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DSHS Authors: 2016 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-diamond2016 Articles (in date order with most recent first)

Forrester MB. Comparison of poisonings managed at military and Veterans Administration hospitals reported to Texas poison centers. Public Health 2016;142:50-55.
Objectives: There is little information on poisonings managed at military and Veterans Administration (VA) hospitals. This investigation described and compared poisonings reported to Texas poison centers that were managed at military and VA hospitals. Study design: Retrospective analysis of poison centre data. Methods: Cases were poisonings among patients aged 18 years or more reported to Texas poison centers during 2000-2015 where management occurred at a military or VA hospital. The distribution of exposures for various demographic and clinical factors was determined for military and veterans hospitals and comparisons were made between the two groups. Results: There were 4353 and 1676 poisonings managed at military and VA hospitals, respectively. Males accounted for 50.5% of the military hospital patients and 84.9% of the VA hospital patients. The mean age for military hospital patients was 31 years and for VA hospital patients was 50 years. The proportion of poisonings managed at military hospitals and VA hospitals, respectively, were intentional (70.0% vs 64.1%), particularly suspected attempted suicide (57.3% vs 47.7%), and unintentional (25.0% vs 30.5%). More than one substance was reported in 37.7% of military and 33.2% of VA hospital poisonings. The most commonly reported substance categories for poisonings managed at military and VA hospitals, respectively, were analgesics (28.4% vs 19.7%), sedatives/hypnotics/antipsychotics (24.7% vs 23.4%), antidepressants (18.7% vs 19.7%) and alcohol (11.3% vs 10.6%). Conclusions: A number of differences were observed between poisonings managed at military and VA hospitals. These differing patterns of poisonings may need to be taken into account in the education, prevention and treatment of poisonings at these hospitals and among the populations they serve.

Nekhlyudov L, Walker R, Ziebell R, Rabin B, Nutt S, Chubak J. Cancer survivors' experiences with insurance, finances, and employment: results from a multisite study. J Cancer Surviv. 2016 Dec;10(6):1104-1111.
Background: Cancer has significant implications on survivors' insurance coverage, financial status, and employment. We aimed to examine how these outcomes vary for survivors of different cancer types. Methods:  Using the Cancer Survivorship Supplement of the Medical Expenditures Panel Survey (MEPS), in 2013, we surveyed survivors of five common cancers who were diagnosed during 2003-2008 and were continuously enrolled in one of three health plans in Massachusetts, Colorado, and Washington State. Results:  Among 615 eligible respondents, 96 % reported having health insurance at the time of or since diagnosis; of those, few reported barriers in coverage to visit doctors or facilities of their choice. Approximately 15 % reported experiencing financial hardships due to cancer. Of the 334 who responded as having been employed at the time of or since diagnosis, approximately 25 % reported that they or their spouses remained at their jobs due to concerns about losing medical insurance. Further, 63 % reported making changes in their jobs or careers (e.g., took extended time off, worked part time, or declined promotion) due to cancer, and 42 % reported that cancer interfered with their physical and/or mental tasks at work or reduced productivity. Negative employment and financial implications were most common among those with lung, breast, and colorectal cancer, and those diagnosed before age 65. Conclusions:  In this insured population, few experienced restrictions in cancer care coverage, though maintaining health insurance often drove employment decisions. Significant negative effects on finances and employment were observed among specific cancer types and younger survivors. Implications for Cancer Survivors:  Our study findings emphasize a need to identify ways of supporting survivors and provide tailored resources to reduce the untoward financial and work-related implications of cancer

Baeva S, Archer NP, Ruggiero K, Hall M, Stagg J, Interis EC, Vega R, Delgado E, Hellerstedt J, Hankins G, Hollier LM; Texas Maternal Mortality and Morbidity Task Force. Maternal Mortality in Texas. Am J Perinatol. 2016 Nov 9. [Epub ahead of print]
A commentary on maternal mortality in Texas is provided in response to a 2016 article in Obstetrics & Gynecology by MacDorman et al. While the Texas Department of State Health Services and the Texas Maternal Mortality and Morbidity Task Force agree that maternal mortality increased sharply from 2010 to 2011, the percentage change or the magnitude of the increase in the maternal mortality rate in Texas differs depending on the statistical methods used to compute and display it. Methodologic challenges in identifying maternal death are also discussed, as well as risk factors and causes of maternal death in Texas. Finally, several state efforts currently underway to address maternal mortality in Texas are described.

Ziqubu-Page T, Forrester MB. Adolescent workplace exposures reported to Texas poison centers. Int J Adolesc Med Health 2016 [Epub ahead of print]
BACKGROUND: Working adolescents, with less experience and less training than adults, may take more risks and get exposed to a wide variety of toxic substances in the workplace. They may get injured when working in inadequately ventilated areas or entering areas of exposure with improper or no protective equipment. OBJECTIVE: The purpose of this study was to describe adolescent occupational exposures reported to poison centers. SUBJECTS: Occupational exposures reported to Texas poison centers during 2000-2015 where patients were 13-19 years in age. METHODS: The distribution of the cases was determined for various factors. RESULTS: There were 2430 adolescent occupational exposures. The most frequently reported major substance categories were chemicals (18%), household cleaning substances (18%), hydrocarbons (10%), and industrial cleaners (9%). Forty-five percent occurred during May-August. Males accounted for 66% of the patients; 27% were 18 years and 37% were 19 years. The most common exposure routes were inhalation (28%), dermal (27%), ingestion (26%), and ocular (24%). The patients were managed on site in 51% of the exposures. Twenty-three percent of the exposures had serious outcomes. CONCLUSION: Adolescents involved in occupational exposures tended to be male and older. Adolescent occupational exposures were likely to involve chemicals and household cleaning substances, occur by ingestion and ocular route, and likely to be managed on site. Most were not likely to have serious outcomes.

Forrester MB. Dry ice: A potential Halloween hazard. TX Public Health J 2016;68(4):4.
No abstract available.

Forrester MB. Niacin ingestions reported to poison centers. TX Public Health J 2016;68(4):4-5.
No abstract available.

Kipp EJ, Mariscal J, Armijos RX, Weigel M, Waldrup K. Genetic evidence of enzootic leishmaniasis in a stray canine and Texas mouse from sites in west and central Texas. Mem Inst Oswaldo Cruz. 2016 Oct;111(10):652-654.
We detected Leishmania mexicana in skin biopsies taken from a stray canine (Canis familiaris) and Texas mouse (Peromyscus attwateri) at two ecologically disparate sites in west and central Texas using polymerase chain reaction (PCR). A single PCR-positive dog was identified from a sample of 96 stray canines and was collected in a peri-urban area in El Paso County, Texas. The PCR-positive P. attwateri was trapped at a wildlife reserve in Mason County, Texas, from a convenience sample of 20 sylvatic mammals of different species. To our knowledge, this represents the first description of L. mexicana in west Texas and extends the known geographic range of the parasite to an area that includes the arid Chihuahuan Desert. Our finding of L. mexicana in P. attwateri represents a new host record and is the first description of the parasite in a wild peromyscid rodent in the United States.

Calvert GM, Beckman J, Prado JB, Bojes H, et al. Acute occupational pesticide-related illness and injury -United States, 2007-2011. MMWR Morb Mortal Wkly Rep. 2016 Oct 14;63(55):11-16.
CDC's National Institute for Occupational Safety and Health (NIOSH) collects data on acute pesticide-related illness and injury reported by 12 states (California, Florida, Iowa, Louisiana, Michigan, Nebraska, North Carolina, New Mexico, New York, Oregon, Texas, and Washington). This report summarizes the data on illnesses and injuries arising from occupational exposure to conventional pesticides from 2007 through 2011. This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016 (1). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (2). In a separate report, data on illnesses and injuries from nonoccupational exposure to pesticides during 2007-2011 are summarized (3).

