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DSHS Authors: 2017 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.texas.gov by calling (512) 776-7559.

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mrl-diamond2017 Articles (in date order with most recent first)

Shafer A, Dazzi F, Ventura J. Factor structure of the Brief Psychiatric Rating Scale - Expanded (BPRS-E) in a large hospitalized sample. J Psychiatr Res. 2017 Oct;93:79-86. doi: 10.1016/j.jpsychires.2017.05.011.
Meta-analytically derived models of the BPRS-E factor structure were tested on a large (n = 33,903) hospitalized sample using confirmatory factor analysis. A modified four factor model (Positive symptoms, Negative symptoms, Affect, and Activation) containing 12 core BPRS-E symptoms based on the meta-analytic models had excellent model fit. An additional five factor, 15 core symptom model, which added a Disorganization factor consistent with the pentagonal model of schizophrenic symptoms also had support with generally good fit. These factors demonstrated acceptable reliability as measured by coefficient alpha (M = 0.77). These factors were compared across three major diagnostic classes and indicated clinically relevant differences between these groups such as depressed patients having higher Affect scores (d = 1.03), manic-mixed episode patients having higher Activation scores (d = 0.83) and schizophrenic patients having higher Positive Symptom scores (d = 0.89) providing evidence for the validity of these factors. Further exploratory factor analyses provided support for the factors of Positive symptoms, Negative symptoms, Affect, and Activation with additional smaller and less robust factors corresponding to Resistance emerging as a fifth factor and Disorganization emerging as a sixth factor.
Copyright © 2017 Elsevier Ltd. All rights reserved.

Pless E, Gloria-Soria A, Evans BR, Kramer V, Bolling BG, et al. Multiple introductions of the dengue vector, Aedes aegypti, into California. PLoS Negl Trop Dis. 2017 Aug 10;11(8):e0005718. doi: 10.1371/journal.pntd.0005718. eCollection 2017 Aug.
The yellow fever mosquito Aedes aegypti inhabits much of the tropical and subtropical world and is a primary vector of dengue, Zika, and chikungunya viruses. Breeding populations of A. aegypti were first reported in California (CA) in 2013. Initial genetic analyses using 12 microsatellites on collections from Northern CA in 2013 indicated the South Central US region as the likely source of the introduction. We expanded genetic analyses of CA A. aegypti by: (a) examining additional Northern CA samples and including samples from Southern CA, (b) including more southern US populations for comparison, and (c) genotyping a subset of samples at 15,698 SNPs. Major results are: (1) Northern and Southern CA populations are distinct. (2) Northern populations are more genetically diverse than Southern CA populations. (3) Northern and Southern CA groups were likely founded by two independent introductions which came from the South Central US and Southwest US/northern Mexico regions respectively. (4) Our genetic data suggest that the founding events giving rise to the Northern CA and Southern CA populations likely occurred before the populations were first recognized in 2013 and 2014, respectively. (5) A Northern CA population analyzed at multiple time-points (two years apart) is genetically stable, consistent with permanent in situ breeding. These results expand previous work on the origin of California A. aegypti with the novel finding that this species entered California on multiple occasions, likely some years before its initial detection. This work has implications for mosquito surveillance and vector control activities not only in California but also in other regions where the distribution of this invasive mosquito is expanding.

Kim J, Swartz MD, Langlois PH, et al. Estimated maternal pesticide exposure from drinking water and heart defects in offspring. Int J Environ Res Public Health. 2017 Aug 8;14(8). pii: E889. doi: 10.3390/ijerph14080889.
Our objective was to examine the relationship between estimated maternal exposure to pesticides in public drinking water and the risk of congenital heart defects (CHD). We used mixed-effects logistic regression to analyze data from 18,291 nonsyndromic cases with heart defects from the Texas Birth Defects Registry and 4414 randomly-selected controls delivered in Texas from 1999 through 2005. Water district-level pesticide exposure was estimated by linking each maternal residential address to the corresponding public water supply district's measured atrazine levels. We repeated analyses among independent subjects from the National Birth Defects Prevention Study (NBDPS) (1620 nonsyndromic cases with heart defects and 1335 controls delivered from 1999 through 2005). No positive associations were observed between high versus low atrazine level and eight CHD subtypes or all included heart defects combined. These findings should be interpreted with caution, in light of potential misclassification and relatively large proportions of subjects with missing atrazine data. Thus, more consistent and complete monitoring and reporting of drinking water contaminants will aid in better understanding the relationships between pesticide water contaminants and birth defects.

