Prevalence of radiographic evidence of paint chip ingestion among children with moderate to severe lead poisoning, St Louis, Missouri, 1989 through 1990

Although experts once believed that ingesting chips of lead-based paint was the major cause of lead poisoning among children, conventional wisdom now holds that lead-contaminated dust and soil are the major routes of exposure. Data from a childhood lead-poisoning treatment clinic were examined to assess the frequency with which children ingest paint chips. For this study, the reports on abdominal radiographs of 90 children with moderate to severe lead poisoning who had received their first chelation treatment during 1989 or 1990 were reviewed. According to a radiologist's evaluation, 13 of 90 abdominal radiographs (14%; 95% confidence interval [CI] 7% to 22%) showed evidence of paint chip ingestion. Of 46 children with blood lead levels greater than or equal to 55 micrograms/dL, 12 (26%) had radiographs that showed paint chips, whereas only 1 (2%) of 44 children with blood lead levels less than 55 micrograms/dL had such radiographs (prevalence ratio = 11.5; 95% CI 1.6 to 84.6). The actual proportion of children with moderate to severe lead poisoning who have consumed leaded-paint chips is likely to be higher than this estimate based on radiographic evidence. While lead-contaminated dust is a major source of lead exposure, ingestion of leaded-paint chips clearly remains an important source of exposure among children with moderate to severe lead poisoning.

Contamination of flexible fiberoptic bronchoscopes with Mycobacterium chelonae linked to an automated bronchoscope disinfection machine

Between December 5, 1989, and September 25, 1990, Mycobacterium chelonae was isolated from endoscopic or bronchial washings in 14 patients on a single clinical service. A phenotypically unique strain of M. chelonae subspecies abscessus that was highly resistant to cefoxitin (MIC greater than 256 micrograms/ml) and different from 13 control isolates of M. chelonae recovered elsewhere in the hospital was identified in all these patients and the rinse water from the bronchoscope disinfecting machine. None of the outbreak patients had evidence of invasive M. chelonae disease. Aggressive infection control measures on the disinfecting machine, including use of sterile water in the wash and rinse cycles, increasing the 2% alkaline glutaraldehyde exposure time, frequent replacement of the glutaraldehyde, and disinfection of the machine, failed to eradicate the M. chelonae, presumably because of the presence of a biofilm inside the machine. Rinsing the scopes with 70% alcohol after automated disinfection eliminated the outbreak strain. This study demonstrates that automated bronchoscope disinfecting machines may become heavily contaminated with mycobacteria that resist usual disinfection, resulting in a source of bronchoscope contamination.

Analyzing the effect of prenatal care on pregnancy outcome: a conditional approach

We used vital statistics data to examine the effect of the time of entry into prenatal care relative to the gestational age of delivery on pregnancy outcome. Early entry into prenatal care was associated with better outcomes only in women who delivered at 37 through 42 weeks of gestation. We are concerned that the evaluation of the effect of prenatal care using vital statistics data may be questionable because of the problems inherent in the data.

Substance abuse during pregnancy in a rural population

Drug abuse during pregnancy in rural populations has received less attention than that in urban populations. Urban studies have reported alarming rates, but it is unknown whether the situation is the same in rural areas. To investigate this, urine samples were collected anonymously from 181 pregnant women who presented to the University of Missouri clinics for care and who resided in communities of less than 25,000. Each urine specimen was tested for cocaine, marijuana, amphetamines, barbiturates, opiates, phencyclidine, benzodiazepines, ethanol, and nicotine. Of the 181 specimens, 83 (46%) contained nicotine, 17 (9.4%) contained marijuana, and one each (0.6%) tested positive for cocaine, barbiturates, ethanol, and benzodiazepines. No other tested substances were detected. Excluding nicotine and ethanol, 20 (11%) of the urine samples tested positive for the screened substances. Review of the prenatal records revealed that 46% of the women reported using tobacco, 15% reported using alcohol, and 8.3% reported illicit drug use during pregnancy. This study indicates that there is a substantial drug abuse problem in rural populations, and that the profile of abuse differs from that of urban populations. Tobacco, ethanol, and marijuana were the most prevalent substances abused during pregnancy, but cocaine was a minor problem. This information may help in directing resources to reduce drug abuse during pregnancy.