Lara DA, Ethen MK, Canfield MA, Nembhard WN, Morris SA. A population-based analysis of mortality in patients with Turner syndrome and hypoplastic left heart syndrome using the Texas Birth Defects Registry. Congenit Heart Dis. 2016 Sep 29. doi: 10.1111/chd.12413. [Epub ahead of print]
Background:  Hypoplastic left heart syndrome (HLHS) is strongly associated with Turner syndrome (TS); outcome data when these conditions coexist is sparse. We aimed to investigate long-term survival and causes of death in this population. Methods:  The Texas Birth Defects Registry was queried for all live born infants with HLHS during 1999-2007. We used Kaplan-Meier and Cox regression analyses to compare survival among patients with HLHS with TS (HLHS/TS+) to patients who had HLHS without genetic disorders or extracardiac birth defects (HLHS/TS-). Results:  Of the 542 patients with HLHS, 11 had TS (2.0%), 71 had other extracardiac birth defects or genetic disorders, and 463 had neither. The median follow-up time was 4.2 y (interquartile range [IQR] 2.1-6.5). Comparing those with HLHS/TS+ to HLHS/TS-, 100% versus 35% were female (P < .001), and median birth weight was 2140 g (IQR 1809-2650) versus 3196 g (IQR 2807-3540, P < .001). Neonatal mortality was 36% in HLHS/TS+ versus 27% in HLHS/TS- (log rank = 0.431). Ten of the 11 TS+ patients died during the study period for cumulative mortality of 91% versus 50% (hazard ratio (HR) for TS+: 2.90, 95% CI 1.53-5.48). Six patients died prior to surgery, 5 underwent Stage 1 palliation (S1P), 3 died after S1P, 2 survived past S2P, and one of these died at age 19 mo. The underlying cause of death was listed as congenital heart disease on all the death certificates of HLHS/TS+ patients. In multivariable analysis controlling for low birth weight (<2500 g), TS remained associated with significantly increased cumulative mortality, although females without TS had higher mortality than males (HR for TS+ versus males: 2.42, 95% CI 1.24-4.73; HR for TS- females versus males: 1.41, 95% CI 1.08-1.83). Conclusion:  TS with HLHS is associated with significant mortality. The increased mortality in females without documented TS calls to question if TS is undetected in a portion of females with HLHS.

Hodo CL, Goodwin CC, Mayes BC, Mariscal JA, Waldrup KA, Hamer SA. Trypanosome species, including Trypanosoma cruzi, in sylvatic and peridomestic bats of Texas, USA. Acta Trop. 2016 Sep 16. pii: S0001-706X(16)30308-4. doi: 10.1016/j.actatropica.2016.09.013. [Epub ahead of print]
In contrast to other mammalian reservoirs, many bat species migrate long-distances and have the potential to introduce exotic pathogens to new areas. Bats have long been associated with blood-borne protozoal trypanosomes of the Schizotrypanum subgenus, which includes the zoonotic parasite Trypanosoma cruzi, agent of Chagas disease. Another member of the subgenus, Trypanosoma dionisii, infects bats of Europe and South America, and genetic similarities between strains from the two continents suggest transcontinental movement of this parasite via bats. Despite the known presence of diverse trypanosomes in bats of Central and South America, and the presence of T. cruzi-infected vectors and wildlife in the US, the role of bats in maintaining and dispersing trypanosomes in the US has not yet been reported. We collected hearts and blood from 8 species of insectivorous bats from 30 counties across Texas. Using PCR and DNA sequencing, we tested 593 bats for trypanosomes and found 1 bat positive for T. cruzi (0.17%), 9 for T. dionisii (1.5%), and 5 for Blastocrithidia spp. (0.8%), a group of insect trypanosomes. The T. cruzi-infected bat was carrying TcI, the strain type associated with human disease in the US. In the T. dionisii-infected bats, we detected three unique variants associated with the three infected bat species. These findings represent the first report of T. cruzi in a bat in the US, of T. dionisii in North America, and of Blastocrithidia spp. in mammals, and underscore the importance of bats in the maintenance of trypanosomes, including agents of human and animal disease, across broad geographic locales.

Forrester MB. Comparison of single- and multiple-person mercury exposures. Arch Environ Occup Health 2016 [Epub ahead of print]
Problem: Elemental and organic mercury are extremely toxic. Method: All mercury exposures reported to Texas poison centers during 2000-2013 were identified. The cases were divided into multiple- and single-person exposure groups and compared, including identification of statistically significant differences (SSD). Results: There were 6,521 single-person exposures and 214 multiple-person incidents involving 734 total persons. 45% of the multiple- and 27% of the single-person exposures involved patients age 6-19 years (SSD). The multiple- and single-person exposures were, respectively, 87% vs 98% unintentional (SSD). The most frequent routes of multiple- and single-person exposures, respectively, involved ingestion (23% vs 72%, SSD), dermal (52% vs 23%, SSD), and inhalation (43% vs 5%, SSD). The most common sites for multiple- and single-person exposures, respectively, were the patient's own residence (56% vs 91%, SSD). Conclusions: Multiple-person mercury exposures are more likely to involve school-age children. A greater proportion of multiple-person exposures were intentional, involved dermal and inhalation routes, and occurred at school.

Jentes ES, Millman AJ, Decenteceo M, Gaul L, et al. Interagency and commercial collaboration during an investigation of Chikungunya and Dengue among returning travelers to the United States. Am J Trop Med Hyg. 2016 Sep 6. pii: 16-0298. [Epub ahead of print]
Public health investigations can require intensive collaboration between numerous governmental and nongovernmental organizations. We describe an investigation involving several governmental and nongovernmental partners that was successfully planned and performed in an organized, comprehensive, and timely manner with several governmental and nongovernmental partners.

Metzger K, Akram H, Feldt B, Stone K, Alvey S, Henley S, Hernandez A, Melville S, Haywood T, Zane D. Epidemiologic investigation of injuries associated with the 2013 fertilizer plant explosion in West, Texas. Disaster Med Public Health Prep. 2016 Aug;10(4):583-90
Objective: On April 17, 2013, a fire and subsequent explosion occurred at the West Fertilizer Company plant in West, Texas, and caused extensive damage to the adjacent neighborhood. This investigation described the fatal and nonfatal injuries caused by the explosion. Methods: Persons injured by the fertilizer plant explosion were identified through death certificates, medical examination reports, medical records, and survivor interviews. Data on patient characteristics, type of injury, and location of injury were collected. Results: Medical record review indicated that 252 individuals sought medical care for nonfatal injuries directly related to the explosion immediately after the explosion. Fifteen patients died of injuries sustained by the blast. Almost one-quarter of patients were admitted for treatment of injuries. Injuries sustained in the explosion included abrasions/contusions, lacerations/penetrating trauma, traumatic brain injuries/concussions, tinnitus/hearing problems, eye injuries, and inhalational injuries. Patients located closer to the explosion were more likely to be admitted to the hospital for treatment of injuries than were those who were located further away. Conclusion: Explosions of this magnitude are rare, but can inflict severe damage to a community and its residents. This investigation could be a useful planning resource for other communities, public health agencies, first responders, and medical facilities.

Agopian AJ, Hoang TT, Mitchell LE, Morrison AC, Tu D, Nassar N, Canfield MA. Maternal hypertension and risk for hypospadias in offspring. Am J Med Genet A. 2016 Aug 29. doi: 10.1002/ajmg.a.37947. [Epub ahead of print]
Hypospadias is one of the most common birth defects in male infants. Maternal hypertension is a suspected risk factor; however, few previous studies have addressed the possibility of reporting bias, and several previous studies have not accounted for hypospadias severity. We analyzed data from the Texas Birth Defects Registry for 10,924 nonsyndromic cases and statewide vital records for deliveries during 1999-2009, using Poisson regression. After adjustment for potential confounders, hypospadias was associated with maternal hypertension (adjusted prevalence ratio: 1.5, 95% confidence interval: 1.4-1.7). Similar associations were observed with gestational and pregestational hypertension, including separate analyses restricted to the subset of cases with severe (second- or third-degree) hypospadias. All of these associations were also similar among the subset of cases with isolated hypospadias (without additional birth defects). To evaluate the potential for bias due to potential hypertension misclassification, we repeated our analyses using logistic regression, comparing the cases to controls with other birth defects. In these analyses, the associations with gestational hypertension were similar, but adjusted associations with pregestational hypertension were no longer observed. Our findings support an association between gestational hypertension and hypospadias in offspring, but also suggest that previously observed associations with pregestational hypertension may have been inflated due to differential misclassification of hypertension (e.g., reporting bias). As gestational hypertension is recognized after hypospadias development, more research is needed to determine if this association reflects an increase in gestational hypertension risk secondary to hypospadias or if both conditions have shared risk factors (e.g., precursors of gestational hypertension).