Soim A, Lin S, Sheridan SC, Langlois PH, et al. Population-based case-control study of the association between weather-related extreme heat events and neural tube defects. Birth Defects Res. 2017 Aug 2. doi: 10.1002/bdr2.1086. [Epub ahead of print]
Background: Elevated body core temperature has been shown to have teratogenic effects in animal studies. Our study evaluated the association between weather-related extreme heat events (EHEs) in the summer season and neural tube defects (NTDs), and further investigated whether pregnant women with a high pregestational body mass index (BMI) have a greater risk of having a child with NTDs associated with exposure to EHE than women with a normal BMI. Methods: We conducted a population-based case-control study among mothers of infants with NTDs and mothers of infants without major birth defects, who participated in the National Birth Defects Prevention Study and had at least 1 day of the third or fourth week postconception during summer months. EHEs were defined using the 95th and the 90th percentiles of the daily maximum universal apparent temperature. Adjusted odds ratios and 95% confidence intervals were calculated using unconditional logistic regression models with Firth's penalized likelihood method while controlling for other known risk factors. Results: Overall, we did not observe a significant association between EHEs and NTDs. At the climate region level, consistently elevated but not statistically significant estimates were observed for at least 2 consecutive days with daily universal apparent maximum temperature above the 95th percentile of the UATmax distribution for the season, year, and weather monitoring station in New York (Northeast), North Carolina and Georgia (Southeast), and Iowa (Upper Midwest). No effect modification by BMI was observed. Conclusion: EHEs occurring during the relevant developmental window of embryogenesis do not appear to appreciably affect the risk of NTDs. Future studies should refine exposure assessment, and more completely account for maternal activities that may modify the effects of weather exposure. 

Nakka P, Archer NP, Xu H, et al. Novel gene and network associations found for acute lymphoblastic leukemia using case-control and family-based studies in multi-ethnic populations. Cancer Epidemiol Biomarkers Prev. 2017 Jul 27. pii: cebp.0360.2017. doi: 10.1158/1055-9965.EPI-17-0360. [Epub ahead of print]
Background: Acute lymphoblastic leukemia (ALL) is the most common childhood cancer, suggesting that germline variants influence ALL risk. Although multiple genome-wide association (GWA) studies have identified variants predisposing children to ALL, it remains unclear whether genetic heterogeneity affects ALL susceptibility and how interactions within and among genes containing ALL-associated variants influence ALL risk. Methods: Here we jointly analyze two published datasets of case-control GWA summary statistics along with germline data from ALL case-parent trios. We use the gene-level association method PEGASUS to identify genes with multiple variants associated with ALL. We then use PEGASUS gene scores as input to the network analysis algorithm HotNet2 to characterize the genomic architecture of ALL. Results: Using PEGASUS, we confirm associations previously observed at genes such as ARID5B, IKZF1, CDKN2A/2B, and PIP4K2A, and we identify novel candidate gene associations. Using HotNet2, we uncover significant gene subnetworks that may underlie inherited ALL risk: a subnetwork involved in B-cell differentiation containing the ALL-associated gene CEBPE; and a subnetwork of homeobox genes including MEIS1. Conclusions: Gene and network analysis uncovers loci associated with ALL that are missed by GWA studies such as MEIS1. Further, ALL-associated loci do not appear to interact directly with each other to influence ALL risk, and instead appear to influence leukemogenesis through multiple, complex pathways. Impact: We present a new pipeline for post-hoc analysis of association studies that yields new insight into the etiology of ALL, and can be applied in future studies to shed light on the genomic underpinnings of cancer.