Meta-analysis of second malignant tumors in head and neck cancer: the case for an endoscopic screening protocol

A meta-analysis was performed on data from the Washington University Department of Otolaryngology Head and Neck Tumor Registry and 24 studies reporting synchronous and metachronous malignancies in head and neck cancer patients. The overall second malignant tumor (second primary) prevalence was 14.2% in 40,287 patients, the majority of tumors being metachronous. Site relationships between index tumors and second primaries revealed significantly high risks along the digestive tract axis or the respiratory tract axis, although lung second primaries were prevalent in all groups. Head and neck second primaries were the largest group, being significantly more common in the oral cavity, oropharynx, and hypopharynx than in the larynx. Oral cavity index tumors showed the highest overall rate of second primary formation. Half of all aerodigestive tract second primaries are detected by 2 years from index tumor presentation, but non-aerodigestive tract tumors are common beyond 5 years. A significantly higher detection rate was proven for the prospective panendoscopy studies. We recommend routine interval endoscopic intervention within 2 years of treatment for optimum detection of second primaries in head and neck cancer patients. Also, a lifetime of clinical surveillance is suggested for aerodigestive tract second neoplasms in oral cavity, oropharynx, and hypopharynx cancer patients and for lung and non-aerodigestive tract neoplasms in larynx cancer patients.

Weighing costs and benefits of adequate prenatal care for 12,023 births in Missouri's Medicaid program, 1988

Numerous studies have shown that the receipt of adequate prenatal care is associated with improvements in pregnancy outcome, particularly a reduction in the risk of low birth weight. Since medical costs for these low birth weight infants are several times higher than for normal birth weight infants, one would expect that medical costs for newborns would be lower for babies whose mothers have had adequate prenatal care than for those with inadequate prenatal care. Explored in this paper is whether the reduction in Medicaid costs for newborn and post-partum maternal care is greater than the increase in prenatal costs for a Medicaid population. The analysis used a file of 12,023 Missouri Medicaid records linked with the corresponding 1988 birth certificates. A modified version of the Kessner index was used to define the adequacy of prenatal care. Prenatal care costs were $233 higher for pregnancies with adequate prenatal care than for those in which prenatal care was inadequate. Newborn and post-partum costs starting within 60 days after the birth were $347 lower for the adequate prenatal care pregnancies, resulting in a savings of $1.49 for each extra $1 spent on prenatal care. Among the other factors studied in determining this benefit to cost ratio were global billing, Supplemental Food Program for Women, Infants, and Children (WIC), and participation in Medicaid under the expanded eligibility provisions that were effective in Missouri in 1988.

Demographic and socioeconomic differences in beliefs about the health effects of smoking

To assess sociodemographic differences in beliefs about the health effects of cigarette smoking and passive smoke exposure, we recently surveyed 2092 adults in St. Louis and Kansas City, Mo. The percentages of respondents who knew that smoking causes lung cancer, emphysema, and heart disease were 76.7, 74.1, and 67.2, respectively. After multivariate adjustment, knowledge about smoking's health effects was generally lower among women, older respondents, those of lower education level, and current smokers. Blacks were generally less likely to appreciate the health effects of active smoking, but were more likely to acknowledge the health effects of passive smoking.

The role of data-driven planning and coalition development in preventing cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Effective programs for the prevention and control of CVD need to include data-based planning and evaluation at the State and local levels. The authors describe the development of data-driven planning and intervention strategies in Missouri. Statewide planning activities have resulted in the formation of an advisory committee and development of a State plan, a resource directory, and training courses. Analysis of mortality data revealed an unusual concentration of CVD deaths in the southeast portion of the State. Local coalitions are being developed in each of six counties in this region to reduce the prevalence of CVD risk factors. A regional behavioral risk factor survey of 1,006 adults identified key risk factors that will be addressed by the coalitions. These data suggested that physical inactivity, obesity, and hypertension are especially acute problems in the area. Key components of the local coalition development included providing localized data and obtaining the strong commitment of the local health departments. Expanded use of chronic disease surveillance data for planning and evaluation will increase the probability that localities, States, and the nation will achieve Year 2000 Health Objectives. The data-based planning process is described as a possible model for use by other States and localities.