Dazzi F, Shafer A, Lauriola M. Meta-analysis of the Brief Psychiatric Rating Scale - Expanded (BPRS-E) structure and arguments for a new version. J Psychiatr Res. 2016 Jul 4;81:140-151.
The factor structure of the 24 item BPRS-E was examined to determine the effect of additional items on consensus scales derived primarily from the 18 item BPRS. A meta-analysis (k = 32, n = 10,084) of previous factor analyses of the BPRS-E was conducted using both a co-occurrence similarity matrix and reproduced correlations. Components generally supporting the consensus scales were found suggesting four relatively invariant subscales: Affect (defined by the core items: anxiety, guilt, depression, suicidality), Positive Symptoms (hallucinations, unusual thought content, suspiciousness, grandiosity), Negative Symptoms (blunted affect, emotional withdrawal, motor retardation) and Activation (excitement, motor hyperactivity, elevated mood, distractibility). The additional BPRS-E items primarily contribute directly to a clear Activation dimension which expands and clarifies the traditional 18 item BPRS structure. Though not statistically supported in this meta-analysis, a fifth factor describing disorganization (conceptual disorganization, disorientation, self-neglect, mannerisms-posturing) was present in some analyses and should be considered. The five factor solution including a disorganization factor has theoretical validity based on the pentagonal model of schizophrenia while also containing the same four primary dimensions that were statistically supported in this meta-analysis. A new version of the BPRS (BPRS-26) with modified and additional items is presented. BPRS-26 is supposed to enhance the stability and the comprehensiveness of the scale and to more closely measure this five factor model.

Forrester MB. Xylazine exposures reported to Texas poison centers. J Emerg Med 2016 [Epub ahead of print]
Background: Xylazine is a sedative, analgesic, anesthetic, and central muscle relaxant approved for animals but not humans. Although xylazine is an emerging drug of abuse, there are limited data on potentially adverse exposures to the drug. Objectives: The intent of this study was to describe potentially adverse xylazine exposures reported to a large poison center system. Methods: All xylazine exposures reported to Texas poison centers between 2000 and 2014 were included. The distribution of cases by select variables was determined. Results: Of 76 total cases, 93% of the patients were ≥20 years of age, and 54% were male. Fifty-one percent of the exposures occurred by injection, 28% by ingestion, 16% were dermal, 14% were ocular, and 3% by inhalation. Sixty-four percent of the exposures were unintentional, 32% were intentional, and 1% each was related to malicious use and adverse reaction. Sixty-seven percent of the patients were already at or en route to a health care facility when the poison center was contacted, 21% were managed on-site, and 9% were referred to a health care facility. The most common clinical effects were drowsiness or lethargy (47%), bradycardia (20%), hypotension (11%), hypertension (9%), puncture or wound (8%), and slurred speech (8%). Conclusion: Xylazine exposures tended to involve patients who were adult males, exposures were typically unintentional; and most often occurred by injection. Most of the patients were already at or en route to a health care facility when a poison center was contacted. The most frequently reported adverse effects were cardiovascular or neurologic in nature.

Forrester MB. Human exposures to pentobarbital-phenytoin combination veterinary drugs. Hum Exp Toxicol 2016 [Epub ahead of print]
A combination of pentobarbital and phenytoin is used as a veterinary euthanasia drug. Because of its lethal effect, this study described pentobarbital phenytoin combination veterinary drug human exposures reported to Texas poison centers during 2000 2015. Of 66 exposures, 73% involved female and 27% male patients. The distribution by patient age was 3% 0-5 years, 5% 6 19 years, 91% 20+ years, and 2% unknown. The most common routes were ocular (41%), ingestion (32%), injection (23%), and dermal (18%). The exposure reasons were unintentional (77%) and intentional (23%). The exposure site was the workplace (52%), patient's own residence (38%), healthcare facility (2%), and other/unknown (9%). The management site was managed on site (48%), at/en route to healthcare facility (45%), referred to healthcare facility (5%), and other (2%). The medical outcomes was no effect (23%), minor effect (30%), moderate effect (8%), major effect (8%), not followed nontoxic (3%), not followed minimal effects (24%), unable to follow potentially toxic (2%), and unrelated (3%). The most common adverse effects were ocular irritation/pain (18%), drowsiness/lethargy (15%), and coma (9%). The most common treatments were dilution/irrigation (70%), IV fluids (21%), and oxygen (14%). This study found few pentobarbital phenytoin combination veterinary drug exposures were reported to Texas poison centers during a 16-year period. Although meant to be administered intravenously, the most common exposure routes were ocular and ingestion. Many of the exposures appeared to be unintentional and occurred at the workplace.

Hoyt AT, Canfield MA, Romitti PA, Botto LD , Anderka MT, Krikov SV, Tarpey MK, Feldkamp ML. Associations between maternal periconceptional exposure to secondhand tobacco smoke and major birth defects. Am J Obstet Gynecol. 2016 Jul 18. pii: S0002-9378(16)30456-2. doi: 10.1016/j.ajog.2016.07.022. [Epub ahead of print]
Background: While associations between secondhand smoke and a few birth defects (namely, oral clefts and neural tube defects) have been noted in the scientific literature, to our knowledge, there is no single or comprehensive source of population-based information on its associations with a range of birth defects among non-smoking mothers. Objective: We utilized data from the National Birth Defects Prevention Study, a large population-based multi-site case-control study, to examine associations between maternal reports of periconceptional exposure to secondhand smoke in the household or workplace/school and major birth defects. Study Design: The multi-site National Birth Defects Prevention Study is the largest case-control study of birth defects to date in the United States. We selected cases from birth defect groups having more than 100 total cases, as well as all non-malformed controls (10,200), from delivery years 1997-2009; 44 birth defects were examined. After excluding cases and controls from multiple births and whose mothers reported active smoking or pre-gestational diabetes, we analyzed data on periconceptional secondhand smoke exposure-encompassing the period one month prior to conception through the first trimester. For the birth defect craniosynostosis, we additionally examined the effect of exposure in the second and third trimesters as well due to the potential sensitivity to teratogens for this defect throughout pregnancy. Covariates included in all final models of birth defects with ≥5 exposed mothers were study site, previous live births, time between estimated date of delivery and interview date, maternal age at estimated date of delivery, race/ethnicity, education, body mass index, nativity, household income divided by number of people supported by this income, periconceptional alcohol consumption and folic acid supplementation. For each birth defect examined, we used logistic regression analyses to estimate both crude and adjusted odds ratios and 95% confidence intervals for both isolated and total case groups for various sources of exposure (household only; workplace/school only; household and workplace/school; household or workplace/school). Results: The prevalence of secondhand smoke exposure only across all sources ranged from 12.9-27.8% for cases and 14.5-15.8% for controls. The adjusted odds ratios for any vs. no secondhand smoke exposure in the household or workplace/school and isolated birth defects were significantly elevated for neural tube defects (anencephaly: adjusted odds ratios=1.66, 95% confidence interval=1.22-2.25; spina bifida: 1.49, 1.20-1.86); orofacial clefts (cleft lip without cleft palate: 1.41, 1.10-1.81; cleft lip with or without cleft palate: 1.24, 1.05-1.46; cleft palate alone: 1.31, 1.06-1.63); bilateral renal agenesis (1.99, 1.05-3.75); amniotic band syndrome-limb body wall complex (1.66, 1.10-2.51); and atrial septal defects, secundum (1.37, 1.09-1.72). There were no significant inverse associations observed. Conclusion: Additional studies replicating the findings are needed to better understand the moderate positive associations observed between periconceptional secondhand smoke and several birth defects in this analysis. Increased odds ratios resulting from chance (e,g., multiple comparisons) or recall bias cannot be ruled out.

Dennis NM, Dennis PA, Shafer A, Weiner RD, Husain MM. Electroconvulsive therapy and all-cause mortality in Texas, 1998-2013. J ECT. 2016 Jul 16. [Epub ahead of print]
Introduction: Electroconvulsive therapy (ECT) remains an effective treatment for major depressive disorder. Since 1995, Texas has maintained an ECT database including patient diagnoses and outcomes, and reporting any deaths within 14 days of receiving an ECT treatment, encompassing a total of 166,711 ECT treatments administered in Texas over the previously unreported period of 1998 to 2013. Methods: Descriptive analysis summarized information on deaths reported during the 16-year period-cause of death, type of treatment (index or maintenance) and patient demographics. Multiple logistic regression of death incidence by treatment session was performed to determine whether patient age, sex, race, diagnosis, or year of treatment was associated with death after ECT. Results: Of those deaths occurring within 1 day of an ECT treatment, the death rate was 2.4 per 100,000 treatments. Looking at all deaths within 14 days of an ECT treatment, the death rate increased to 18 per 100,000 treatments but included all deaths regardless of likelihood of causal association with ECT, for example, accidents and suicides, the latter a leading cause of death among individuals with severe major depression or other disorders for which ECT is indicated. Death rate increased significantly with increasing patient age (P = 0.001) and male sex (P = 0.009), and there was a nonsignificant trend toward increased death amongst patients with bipolar disorder or schizophrenia (P = 0.058) versus depression. Conclusions: Our data indicate that ECT is in general a safe procedure with respect to the likelihood of immediate death. Suicide remains a significant risk in ECT patients, despite evidence that ECT reduces suicidal ideation.