Kim J, Langlois PH, Mitchell LE, Agopian AJ. Maternal occupation and the risk of neural tube defects in offspring. Arch Environ Occup Health. 2017 Jul 19:0. doi: 10.1080/19338244.2017.1356259. [Epub ahead of print]
We evaluated the association between maternal occupation and the risk of neural tube defects (NTDs) in offspring. Data for 491 nonsyndromic cases were obtained from the Texas Birth Defects Registry for deliveries between 1999 and 2009. We randomly selected 2,291 controls among all live births in Texas during this time. Maternal occupations were classified using automated software and manual assignment. Multivariable logistic regression analyses were used to examine the relationship between maternal occupation and risk for any NTD, adjusting for maternal race/ethnicity, any diabetes, and maternal body mass index. These analyses were repeated for spina bifida specifically. Some maternal occupations, particularly those related to business/finance, healthcare practice, and cleaning/maintenance, were significantly associated with increased risk of spina bifida and/or any NTD. Further research is needed to identify the specific occupational exposures related to NTD risk.

Forrester MB. Pediatric Orbeez ingestions reported to Texas poison centers. Pediatr Emerg Care 2017 [Epub ahead of print]
Objectives: There is concern that ingestion of superabsorbent polymer toys, which can absorb large amounts of fluid and increase greatly in volume, may pose a risk if swallowed by children. The intent of this study was to characterize pediatric Orbeez ingestions reported to a statewide poison center system. Methods: Cases were Orbeez ingestions among patients 19 years or younger reported to Texas poison centers during January 2011 to June 2016. The distribution by various demographic and clinical factors was determined. Results: Of 110 total cases, 56% were female and 55% were 5 years or younger. Eighty-six percent of the ingestions were unintentional. Sixty-nine percent occurred at the patient's home and 28% at school. Seventy-eight percent of the patients were managed on site. The reported adverse effects were vomiting (4%), abdominal pain (3%), constipation (1%), diarrhea (1%), and fever (1%). The reported treatments were dilution (42%), food or snack (16%), other emetics (1%), whole bowel irrigation (1%), antihistamines (1%), and intravenous fluids (1%). Conclusions: Pediatric Orbeez ingestions tended to involve younger children, were unintentional, and occurred at the child's home or school. Most ingestions were managed outside of a healthcare facility. This study provides further evidence that ingestion of Orbeez by children is not likely to result in serious problems, such as intestinal obstruction. The information in this investigation may assist in prevention and education activities.

Wang JC, Cordero J, Sun Y, et al. Planktonic growth of Pseudomonas aeruginosa around a dual-species biofilm supports the growth of Fusobacterium nucleatum within that biofilm. Int J Otolaryngol. 2017;2017:3037191. doi: 10.1155/2017/3037191. Epub 2017 Jul 17.
Purpose: The goal of this study was to understand the potential interaction between Pseudomonas aeruginosa and Fusobacterium nucleatum within the middle ear. Methods: We examined the microbiota of ear fluid and tympanostomy tubes (TTs) obtained from patients with posttympanostomy tube otorrhea. We also examined biofilms formed by P. aeruginosa and F. nucleatum, singly or together, under aerobic or anaerobic conditions. Results: While the facultative anaerobe P. aeruginosa dominated the bacterial population within the ear fluid, strict anaerobes, including F. nucleatum, dominated bacterial populations within the TTs. F. nucleatum was able to grow under aerobic conditions only in the presence of P. aeruginosa, whose growth reduced the level of dissolved oxygen within the broth to nearly anoxic condition within 4 h after inoculation. The presence of P. aeruginosa allowed F. nucleatum to maintain its growth for 72 h within the dual-species biofilm but not within the planktonic growth. Visualization of the biofilms revealed coaggregation of P. aeruginosa and F. nucleatum. Conclusion: Extrapolation of these results suggests that, within the middle ear fluid, the growth of P. aeruginosa produces the anaerobic conditions required for the growth of F. nucleatum, both within effusion and within biofilms.

