced celery ingredient at hospital A, and in 19 of >200 swabs of multiple surfaces and in 8 of 11 diced celery products at the processing plant. PCR testing detected Listeria in only 3 of 10 environmental and food samples from which it was isolated by culturing. The facility was closed, products were recalled, and the outbreak ended. Conclusions: Contaminated diced celery caused a baffling, lengthy outbreak of hospital-acquired listeriosis. PCR testing often failed to detect the pathogen, suggesting its reliability should be further evaluated. Listeriosis risk should be considered in fresh produce selections for immunocompromised patients.

Exposures to 1,3-dimethylamylamine-Containing Products Reported to Texas Poison Centers.
Forrester MB.
Hum Exp Toxicol 2013;32:18-23.
1,3-Dimethylamylamine (DMAA) is an ingredient in a number of weight loss and exercise performance enhancing products. However, information on the safety of DMAA-containing products is limited. Exposures to DMAA-containing products reported to Texas poison centers during 2010-2011 were identified and selected factors were examined. A total of 56 exposures were found, of which 75.0% were reported during 2011. OxyElite Pro™ was the reported product in 80.4% of the exposures. The patients were 51.8% male and 55.4% age ≤5 years. The patient was managed on site (such as at home) in 57.1% of the cases, and the exposure was known or expected to result in an outcome that was classified as not serious in 80.4%. The most frequently reported clinical effects were tachycardia (28.6%), nausea (16.1%), and vomiting (12.5%). The most common treatments were dilution (41.1%), food (19.6%), and activated charcoal (14.3%). It should be noted that the adverse clinical effects may be due to other ingredients in the DMAA-containing products, such as caffeine.

The "Cinnamon Challenge" - Potentially Serious Consequences of a Popular Dare.
Forrester MB. 
Texas Public Health Journal 2013;65(1):5-6. (No abstract available.)

2C Series Phenethylamine Derivative Exposures in Texas.
Forrester MB.
Subst Abus 2013;34:81-82. (No abstract available.)

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Last updated February 02, 2016