Forrester MB. Pediatric ingestions of lidocaine products. TX Public Health J 2016;68(3):4.
No abstract available.
 
Forrester MB. Impact of "pill mill" legislation on prescription opioid analgesic exposures reported to Texas poison centers. TX Public Health J 2016;68(3):5-6.
No abstract available.

McLellan D. Public health resources: Zika virus index. TX Public Health J 2016;68(3):7-9.

Kim J, Langlois PH, Herdt-Losavio ML, Agopian AJ. A case-control study of maternal occupation and the risk of orofacial clefts. J Occup Environ Med. 2016 Jul 12. [Epub ahead of print]
Objectives: The aim of this study was to examine the association between maternal occupation and risk of orofacial clefts in offspring. Methods: Data were obtained from the Texas Birth Defects Registry and vital records for 1999 to 2009 deliveries. We used automated software to assist in classifying occupations into standard codes. Using multivariable logistic regression, the risk for cleft lip with or without cleft palate (CLP) or cleft palate only (CP) in offspring was compared between women in each of 20 major occupation groups to women in every other occupation group. Results: Significant positive associations were observed between business/finance and architecture/engineering occupations and CP and between cleaning-related occupations and CLP. A significant negative association was observed between office and administrative support occupations and CLP. Conclusions: This study supports previous reports of increased risk of orofacial clefts in offspring among women in certain occupations.

Trueblood AB, Forrester MB, Han D, Shipp EM, Cizmas LH. Pesticide-related poison center exposures in children and adolescents aged ≤19 years in Texas, 2000-2013. Clin Toxicol (Phila) 2016 [Epub ahead of print] To 2016;54:852-856.
Context: Although national poison center data show that pesticides were the 8th most commonly reported substance category (3.27%) for children aged ≤5 years in 2014, there is limited information on childhood and adolescent pesticide exposures. Objective: This study assessed pesticide-related poison center exposures in children and adolescents aged ≤19 years from 2000–2013 in Texas to characterize the potential burden of pesticides. Materials and Methods: Pesticide-related poison center exposures among children and adolescents aged ≤19 years reported to Texas poison centers were identified. The distribution of exposures was estimated by gender, age category, medical outcome, management site, exposure route, and pesticide category. Results: From 2000 to 2013, there were 61,147 pesticide-related poison center exposures in children and adolescents aged ≤19 years. The prevalence was highest among males at 864.24 per 100,000 population. The prevalence of unintentional exposures was highest among children aged ≤5 years at 2310.69 per 100,000 population, whereas the prevalence of intentional exposures was highest among adolescents aged 13–19 years at 13.82 per 100,000 population. A majority of medical outcomes reported were classified as having no effect (30.24%) and not followed, but minimal clinical effects possible (42.74%). Of all the exposures, 81.24% were managed on site. However, 57% of intentional exposures were referred to or treated at a health-care facility. The most common routes of exposure were ingestion (80.83%) and dermal (17.21%). The most common pesticide categories included rodenticides (30.02%), pyrethrins/pyrethroids (20.69%), and other and unspecified insecticides (18.14%). Discussion: The study found differences in the frequency of exposures by intent for sex and age categories, and identified the most common medical outcomes, management site, exposure route, and pesticide category. Conclusion: Through characterizing pesticide-related poison center exposures, future interventions can be designed to address groups with higher prevalence of exposure.

Nogueira LM, Thai CL, Nelson W, Oh A. Nutrition label numeracy: disparities and association with health behaviors. Am J Health Behav. 2016 Jul;40(4):427-36.
Objective:  We investigated the relative importance of nutrition label numeracy and sociodemographic characteristics in predicting health behaviors. Methods:  Secondary data analysis of data collected from the National Cancer Institute's Health Information National Trends Survey (HINTS 4, cycle 3, 2013). Weighted age-adjusted ordinal logistical regression was used to evaluate sociodemographic characteristics among individuals with different nutrition label numeracy levels. Dominance analysis was conducted to rank nutrition label numeracy and sociodemographic characteristics in order of importance as predictors of health behavior. Results: Lower levels of nutrition label numeracy were associated with older age, black and Hispanic race/ethnicity, unemployment, being born outside of the United States, lower English proficiency, lower education achievement, lower income, and living in the South. Nutrition label numeracy and income were the most important predictors of health behaviors, accounting for about 50% of the variance in fruit consumption and level of effort, frustration, concern, and confusion experienced while seeking health information. Conclusions: Nutrition label numeracy differed significantly among sociodemographic groups and was a strong predictor of health behaviors. When developing health interventions targeting dietary behaviors, disparities in nutrition label numeracy comprehension should be considered.

Eshofonie AO, Lin H, Valcin RP, Irvin D, Goss K, Piper J. Challenges in investigating a Salmonellosis outbreak in a correctional facility. J Correct Health Care. 2016 Jul;22(3):200-5.
Timely reporting of disease outbreak and access to the outbreak site are necessary for prompt investigation and control. Local health departments (LHDs) establish the reporting time frames, methods, and communication channels within their jurisdictions in advance. This report describes a salmonellosis outbreak investigation in a federal correctional center (FCC) that was delayed due to issues with jurisdictional ownership and with separate reporting protocols for the FCC. The setting of the outbreak within an FCC posed additional unique challenges to the outbreak investigation. These challenges resulted in the outbreak response being delayed by 6 days and inconclusive investigation. It is recommended that LHDs and FCCs work together to create an advance protocol for improved public health coordination, oversight, and response. 

Kemper AR, Brosco J, Comeau AM, Tanksley S, et al. Newborn screening for X-linked adrenoleukodystrophy: evidence summary and advisory committee recommendation. Genet Med. 2016 Jun 23. doi: 10.1038/gim.2016.68. [Epub ahead of print]
The secretary of the US Department of Health and Human Services in February 2016 recommended that X-linked adrenoleukodystrophy (X-ALD) be added to the recommended uniform screening panel for state newborn screening programs. This decision was informed by data presented on the accuracy of screening from New York, the only state that currently offers X-ALD newborn screening, and published and unpublished data showing health benefits of earlier treatment (hematopoietic stem cell transplantation and adrenal hormone replacement therapy) for the childhood cerebral form of X-ALD. X-ALD newborn screening also identifies individuals with later-onset disease, but poor genotype-phenotype correlation makes predicting health outcomes difficult and might increase the risk of unnecessary treatment. Few data are available regarding the harms of screening and presymptomatic identification. Significant challenges exist for implementing comprehensive X-ALD newborn screening, including incorporation of the test, coordinating follow-up diagnostic and treatment care, and coordination of extended family testing after case identification.

Lara DA, Fixler DE, Ethen MK, Canfield MA, Nembhard WN, Morris SA. Prenatal diagnosis, hospital characteristics, and mortality in transposition of the great arteries. Birth Defects Res A Clin Mol Teratol. 2016 Jun 14. doi: 10.1002/bdra.23525. [Epub ahead of print]
Background: The role of prenatal diagnosis in reducing neonatal mortality from transposition of the great arteries (TGA) is controversial. Factors affected by prenatal diagnosis such as proximity at birth to a cardiac surgical center (CSC) and CSC volume are associated with mortality in congenital heart disease. The purpose of the study was to determine the associations between prenatal diagnosis, distance from birthplace to a CSC, CSC TGA volume, and neonatal mortality in patients with TGA. Methods:  The Texas Birth Defects Registry was queried for all live born infants with TGA from 1999 to 2007. Four hundred sixty-eight cases of TGA were included. Results:  Forty-eight patients (10.3%) were prenatally diagnosed, and 20 patients died before age 28 days (4.3%). Neither prenatal diagnosis nor close proximity to a CSC at birth (p > 0.05) were associated with decreased mortality. Low CSC TGA volume was associated with increased mortality (p < 0.0002). Mortality at the CSCs with <5 patients per year was 9.6%; CSCs with 5 to 10 patients per year had 0% mortality, and those with >10 patients per year had 2.3% mortality. In multivariable logistic regression, only preterm birth (odds ratio, 7.05; 95% confidence interval, 4.13-12.05) and lower CSC volume (p < 0.001) were associated with neonatal mortality, although prenatal diagnosis attenuated the detrimental association of lower volume CSCs with higher mortality (p for interaction = 0.047). Conclusion:  Lower CSC TGA patient volume was associated with higher neonatal mortality. Prenatal diagnosis may improve survival in lower volume CSCs.