Haidar A, Carey FR, Ranjit N, Archer N, Hoelscher D. Self-reported use of nutrition labels to make food choices is associated with healthier dietary behaviours in adolescents. Public Health Nutr. 2017 Jul 14:1-11. doi: 10.1017/S1368980017001252. [Epub ahead of print]
Objective: The study aimed to examine nutrition label use and dietary behaviours among ethnically diverse middle- and high-school students, in Texas, USA. Design: The School Physical Activity and Nutrition (SPAN) survey is a cross-sectional statewide study using a self-administered questionnaire to assess nutrition and physical activity behaviours. Height and weight measurements were used to determine BMI. Multivariable logistic regression was used to determine associations between nutrition label use and dietary behaviours, with gender, grade, ethnicity, BMI, parent education, socio-economic status and nutrition knowledge as covariates. Setting: Participants from 283 schools, weighted to represent Texas youth. Subjects: SPAN 2009-2011 included 6716 8th and 11th graders (3465 girls and 3251 boys). The study population consisted of 39·83 % White/Other, 14·61 % African-American and 45·56 % Hispanic adolescents; with a mean age of 14·9 years, and 61·95 % at a healthy weight, 15·71 % having overweight and 22·34 % having obesity. Results: Adolescents who did not use nutrition labels had 1·69 times greater odds of consuming ≥1 sugary beverages/d (P<0·05). Adolescents who used nutrition labels had 2·13 times greater odds of consuming ≥1 fruits and vegetables/d (P<0·05). Adolescents who used nutrition labels had significantly higher healthy eating scores than those who did not (P<0·001). For every 1-point increase in nutrition knowledge, adolescents had 1·22 greater odds of using nutrition labels. Conclusions: Nutrition label use is associated with healthier dietary behaviours in adolescents. Intervention strategies for youth should include efforts to teach adolescents to use labels to make healthy food choices.

Forrester MB. Comparison of single- and multiple-person mercury exposures. Arch Environ Occup Health 2017;72:299-302.
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.

Zhu L, Müller GC, Marshall JM, Arheart KL, Qualls WA, et al. Is outdoor vector control needed for malaria elimination? An individual-based modelling study. Malar J. 2017 Jul 3;16(1):266. doi: 10.1186/s12936-017-1920-y.
Background: Residual malaria transmission has been reported in many areas even with adequate indoor vector control coverage, such as long-lasting insecticidal nets (LLINs). The increased insecticide resistance in Anopheles mosquitoes has resulted in reduced efficacy of the widely used indoor tools and has been linked with an increase in outdoor malaria transmission. There are considerations of incorporating outdoor interventions into integrated vector management (IVM) to achieve malaria elimination; however, more information on the combination of tools for effective control is needed to determine their utilization. Methods: A spatial individual-based model was modified to simulate the environment and malaria transmission activities in a hypothetical, isolated African village setting. LLINs and outdoor attractive toxic sugar bait (ATSB) stations were used as examples of indoor and outdoor interventions, respectively. Different interventions and lengths of efficacy periods were tested. Simulations continued for 420 days, and each simulation scenario was repeated 50 times. Mosquito populations, entomologic inoculation rates (EIRs), probabilities of local mosquito extinction, and proportion of time when the annual EIR was reduced below one were compared between different intervention types and efficacy periods. Results: In the village setting with clustered houses, the combinational intervention of 50% LLINs plus outdoor ATSBs significantly reduced mosquito population and EIR in short term, increased the probability of local mosquito extinction, and increased the time when annual EIR is less than one per person compared to 50% LLINs alone; outdoor ATSBs alone significantly reduced mosquito population in short term, increased the probability of mosquito extinction, and increased the time when annual EIR is less than one compared to 50% LLINs alone, but there was no significant difference in EIR in short term between 50% LLINs and outdoor ATSBs. In the village setting with dispersed houses, the combinational intervention of 50% LLINs plus outdoor ATSBs significantly reduced mosquito population in short term, increased the probability of mosquito extinction, and increased the time when annual EIR is less than one per person compared to 50% LLINs alone; outdoor ATSBs alone significantly reduced mosquito population in short term, but there were no significant difference in the probability of mosquito extinction and the time when annual EIR is less than one between 50% LLIN and outdoor ATSBs; and there was no significant difference in EIR between all three interventions. A minimum of 2 months of efficacy period is needed to bring out the best possible effect of the vector control tools, and to achieve long-term mosquito reduction, a minimum of 3 months of efficacy period is needed. Conclusions: The results highlight the value of incorporating outdoor vector control into IVM as a supplement to traditional indoor practices for malaria elimination in Africa, especially in village settings of clustered houses where LLINs alone is far from sufficient.

Saxena V, Bolling BG, Wang T. West Nile Virus. Clin Lab Med. 2017 Jun;37(2):243-252. doi: 10.1016/j.cll.2017.01.001. Epub 2017 Mar 3.
No abstract available.