Forrester MB. Pediatric exposures to Bombina toads reported to poison centers. Pediatr Emerg Care 2016 May 12 [Epub ahead of print]
OBJECTIVES: Fire-bellied toads (genus Bombina) secrete toxins from their skin that may cause problems to humans, particularly if they get in the eye. This study aimed to describe pediatric exposures to fire-bellied toads reported to a large poison center system. METHODS: Cases were fire-bellied toad exposures among patients aged 13 years or younger reported to Texas poison centers during 2000-2014. The distribution by various demographic and clinical factors was determined. RESULTS: Of 20 total exposures, the mean patient age was 5.8 years (range, 2-13 years); 70% of the patients were boys. The exposure route was ocular (70%), dermal (55%), and ingestion (20%). Eighty-five percent of the exposures occurred at the patient's own residence. Sixty percent of the patients were managed onsite, and 40% were already at or en route to a health care facility. The medical outcome was as follows: minor effects (45%), moderate effects (5%), and not followed but judged to have minimal clinical effects (50%). The most common reported symptoms were ocular irritation/pain (65%), dermal irritation/pain (30%), and red eye (20%). Decontamination by dilution/irrigation/wash was reported in 95% of the patients. CONCLUSIONS: Few pediatric exposures to fire-bellied toads were reported. Those that were reported were most likely to involve ocular followed by dermal routes. The exposures tended not to be serious and could be managed outside of a health care facility.

Gong X, Zhan FB, Brender JD, Langlois PH, Lin Y. Validity of the Emission Weighted Proximity Model in estimating air pollution exposure intensities in large geographic areas. Sci Total Environ. 2016 May 3;563-564:478-485.
Background: Accurate estimates of air pollution exposure intensities are important to support environmental epidemiology analyses that require data covering large geographic areas over multiple years. The Emission Weighted Proximity Model (EWPM) and the National-Scale Air Toxics Assessment (NATA) are two viable approaches for obtaining estimate exposure intensities. The advantages of the EWPM include its simplicity and significantly lower costs of implementation. However, very limited data are available regarding the validity of the results from the EWPM and how these results would fare when compared with those from the NATA. Methods: This study evaluates the validity of the estimated exposure intensities from the EWPM through a correlation analysis with ground monitoring data obtained by the Texas Commission on Environmental Quality (TCEQ). The monitoring data used in the comparison included 27 non-criteria air pollutants at 48 monitoring sites in Texas in 2005. In addition, this study compares the results from the EWPM with those from NATA using the TCEQ data as a gold standard. Results: Analysis results suggest that estimated exposure intensities from the EWPM and the NATA were comparable when the intensities from both approaches are used to categorize environmental exposure intensities into different levels in relative terms. Conclusion:  These findings suggest that the EWPM is a valid alternative approach to the NATA in situations where epidemiological analysis requires both environmental data and health outcome data that cover a large geographic area over multiple years.

Forrester MB. Scorpion stings in the workplace. TX Public Health J 2016;68(2):4-5.
No abstract available.

Forrester MB. Wisteria is not just a lane desperate housewives live on. TX Public Health J 2016;68(2):5-6. 
No abstract available.

Sontag MK, Lee R, Wright D, Freedenberg D, Sagel SD. Improving the sensitivity and positive predictive value in a cystic fibrosis newborn screening program using a repeat immunoreactive trypsinogen and genetic analysis. J Pediatr. 2016 Apr 27. pii: S0022-3476(16)00427-3. doi: 10.1016/j.jpeds.2016.03.046. [Epub ahead of print]
Objective: To evaluate the performance of a new cystic fibrosis (CF) newborn screening algorithm, comprised of immunoreactive trypsinogen (IRT) in first (24-48 hours of life) and second (7-14 days of life) dried blood spot plus DNA on second dried blood spot, over existing algorithms. Study Design:  A retrospective review of the IRT/IRT/DNA algorithm implemented in Colorado, Wyoming, and Texas. Results: A total of 1 520 079 newborns were screened, 32 557 (2.1%) had abnormal first IRT; 8794 (0.54%) on second. Furthermore, 14 653 mutation analyses were performed; 1391 newborns were referred for diagnostic testing; 274 newborns were diagnosed; and 201/274 (73%) of newborns had 2 mutations on the newborn screening CFTR panel. Sensitivity was 96.2%, compared with sensitivity of 76.1% observed with IRT/IRT (105 ng/mL cut-offs, P < .0001). The ratio of newborns with CF to heterozygote carriers was 1:2.5, and newborns with CF to newborns with CFTR-related metabolic syndrome was 10.8:1. The overall positive predictive value was 20%. The median age of diagnosis was 28, 30, and 39.5 days in the 3 states. Conclusions:  IRT/IRT/DNA is more sensitive than IRT/IRT because of lower cut-offs (∼97 percentile or 60 ng/mL); higher cut-offs in IRT/IRT programs (>99 percentile, 105 ng/mL) would not achieve sufficient sensitivity. Carrier identification and identification of newborns with CFTR-related metabolic syndrome is less common in IRT/IRT/DNA compared with IRT/DNA. The time to diagnosis is nominally longer, but diagnosis can be achieved in the neonatal period and opportunities to further improve timeliness have been enacted. IRT/IRT/DNA algorithm should be considered by programs with 2 routine screens.

Gorchakov R, Trosclair LP, Wozniak EJ, et al. Trypanosoma cruzi infection prevalence and bloodmeal analysis in triatomine vectors of Chagas disease from rural peridomestic locations in Texas, 2013-2014. J Med Entomol. 2016 Apr 22. pii: tjw040. [Epub ahead of print]
Protozoan pathogen Trypanosoma cruzi (Chagas, 1909) is the etiologic agent of Chagas disease, which affects millions of people in Latin America. Recently, the disease has been gaining attention in Texas and the southern United States. Transmission cycle of the parasite involves alternating infection between insect vectors and vertebrate hosts (including humans, wildlife, and domestic animals). To evaluate vector T. cruzi parasite burden and feeding patterns, we tested triatomine vectors from 23 central, southern, and northeastern counties of Texas. Out of the 68 submitted specimens, the majority were genetically identified as Triatoma gerstaeckeri (Stal, 1859), with a few samples of Triatoma sanguisuga (LeConte, 1855), Triatoma lecticularia (Stal, 1859), Triatoma rubida (Uhler, 1894), and Triatoma protracta woodi (Usinger, 1939). We found almost two-thirds of the submitted insects were polymerase chain reaction-positive for T. cruzi Bloodmeal sources were determined for most of the insects, and 16 different species of mammals were identified as hosts. The most prevalent type of bloodmeal was human, with over half of these insects found to be positive for T. cruzi High infection rate of the triatomine vectors combined with high incidence of feeding on humans highlight the importance of Chagas disease surveillance in Texas. With our previous findings of autochthonous transmission of Chagas disease, urgent measures are needed to increase public awareness, vector control in and around homes, and Chagas screening of residents who present with a history of a triatomine exposure.

Yanik E, Nogueira LM, Koch L, et al. Comparison of cancer diagnoses between the US solid organ transplant registry and linked central cancer registries. Am J Transplant. 2016 Apr 7. doi: 10.1111/ajt.13818. [Epub ahead of print]
US transplant centers are required to report cancers in transplant recipients to the transplant network. The accuracy and completeness of these data, collected in the Scientific Registry of Transplant Recipients (SRTR), are unknown. We compared diagnoses in the SRTR and 15 linked cancer registries, for colorectal, liver, lung, breast, prostate, and kidney cancers, melanoma, and non-Hodgkin lymphoma (NHL). Among 187,384 transplants, 9323 cancers were documented in the SRTR or cancer registries. Only 36.8% of cancers were in both, with 47.5% and 15.7% of cases additionally documented solely in cancer registries or the SRTR, respectively. Agreement between the SRTR and cancer registries varied (kappa: 0.28 for liver cancer, 0.52-0.66 for lung, prostate, kidney, colorectum and breast cancers). Upon evaluation, some NHLs documented only in cancer registries were identified in the SRTR as another type of post-transplant lymphoproliferative disorder. Some SRTR-only cases were explained by miscoding (colorectal cancer instead of anal cancer, metastases as lung or liver cancers) or missed matches with cancer registries, partly due to out-migration from their catchment areas. Estimated sensitivity for identifying cancer was 52.5% for the SRTR and 84.3% for cancer registries. In conclusion, SRTR cancer data are substantially incomplete, limiting their usefulness for surveillance and research. 

Kirsch KR, Feldt BA, Zane DF, Haywood T, Jones RW, Horney JA. Longitudinal community assessment for public health emergency response to wildfire, Bastrop County, Texas. Health Secur. 2016 Mar-Apr;14(2):93-104.
On September 4, 2011, a wildfire ignited in Bastrop County, Texas, resulting in losses of 34,068 acres of land and 1,645 homes and 2 deaths. At the request of the Texas Department of State Health Services Health Service Region 7 and the Bastrop County Office of Emergency Management, Community Assessments for Public Health Emergency Response (CASPER) were conducted in the weeks following the wildfire and again 3.5 years later to assess both the immediate and long-term public health and preparedness impacts of the wildfire. The objective of these assessments was to learn more about the trajectory of disaster recovery, including rebuilding, evacuation, household emergency planning, and mental and physical health outcomes among both adults and children. In 2015, households exposed to the 2011 wildfires were significantly more likely to have established a family meeting place and evacuation route, to have confidence in the local government's ability to respond to disaster, and to report symptoms of depression and higher stress. Longitudinal assessments using the CASPER method can provide actionable information for improved planning, preparedness, and recovery to public health and emergency management agencies and community residents.

Shiels MS, Pfeiffer RM, Besson C, Nogueira L, et al.  Trends in primary central nervous system lymphoma incidence and survival in the U.S. Br J Haematol. 2016 Mar 28. doi: 10.1111/bjh.14073. [Epub ahead of print]
It is suspected that primary central nervous system lymphoma (PCNSL) rates are increasing among immunocompetent people. We estimated PCNSL trends in incidence and survival among immunocompetent persons by excluding cases among human immunodeficiency virus (HIV)-infected persons and transplant recipients. PCNSL data were derived from 10 Surveillance, Epidemiology and End Results (SEER) cancer registries (1992-2011). HIV-infected cases had reported HIV infection or death due to HIV. Transplant recipient cases were estimated from the Transplant Cancer Match Study. We estimated PCNSL trends overall and among immunocompetent individuals, and survival by HIV status. A total of 4158 PCNSLs were diagnosed (36% HIV-infected; 0·9% transplant recipients). HIV prevalence in PCNSL cases declined from 64·1% (1992-1996) to 12·7% (2007-2011), while the prevalence of transplant recipients remained low. General population PCNSL rates were strongly influenced by immunosuppressed cases, particularly in 20-39 year-old men. Among immunocompetent people, PCNSL rates in men and women aged 65+ years increased significantly (1·7% and 1·6%/year), but remained stable in other age groups. Five-year survival was poor, particularly among HIV-infected cases (9·0%). Among HIV-uninfected cases, 5-year survival increased from 19·1% (1992-1994) to 30·1% (2004-2006). In summary, PCNSL rates have increased among immunocompetent elderly adults, but not in younger individuals. Survival remains poor for both HIV-infected and HIV-uninfected PCNSL patients.

Lim H, Beasley CW, Whitehead LW, Langlois PH, et al. Maternal exposure to radiographic exams and major structural birth defects. Birth Defects Res A Clin Mol Teratol. 2016 Mar 22. doi: 10.1002/bdra.23496. [Epub ahead of print]
Background: An increasing number of radiologic exams are performed in the United States, but very few studies have examined the effects of maternal exposure to radiologic exams during the periconceptional period and birth defects. Objectives: To assess the association between maternal exposure to radiologic exams during the periconceptional period and 19 categories of birth defects using a large population-based study of birth defects. Methods: We studied 27,809 case mothers and 10,200 control mothers who participated in the National Birth Defects Prevention Study and delivered between 1997 and 2009. Maternal exposure to radiologic exams that delivered ionizing radiation to the urinary tract, lumbar spine, abdomen, or pelvis were identified based on the mother's report of type of radiologic exams, organ or body part scanned and the month during which the exam occurred RESULTS: Overall, 0.9% of mothers reported exposure to one of these types of radiographic exams during the periconceptional period. We observed significant associations between maternal exposure during the first trimester and isolated Dandy-Walker malformation (odds ratio = 7.7; 95% confidence interval, 1.8-33) and isolated d-transposition of the great arteries (odds ratio = 3.8; 95% confidence interval, 1.4-10.3). However, the result for isolated Dandy-Walker malformation was based on only two exposed cases. Conclusion: These results should be interpreted cautiously because multiple statistical tests were conducted and measurements of exposure were based on maternal report. However, our results may be useful for generating hypotheses for future studies.

Walters MS, Simmons L, Anderson TC, Borders J, et al. Outbreaks of Salmonellosis from small turtles. Pediatrics. 2016 Jan;137(1). doi: 10.1542/peds.2015-1735. Epub 2015 Dec 24.
Objective:  Turtle-associated salmonellosis (TAS), especially in children, is a reemerging public health issue. In 1975, small pet turtles (shell length <4 inches) sales were banned by federal law; reductions in pediatric TAS followed. Since 2006, the number of multistate TAS outbreaks has increased. We describe 8 multistate outbreaks with illness-onset dates occurring in 2011-2013. Methods:  We conducted epidemiologic, environmental, and traceback investigations. Cases were defined as infection with ≥ 1 of 10 molecular subtypes of Salmonella Sandiego, Pomona, Poona, Typhimurium, and I 4,[5],12:i:-. Water samples from turtle habitats linked to human illnesses were cultured for Salmonella. Results:  We identified 8 outbreaks totaling 473 cases from 41 states, Washington DC, and Puerto Rico with illness onsets during May 2011-September 2013. The median patient age was 4 years (range: 1 month-94 years); 45% percent were Hispanic; and 28% were hospitalized. In the week preceding illness, 68% (187 of 273) of case-patients reported turtle exposure; among these, 88% (124 of 141) described small turtles. Outbreak strains were isolated from turtle habitats linked to human illnesses in seven outbreaks. Traceback investigations identified 2 Louisiana turtle farms as the source of small turtles linked to 1 outbreak; 1 outbreak strain was isolated from turtle pond water from 1 turtle farm. Conclusions:  Eight multistate outbreaks associated with small turtles were investigated during 2011-2013. Children <5 years and Hispanics were disproportionately affected. Prevention efforts should focus on patient education targeting families with young children and Hispanics and enactment of state and local regulations to complement federal sales restrictions.

Marks SM, Hirsch-Moverman Y, Salcedo K, Seaworth B, et al. Characteristics and costs of multidrug-resistant tuberculosis in-patient care in the United States, 2005-2007. Int J Tuberc Lung Dis. 2016 Apr;20(4):435-41.
Objective: A population-based study of 135 multidrug-resistant tuberculosis (MDR-TB) patients reported to the Centers for Disease Control and Prevention (CDC) during 2005-2007 found 73% were hospitalized. We analyzed factors associated with hospitalization. Methods: We assessed statistically significant multivariable associations with US in-patient TB diagnosis, frequency of hospitalization, length of hospital stay, and in-patient direct costs to the health care system. Results: Of 98 hospitalized patients, 83 (85%) were foreign-born. Blacks, diabetics, or smokers were more likely, and patients with disseminated disease less likely, to receive their TB diagnosis while hospitalized. Patients aged ⩾65 years, those with the acquired immune-deficiency syndrome (AIDS), or with private insurance, were hospitalized more frequently. Excluding deaths, length of stay was greater for patients aged ⩾65 years, those with extensively drug-resistant TB (XDR-TB), those residing in Texas, those with AIDS, those who were unemployed, or those who had TB resistant to all first-line medications vs. others. Average hospitalization cost per XDR-TB patient (US$285 000) was 3.5 times that per MDR-TB patient (US$81 000), in 2010 dollars.

Vosvick M, Fritz S, Henry D, Prybutok V, Sheu S, Poe J. Correlates and racial/ethnic differences in bareback sex among men who have sex with men with unknown or negative HIV serostatus. AIDS Behav. 2016 Mar 16. [Epub ahead of print]
Men who have sex with men (MSM), particularly racial/ethnic minority MSM, are disproportionately affected by HIV in the United States and Texas. Bareback sex or condomless anal intercourse (CAI) can be a high HIV risk behavior. Despite this, a majority of MSM continues to engage in barebacking. Research suggests racial/ethnic differences in barebacking exist; however, these conclusions remain unclear due to insufficient sample sizes to compare racial/ethnic groups. Our cross-sectional correlational design explores barebacking correlates (substance use during sex, safe sex fatigue, and optimistic HIV treatment beliefs) within and between racial/ethnic groups among 366 MSM. Regression models are significant for Latino and African-American MSM alone and for all MSM combined, though not significant for European-American and Other Race/Ethnicity MSM alone. Our findings suggest motivations and behaviors underlying barebacking among MSM vary by racial/ethnic membership with clinical implications for informing culturally sensitive HIV interventions and prevention programs for target racial/ethnic groups.