Agopian AJ, Kim J, Langlois PH, et al. Maternal occupational physical activity and risk for orofacial clefts. Am J Ind Med. 2017 May 19. doi: 10.1002/ajim.22731. [Epub ahead of print]
Objectives: To perform a case-control study of maternal occupational physical activity and risk for orofacial clefts in Texas during 1999-2009. Methods: We used logistic regression to assess 14 measures of physical activity estimated from a job exposure matrix, using the maternal occupation reported on the birth certificate, among 887 children with cleft lip with or without cleft palate (CLP), 436 children with cleft palate only (CP), and 1932 controls. Results: After adjusting for several potential confounders, seven measures of physical activity (as a categorical and/or continuous variable) were significantly associated with CLP, CP, or both. Positive associations were seen for keeping balance, kneeling, standing, and walking/running (odds ratio 95% confidence interval range 1.0-1.9 for fourth versus first quartile). A significant positive trend was also seen for bending/twisting. Negative associations were seen for repetitive motion and sitting. Conclusions:  Maternal occupational physical activity may be related to the etiology of orofacial clefts.

Stingone JA, Luben TJ, Carmichael SL, Aylsworth AS, Botto LD, Correa A, Gilboa SM, Langlois PH, et al. Maternal exposure to nitrogen dioxide, intake of methyl nutrients and congenital heart defects in offspring. Am J Epidemiol. 2017 May 18. doi: 10.1093/aje/kwx139. [Epub ahead of print]
Nutrients that regulate methylation processes may modify susceptibility to the effects of air pollutants. Data from the National Birth Defects Prevention Study, 1997-2006, were used to estimate associations between maternal exposure to nitrogen dioxide (NO2), dietary intake of methyl nutrients and the odds of congenital heart defects in offspring. NO2 concentrations, a marker of traffic-related air pollution, averaged across post-conception weeks 2-8, were assigned to 6160 non-diabetic mothers of cases and controls using inverse distance-squared weighting of air monitors within 50 km of maternal residence. Intake of choline, folate, methionine, and vitamins B6 and B12 were assessed using a food frequency questionnaire. Hierarchical regression models, which accounted for similarities across defects, were constructed and relative excess risks due to interaction were calculated. Relative to women with the lowest NO2 exposure and high methionine intake, women with the highest NO2 exposure and lowest methionine intake had the greatest odds of offspring with a perimembranous ventricular septal defect (Odds Ratio: 3.23, 95% Confidence Interval, 1.74, 6.01; Relative Excess Risk due to Interaction: 2.15, 95% Confidence Interval, 0.39, 3.92). Considerable departure from additivity was not observed for other defects. These results provide modest evidence of interaction between nutrition and NO2 exposure during pregnancy.

J-Y Feng JY, Jarlsberg LG, Salcedo K, Rose J, Janes M, Lin SG, Osmond DH, Jost KC, et al. Clinical and bacteriological characteristics associated with clustering of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2017 May 16. doi: 10.5588/ijtld.16.0510. [Epub ahead of print]
Setting: The impact of the genetic characteristics of Mycobacterium tuberculosis on the clustering of multidrug-resistant tuberculosis (MDR-TB) has not been analyzed together with clinical and demographic characteristics. Objective: To determine factors associated with genotypic clustering of MDR-TB in a community-based study. Design: We measured the proportion of clustered cases among MDR-TB patients and determined the impact of clinical and demographic characteristics and that of three M. tuberculosis genetic characteristics: lineage, drug resistance-associated mutations, and rpoA and rpoC compensatory mutations. Results: Of 174 patients from California and Texas included in the study, the number infected by East-Asian, Euro-American, Indo-Oceanic and East-African-Indian M. tuberculosis lineages were respectively 70 (40.2%), 69 (39.7%), 33 (19.0%) and 2 (1.1%). The most common mutations associated with isoniazid and rifampin resistance were respectively katG S315T and rpoB S531L. Potential compensatory mutations in rpoA and rpoC were found in 35 isolates (20.1%). Hispanic ethnicity (OR 26.50, 95%CI 3.73-386.80), infection with an East-Asian M. tuberculosis lineage (OR 30.00, 95%CI 4.20-462.40) and rpoB mutation S531L (OR 4.03, 95%CI 1.05-23.10) were independent factors associated with genotypic clustering. Conclusion: Among the bacterial factors studied, East-Asian lineage and rpoB S531L mutation were independently associated with genotypic clustering, suggesting that bacterial factors have an impact on the ability of M. tuberculosis to cause secondary cases.