Haynes A, Kleinschmidt K, Forrester MB, Young A. Trends in analgesic exposures reported to Texas poison centers following increased regulation of hydrocodone. Clin Toxicol (Phila) 2016 [Epub ahead of print]
Context: In October 2014, the Drug Enforcement Administration reclassified hydrocodone to schedule II, increasing regulations on use. The impact of rescheduling hydrocodone on opioid exposures is unclear, especially in states with special restrictions required for prescribing schedule II agents. Objective: To assess whether changes in exposures to prescription opioid analgesics and heroin as reported to poison centers occurred in the 6 months after hydrocodone rescheduling. We hypothesized that hydrocodone exposures would decrease, while less tightly regulated opioids, such as codeine and tramadol, would increase. Materials and Methods: This study compares opioid analgesic exposures reported to Texas Poison Centers before and after this change in a state that requires special prescription pads for Schedule II agents. Cases included all opioid analgesic exposures reported to a statewide poison center network, comparing exposures from 6 months before to 6 months after heightened regulations. Specific opioids with large changes in reported exposures were further characterized by patient age and exposure intent. Results: Hydrocodone exposures decreased from 1567 to 1135 (28%, p = 0.00017), decreasing for all ages. Codeine exposures increased significantly from 189 to 522 (176%, p = 0.00014), including a 263% increase for age >20 years. Codeine misuse increased 443% and adverse drug events 327%. Oxycodone exposures increased from 134 to 189 (39%, p = 0.0143), increasing only among patients age >20 years. Reported heroin exposures increased from 156 to 179 (15%, p = 0.2286) and tramadol from 666 to 708 (6%, p = 0.0193). Other opioid exposures changed little or had limited reports. Discussion: The increased regulation of hydrocodone was followed temporally by a decrease in reported hydrocodone exposures, but also increases in codeine, oxycodone and tramadol exposures. This may reflect a shift in prescribing practices, changes in street availability of hydrocodone or decreased drug diversion. Conclusion: The increased regulation was temporally associated with decreased hydrocodone exposures reported to Texas Poison Centers.

Zane DF, Haywood T, Adams B, et al. Lessons learned from the field: community assessment for public health emergency response. TX Public Health J 2016;68(1):6-13.
The Community Assessment for Public Health Emergency Response (CASPER) is a tool created for rapidly assessing public health threats and needs. CASPERs can be conducted in both disaster and non-disaster settings. It can provide situational awareness to public health and emergency management officials to strengthen disaster response and recovery, assist with public health preparedness planning efforts, and identify routine public health issues. Since 2001, Texas has ranked second in the nation in the number of CASPERs conducted. Multiple local health departments and the Texas Department of State Health Services have conducted CASPERS in their jurisdictions. We were interested in identifying and sharing lessons learned in conducting CASPERs.

Day L, Kleinschmidt K, Forrester MB, Feng SY. Comparison of unintentional exposures to codeine and hydrocodone reported to Texas poison centers. J Emerg Med 2016;50:744-752. [Epub ahead of print]
BACKGROUND: Hydrocodone has recently been reclassified as a Schedule II drug by the United States Drug Enforcement Administration and Food and Drug Administration in order to curtail prescription drug abuse. There is concern that analgesic substitutes, such as codeine, will not be as safe or effective. OBJECTIVE: The purpose of this study is to compare the demographics, adverse events, and medical outcomes of patients who had unintentional hydrocodone or codeine exposures through the use of a state's poison center database. METHODS: The Texas Poison Center Network's database was utilized to find all reported unintentional ingestions or adverse reactions of products containing codeine or hydrocodone. Comparisons were made between the two medications by calculating the rate ratios (RR) and 95% confidence intervals (CI). RESULTS: Children aged 5 years or younger were more exposed to codeine (51.6%). Hydrocodone exposures had more serious outcomes (11% vs. 9%; RR = 0.82; 95% CI 0.73-0.91) and had more nausea (7.1% vs. 2.8%; RR = 0.4; 95% CI 0.32-0.48) and vomiting (6.5% vs. 3.3%; RR = 0.51; 95% CI 0.43-0.62). Hydrocodone had a higher rate of intravenous fluids administration (2.4% vs. 1.7%; RR = 0.71; 95% CI 0.54-0.92) and antiemetics (0.4% vs. 0.1%; RR = 0.23; 95% CI 0.08-0.64). Codeine was more closely associated with dermal reactions and patients were given antihistamines (2.5% vs. 1.3%; RR = 1.88; 95% CI 1.46-2.41) more frequently. Cardiovascular side effects, ataxia, and headache occurred equally between the groups. CONCLUSIONS: Both drugs had a wide array of reported side effects, but the overall incidence of serious outcomes was low.

Socias C, Liang Y, Delclos G, Graves J, Hendrikson E, Cooper S. The feasibility of using electronic health records to describe demographic and clinical indicators of migrant and seasonal farmworkers. J Agromedicine. 2016;21(1):71-81.
Few extensive, national clinical databases exist on the health of migrant and seasonal farmworkers (MSFWs). Electronic health records (EHRs) are increasingly utilized by Federally Qualified Health Centers (FQHCs) and have the potential to improve clinical care and complement current surveillance and epidemiologic studies of underserved working populations, such as MSFWs. The aim of this feasibility study was to describe the demographics and baseline clinical indicators of patients at an FQHC by MSFW status. The authors described 2012 patient demographics, social history, medical indicators, and diagnoses by MSFW status from the de-identified EHR database of a large, multisite Colorado Migrant Health Center (MHC). Included in the study were 41,817 patients from 2012: 553 (1.3%) MSFWs, 20,665 (49.4%) non-MSFWs, and 20,599 (49.3%) who had no information in the MSFW field. MSFWs were more often male, married, employed, Hispanic, and Spanish-speaking compared with non-MSFWs. The most frequent diagnoses for all patients were hypertension, overweight/obesity, lipid disorder, type 2 diabetes, or a back disorder. Although there were significant missing values, this feasibility study was able to analyze medical data in a timely manner and show that Meaningful Use requirements can improve the usability of EHR data for epidemiologic research of MSFWs and other patients at FQHCs. The results of this study were consistent with current literature available for MSFWs. By reaching this vulnerable working population, EHRs may be a key data source for occupational injury and illness surveillance and research.

Forrester MB. Pattern of mefloquine ingestions reported to Texas poison centers. J Pharm Technol 2016;32:60-64.
Background. Mefloquine is an antimalarial drug available in the United States that in 2013 was given a black box warning about the potential for neurologic and psychiatric adverse effects. Objective. This study describes mefloquine ingestions reported to a large statewide poison center system. Methods. The distribution of all mefloquine ingestions reported to Texas poison centers during 2010 to 2014 was determined for dose, year, patient age and gender, exposure site, ingestion reason, management site, medical outcome, clinical effects, and treatments. Results. Of 63 total cases, the mean dose was 672 mg (range = 188-3500 mg). The patient age distribution was 5 years or less (27.0%), 6 to 19 years (12.7%), and 20 years or more (58.7%); 52.4% of the patients were male. Therapeutic errors accounted for 71.4% of the cases and adverse reactions 19.0%. The management site was 52.4% on site, 19.0% already at/en route to a health care facility, and 23.8% referred to a health care facility. The medical outcome was not serious in 79.4% of the cases. The most common adverse effects were gastrointestinal (28.6%) or neurological (20.6%) in nature. One case each was reported to have depression, paranoia, and almost psychotic presentation. Conclusions. Few mefloquine ingestions were reported to Texas poison centers. Those that were reported tended to involve adult males and were due to therapeutic error or adverse reaction. Although mefloquine ingestions may result in potentially serious side effects, the exposures reported to Texas poison centers tended not to be serious with few adverse effects and were managed outside of health care facilities.

Warren JL, Stingone JA, Herring AH, Langlois PH, et al. Bayesian multinomial probit modeling of daily windows of susceptibility for maternal PM2.5 exposure and congenital heart defects. Stat Med. 2016 Feb 7. doi: 10.1002/sim.6891. [Epub ahead of print]
Epidemiologic studies suggest that maternal ambient air pollution exposure during critical periods of pregnancy is associated with adverse effects on fetal development. In this work, we introduce new methodology for identifying critical periods of development during post-conception gestational weeks 2-8 where elevated exposure to particulate matter less than 2.5 µm (PM2.5) adversely impacts development of the heart. Past studies have focused on highly aggregated temporal levels of exposure during the pregnancy and have failed to account for anatomical similarities between the considered congenital heart defects. We introduce a multinomial probit model in the Bayesian setting that allows for joint identification of susceptible daily periods during pregnancy for 12 types of congenital heart defects with respect to maternal PM2.5 exposure. We apply the model to a dataset of mothers from the National Birth Defect Prevention Study where daily PM2.5 exposures from post-conception gestational weeks 2-8 are assigned using predictions from the downscaler pollution model. This approach is compared with two aggregated exposure models that define exposure as the average value over post-conception gestational weeks 2-8 and the average over individual weeks, respectively. Results suggest an association between increased PM2.5 exposure on post-conception gestational day 53 with the development of pulmonary valve stenosis and exposures during days 50 and 51 with tetralogy of Fallot. Significant associations are masked when using the aggregated exposure models. Simulation study results suggest that the findings are robust to multiple sources of error. The general form of the model allows for different exposures and health outcomes to be considered in future applications. Copyright © 2016 John Wiley & Sons, Ltd.

Luke B, Brown MB, Spector LG, Williams M, et al. Embryo banking among women diagnosed with cancer: a pilot population-based study in New York, Texas, and Illinois. J Assist Reprod Genet. 2016 Feb 3. [Epub ahead of print]
Purpose: The purpose of the present study is to estimate the proportion of women with cancer who return to use the embryos that they have banked and to compare this proportion to that of women without cancer who bank embryos. Methods: This is a cohort study of three groups of women from New York, Texas, and Illinois who used embryo banking in their first assisted reproductive technology (ART) treatment cycle: two groups with cancer (222 women without an infertility diagnosis and 48 women with an infertility diagnosis) and a control group without cancer (68 women with the infertility diagnosis of male factor only). Women were included only if their first ART cycle reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) occurred between 2004 and 2009. Cancer cases were identified from each State Cancer Registry from 5 years prior to initiation of ART treatment to 6 months post-initiation; mean follow-up after the first ART cycle was 2.0 years. Results: Women with cancer without an infertility diagnosis returned for a subsequent ART cycle at a lower rate (10.8 %) than those with an infertility diagnosis (31.3 %, p = 0.0010) or the control group (85.3 %, p < 0.0001). Among those who returned for a subsequent cycle, women with cancer waited a longer time to return (14.3 months without an infertility diagnosis and 8.3 months with an infertility diagnosis, p = 0.13) compared to the control group (2.8 months, p = 0.0007). The live birth rate among women who did not utilize embryo banking in their second cycle did not differ significantly across the three study groups, ranging from 25.0 and 42.9 % for women with cancer with and without an infertility diagnosis, respectively, to 36.2 % for women in the control group. Conclusions: Women with cancer without an infertility diagnosis are either less likely to return for subsequent treatment or will wait a longer time to return than women with an infertility diagnosis or those that do not have cancer. A longer-term study is necessary to assess whether these women return to use their frozen embryos after cancer treatment or are able to spontaneously conceive and if those subsequent pregnancies are adversely affected by the cancer diagnosis or therapy.

Goldenberg AJ, Comeau AM, Grosse SD, Tanksley S, et al. Evaluating harms in the assessment of net benefit: a framework for newborn screening condition review. Matern Child Health J. 2016 Feb 1. [Epub ahead of print]
Background: The Department of Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children ("Advisory Committee") makes recommendations to the HHS Secretary regarding addition of new conditions to the national Recommended Uniform Screening Panel for newborns. The Advisory Committee's decision-making process includes assessing the net benefit of screening for nominated conditions, informed by systematic evidence reviews generated by an independent Condition Review Workgroup. The evidence base regarding harms associated with screening for specific conditions is often more limited than that for benefits. Procedures: The process for defining potential harms from newborn screening reviewed the frameworks from other public health evidence-based review processes, adapted to newborn screening by experts in systematic review, newborn screening programs and bioethics, with input from and approval by the Advisory Committee. Main findings: To support the Advisory Committee's review of nominated conditions, the Workgroup has developed a standardized approach to evaluation of harms and relevant gaps in the evidence. Types of harms include the physical burden to infants; psychosocial and logistic burdens to families from screening or diagnostic evaluation; increased risk of medical treatment for infants diagnosed earlier than children with clinical presentation; delayed diagnosis from false negative results; psychosocial harm from false positive results; uncertainty of clinical diagnosis, age of onset or clinical spectrum; and disparities in access to diagnosis or therapy. Conclusions: Estimating the numbers of children at risk, the magnitude, timing and likelihood of harms will be integrated into Workgroup reports to the Advisory Committee.

Forrester MB. Explosions and fires reported with electronic cigarettes. TX Public Health J 2016;68(1):3-4.
No abstract.

Forrester MB, Maxwell JC. NBOMe designer drugs reported to Texas forensic laboratories. TX Public Health J 2016;68(1):4-5.
No abstract.

Fortenberry GZ, Beckman J, Schwartz A, Bojes H9, et al. Magnitude and characteristics of acute paraquat- and diquat-related illnesses in the US: 1998-2013. Environ Res. 2016 Jan 11;146:191-199. doi: 10.1016/j.envres.2016.01.003.
Background: Paraquat and diquat are among the most commonly used herbicides in the world. Objectives: Determine the magnitude, characteristics, and root causes for acute paraquat- and diquat-related illnesses in the US METHODS: Illnesses associated with paraquat or diquat exposure occurring from 1998 through 2011 were identified from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Program, the California Department of Pesticide Regulation (CDPR) Pesticide Illness Surveillance Program (PISP), and the Incident Data System (IDS). Cases identified by the National Poison Data System (NPDS) were reviewed for the years 1998-2003 and 2006-2013. Results: A total of 300 paraquat- and 144 diquat-related acute illnesses were identified by SENSOR, PISP, and IDS. NPDS identified 693 paraquat- and 2128 diquat-related acute illnesses. In SENSOR/PISP/IDS, illnesses were commonly low severity (paraquat=41%; diquat=81%); however, SENSOR/PISP/IDS identified 24 deaths caused by paraquat and 5 deaths associated with diquat. Nineteen paraquat-related deaths were due to ingestion, seven of which were unintentional, often due to improper storage in beverage bottles. In SENSOR/PISP/IDS, paraquat and diquat-related acute illnesses were work-related in 68% (n=203) and 29% (n=42) of cases, respectively. When herbicide application site was known, the vast majority of acute paraquat-related illnesses (81%) arose from agricultural applications. Common root causes of illness were failure to use adequate personal protective equipment (PPE), application equipment failure, and spill/splash of herbicide. Conclusions: Although the magnitude of acute paraquat/diquat-related illnesses was relatively low, several fatalities were identified. Many illnesses could be prevented through stricter compliance with label requirements (e.g. ensuring proper herbicide storage and PPE use), and through enhanced training of certified applicators.

Cervantes DT, Ball JM, Edwards J, Payne S. Horses naturally infected with EIAV harbor 2 distinct SU populations but are monophyletic with respect to IN. Virus Genes. 2016 Jan 6. [Epub ahead of print]
Equine infectious anemia virus (EIAV) causes lifelong infections ranging from acutely fatal, to chronic, to asymptomatic. Within infected animals, EIAV is found as a quasispecies. Many experimental studies on EIAV, carried out in the U.S. over the past 70 years, have used either the highly virulent Wyoming (EIAVWYO) field strain or various derivatives of that strain. These infections have provided insights into the variety of genetic changes that accumulate in the env gene and LTR in experimentally infected horses. In the current study, we obtained EIAV sequences from blood samples collected from naturally infected Texas horses between 2000 and 2002. We found surface (SU) and long terminal repeat (LTR) sequences clearly related to EIAVWYO and its cell culture-adapted derivatives. Some blood samples yielded SU or LTR sequences belonging to 2 discrete clusters. In these cases, SU and LTR variation between animals was no greater than sequence variation within animals. In contrast, a portion of integrase (IN) was more homogeneous within animals than between animals. These results suggest that specific selective pressures are applied to SU and LTR sequences, potentially driving generation of two distinct sequence clusters within a horse. We speculate that viruses in one cluster may be more highly expressed and easily transmitted while those in the second cluster support long-term inapparent infection. The presence of homogeneous IN sequences within a horse supports the hypothesis that SU and LTR sequences diverged after the initial infection.

Last updated November 30, 2016