Hoang TT, Marengo LK, Mitchell LE, Canfield MA, Agopian AJ. Original findings and updated meta-analysis for the association between maternal diabetes and risk for congenital heart disease phenotypes. Am J Epidemiol. 2017 May 13:1-11. doi: 10.1093/aje/kwx033. [Epub ahead of print]
Maternal diabetes is associated with congenital heart defects (CHDs) as a group, but few studies have assessed risk for specific CHD phenotypes. We analyzed these relationships using data from the Texas Birth Defects Registry and statewide vital records for deliveries taking place in 1999-2009 (n = 48,249 cases). We used Poisson regression to calculate prevalence ratios for the associations between maternal diabetes (pregestational or gestational) and each CHD phenotype, adjusting for potential confounders. Analyses were repeated by type of diabetes. To address the potential for misclassification bias, we performed logistic regression, using malformed controls. We also conducted meta-analyses, combining our estimates of the association between pregestational diabetes and each CHD phenotype with previous estimates. The prevalence of every CHD phenotype was greater among women with pregestational diabetes than among nondiabetic women. Most of these differences were statistically significant (adjusted prevalence ratios = 2.47-13.20). Associations were slightly attenuated for many CHD phenotypes among women with gestational diabetes. The observed associations did not appear to be the result of misclassification bias. In our meta-analysis, pregestational diabetes was significantly associated with each CHD phenotype. These findings contribute to a better understanding of the teratogenic effects of maternal diabetes and improved counseling for risk of specific CHD phenotypes.

Forrester MB. Human exposures to pentobarbital-phenytoin combination veterinary drugs. Hum Exp Toxicol 2017;36:755-761.
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.

Pieracci EG, Evert N, Drexler NA, Mayes B, Vilcins I, Huang P, et al. Fatal flea-borne typhus in Texas: a retrospective case series, 1985-2015. Am J Trop Med Hyg. 2017 May;96(5):1088-1093. doi: 10.4269/ajtmh.16-0465.
Flea-borne (murine) typhus is a global rickettsiosis caused by Rickettsia typhi. Although flea-borne typhus is no longer nationally notifiable, cases are reported for surveillance purposes in a few U.S. states. The infection is typically self-limiting, but may be severe or life-threatening in some patients. We performed a retrospective review of confirmed or probable cases of fatal flea-borne typhus reported to the Texas Department of State Health Services during 1985-2015. When available, medical charts were also examined. Eleven cases of fatal flea-borne typhus were identified. The median patient age was 62 years (range, 36-84 years) and 8 (73%) were male. Patients presented most commonly with fever (100%), nausea and vomiting (55%), and rash (55%). Respiratory (55%) and neurologic (45%) manifestations were also identified frequently. Laboratory abnormalities included thrombocytopenia (82%) and elevated hepatic transaminases (63%). Flea or animal contact before illness onset was frequently reported (55%). The median time from hospitalization to administration of a tetracycline-class drug was 4 days (range, 0-5 days). The median time from symptom onset to death was 14 days (range, 1-34 days). Flea-borne typhus can be a life-threatening disease if not treated in a timely manner with appropriate tetracycline-class antibiotics. Flea-borne typhus should be considered in febrile patients with animal or flea exposure and respiratory or neurologic symptoms of unknown etiology.

Forrester MB. Pediatric Nandina domestica ingestions reported to poison centers. Hum Exp Toxicol 2017 [Epub ahead of print]
Nandina domestica is grown as an ornamental plant in the United States but has also been reported as an invasive plant in a number of states. Parts of the plant, particularly the berries, contain cyanogenic glycosides that convert to hydrogen cyanide when ingested. This investigation characterized N. domestica ingestions involving patients of age 5 years and less reported to Texas poison centers during 2000–2015. There were 875 total N. domestica ingestions. A seasonal pattern was observed with the highest proportion of ingestions occurring in March (18.5%) and April (14.7%). The patients were male in 55.0% of the cases; 40.8% of the patients were of age 1 and 37.0% of age 2. Berries were specifically mentioned in 709 ingestions, of which 57.3% involved one berry and 28.5% an unknown number of berries. The ingestion occurred at the patient’s own residence in 92.9% of the cases, and the patient was managed on site in 97.0%. The most frequently reported clinical effects were vomiting (3.7%), abdominal pain (1.0%), diarrhea (0.9%), and nausea (0.7%). In conclusion, N. domestica ingestions among young children generally do not result in serious outcomes and can be managed successfully outside of a healthcare facility.

Forrester MB. Texas bull nettle (Cnidoscolus texanus) exposures reported to Texas poison centers. Wilderness Environ Med 2017 [Epub ahead of print]
Objective: Texas bull nettle (Cnidoscolus texanus) is covered in bristly hairs similar to stinging nettle. Contact with the plant may result in intense dermal pain, burning, itching, cellulitis, and allergic reaction. This study characterizes C. texanus exposures reported to a large state-wide poison center system. Methods: Cases were C. texanus exposures reported to Texas poison centers during 2000-2015. The distribution of cases was determined for patient demographics, exposure circumstances, and patient outcome. Results: A total of 140 C. texanus exposures were identified. Twenty percent of the patients were aged ?=5 years, 21% were 6 to 12 years, 5% were 13 to 19 years, and 51% were ?=20years; and 51% of the patients were male. Eighty-one percent of the exposures occurred at the patient's own residence, 11% in a public area, 2% at another residence, and 1% at school. Seventy-eight percent of the patients were managed on site, 13% were already at or en route to a health care facility, and 6% were referred to a health care facility. Eighty-eight percent of the exposures resulted in dermal effects: irritation or pain (56%), erythema or flushing (31%), edema (27%), pruritus (24%), rash (19%), puncture or wound (19%), and hives or welts (11%). Conclusions: C. texanus exposures reported to Texas poison centers were most likely to be unintentional and occur at the patient's own residence. The outcomes of the exposures tended not to be serious and could be managed successfully outside of health care facilities.

Forrester MB. Copper sulfate: A potential hazard at school. TX Public Health J 2017;69(2):4.

Nelson SM, Gao YT, Nogueira LM, et al. Diet and biliary tract cancer risk in Shanghai, China. PLoS One. 2017 Mar 13;12(3):e0173935. doi: 10.1371/journal.pone.0173935.
Trends in biliary tract cancer incidence rates have increased in Shanghai, China. These trends have coincided with economic and developmental growth, as well as a shift in dietary patterns to a more Westernized diet. To examine the effect of dietary changes on incident disease, we evaluated associations between diet and biliary tract cancers amongst men and women from a population-based case-control study in Shanghai, China. Biliary tract cancer cases were recruited from 42 collaborating hospitals in urban Shanghai, and population-based controls were randomly selected from the Shanghai Household Registry. Food frequency questionnaire data were available for 225 gallbladder, 190 extrahepatic bile duct, and 68 ampulla of Vater cancer cases. A total of 39 food groups were created and examined for associations with biliary tract cancer. Interestingly, only four food groups demonstrated a suggested association with gallbladder, extrahepatic bile duct, or ampulla of Vater cancers. The allium food group, consisting of onions, garlic, and shallots showed an inverse association with gallbladder cancer (OR: 0.81, 95% CI: 0.68-0.97). Similar trends were seen in the food group containing seaweed and kelp (OR: 0.79, 95% CI: 0.67-0.96). In contrast, both preserved vegetables and salted meats food groups showed positive associations with gallbladder cancer (OR:1.27, 95% CI: 1.06-1.52; OR: 1.18, 95% CI: 1.02-1.37, respectively). Each of these four food groups showed similar trends for extrahepatic bile duct and ampulla of Vater cancers. The results of our analysis suggest intake of foods with greater anti-inflammatory properties may play a role in decreasing the risk of biliary tract cancers. Future studies should be done to better understand effects of cultural changes on diet, and to further examine the impact diet and inflammation have on biliary tract cancer incidence.

Adam JK, Abeyta R, Smith B, Gaul L, et al. Clinician survey to determine knowledge of dengue and clinical management practices, Texas, 2014. Am J Trop Med Hyg. 2017 Jan 30. pii: 16-0367. doi: 10.4269/ajtmh.16-0367. [Epub ahead of print]
Dengue, a mosquito-borne viral disease, is increasingly being identified as a cause of outbreaks in the United States. During July-December 2013, a total of three south Texas counties reported 53 laboratory-confirmed dengue cases; 26 were locally acquired, constituting the largest outbreak in Texas since 2005. Because dengue outbreaks are expected to continue in south Texas and early case identification and timely treatment can reduce mortality, we sought to determine clinicians' knowledge of dengue and its clinical management. A survey was sent to 2,375 south Texas clinicians; 217 (9%) completed the survey. Approximately half of participants demonstrated knowledge needed to identify dengue cases, including symptoms (56%), early indicators of shock (54%), or timing of thrombocytopenia (48%). Fewer than 20% correctly identified all prevention messages, severe dengue warning signs, or circumstances in which a dengue patient should return for care. Knowledge of clinical management was limited; few participants correctly identified scenarios when plasma leakage occurred (10%) or a crystalloid solution was indicated (7%); however, 45% correctly identified when a blood transfusion was indicated. Because of the ongoing threat of dengue, we recommend clinicians in south Texas receive dengue clinical management training.

Forrester MB. Snow globes: A potential Christmas hazard. TX Public Health J 2017;69(1):4.
No abstract available.

Honein MA, Dawson AL, Petersen EE, Jones AM, Lee EH, Yazdy MM, Ahmad N, Macdonald J, Evert N, et al. Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy. JAMA. 2017 Jan 3;317(1):59-68. doi: 10.1001/jama.2016.19006.
Importance: Understanding the risk of birth defects associated with Zika virus infection during pregnancy may help guide communication, prevention, and planning efforts. In the absence of Zika virus, microcephaly occurs in approximately 7 per 10 000 live births. Objective: To estimate the preliminary proportion of fetuses or infants with birth defects after maternal Zika virus infection by trimester of infection and maternal symptoms. Design, Setting, and Participants: Completed pregnancies with maternal, fetal, or infant laboratory evidence of possible recent Zika virus infection and outcomes reported in the continental United States and Hawaii from January 15 to September 22, 2016, in the US Zika Pregnancy Registry, a collaboration between the CDC and state and local health departments. Exposures: Laboratory evidence of possible recent Zika virus infection in a maternal, placental, fetal, or infant sample. Main Outcomes and Measures: Birth defects potentially Zika associated: brain abnormalities with or without microcephaly, neural tube defects and other early brain malformations, eye abnormalities, and other central nervous system consequences. Results: Among 442 completed pregnancies in women (median age, 28 years; range, 15-50 years) with laboratory evidence of possible recent Zika virus infection, birth defects potentially related to Zika virus were identified in 26 (6%; 95% CI, 4%-8%) fetuses or infants. There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%; 95% CI, 4%-9%) pregnant asymptomatic women and 10 of 167 (6%; 95% CI, 3%-11%) symptomatic pregnant women. Of the 26 affected fetuses or infants, 4 had microcephaly and no reported neuroimaging, 14 had microcephaly and brain abnormalities, and 4 had brain abnormalities without microcephaly; reported brain abnormalities included intracranial calcifications, corpus callosum abnormalities, abnormal cortical formation, cerebral atrophy, ventriculomegaly, hydrocephaly, and cerebellar abnormalities. Infants with microcephaly (18/442) represent 4% of completed pregnancies. Birth defects were reported in 9 of 85 (11%; 95% CI, 6%-19%) completed pregnancies with maternal symptoms or exposure exclusively in the first trimester (or first trimester and periconceptional period), with no reports of birth defects among fetuses or infants with prenatal exposure to Zika virus infection only in the second or third trimesters. Conclusions and Relevance: Among pregnant women in the United States with completed pregnancies and laboratory evidence of possible recent Zika infection, 6% of fetuses or infants had evidence of Zika-associated birth defects, primarily brain abnormalities and microcephaly, whereas among women with first-trimester Zika infection, 11% of fetuses or infants had evidence of Zika-associated birth defects. These findings support the importance of screening pregnant women for Zika virus exposure.

Forrester MB. Comparison of poisonings managed at military and Veterans Administration hospitals reported to Texas poison centers. Public Health 2017;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.

Last updated August 24, 2017