A new approach to evaluate the impact of climate on human mortality

The objective of this study is to introduce a new procedure to determine the impact of climate on human mortality with the use of a synoptic climatological approach. The holistic nature of synoptic categories allows for the simultaneous evaluation of numerous weather elements as they realistically appear within air masses. In addition, this approach allows for a better distinction between pollution-induced mortality and weather-induced mortality. A synoptic categorization was performed for St. Louis, Missouri, and each category was evaluated in terms of its mean daily mortality. Of 10 summer categories found in St. Louis, one possessed the highest mean mortality by far, and 8 of the top 10 mortality days in St. Louis occurred when this category was present. Further analysis determined that long, consecutive day periods of this hot, oppressive category are associated with a continuing rise in mortality. It was determined that the procedure described here has the potential to be used in a weather/mortality watch-warning system. Finally, it appears that day-to-day mortality fluctuations are much more sensitive to weather than to pollution concentrations, as the oppressive category associated with the greatest mortality possessed levels of six major pollutants that were not noteworthy.

A new approach to evaluate the impact of climate on human mortality

The objective of this study is to introduce a new procedure to determine the impact of climate on human mortality with the use of a synoptic climatological approach. The holistic nature of synoptic categories allows for the simultaneous evaluation of numerous weather elements as they realistically appear within air masses. In addition, this approach allows for a better distinction between pollution-induced mortality and weather-induced mortality. A synoptic categorization was performed for St. Louis, Missouri, and each category was evaluated in terms of its mean daily mortality. Of 10 summer categories found in St. Louis, one possessed the highest mean mortality by far, and 8 of the top 10 mortality days in St. Louis occurred when this category was present. Further analysis determined that long, consecutive day periods of this hot, oppressive category are associated with a continuing rise in mortality. It was determined that the procedure described here has the potential to be used in a weather/mortality watch-warning system. Finally, it appears that day-to-day mortality fluctuations are much more sensitive to weather than to pollution concentrations, as the oppressive category associated with the greatest mortality possessed levels of six major pollutants that were not noteworthy.

Evaluation of chronic bronchitis, chronic obstructive pulmonary disease, and ventilatory function among workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is produced as an undesirable contaminant in the manufacture of 2,4,5-trichlorophenol (TCP) and its derivatives. There is considerable concern about the health effects that may be associated with exposure to TCDD-contaminated substances. A cross-sectional medical study that included a comprehensive medical history, medical examination, and measurement of pulmonary function was conducted on workers employed more than 15 yr earlier in the manufacture of NaTCP and its derivatives at two chemical plants. The workers had substantial exposure to substances contaminated with TCDD, as evidenced by a mean serum TCDD level, lipid adjusted, of 200 ppt compared with a mean of 7 ppt in the unexposed reference group. The comparison group consisted of individuals with no occupational exposure to phenoxy herbicides who lived in the same communities as the workers. A total of 281 workers and 260 unexposed referents participated in the medical examination. Logistic and linear regression analyses, which contained categorical and continuous measures of TCDD exposure, were performed to control for important confounders, including cigarette and alcohol consumption. No difference was found between workers and referents in the risk for chronic bronchitis or COPD. Analysis of the ventilatory function data revealed no association between history of exposure to substances contaminated with TCDD and the forced expiratory volume at one second (FEV1), forced vital capacity (FVC), or the ratio of FEV1 to FVC (FEV1/FVC%).

Prevalence of histoplasmosis in a midsouthern population

We found a histoplasmin reactivity rate of 69% in a selected population of normal midsouthern adults. This prevalence is similar to that previously reported and has major clinical implications for area residents who are infected with human immunodeficiency virus and are at risk for disseminated disease with Histoplasma capsulatum.

Cigarette smoking and risk of adult leukemia

A case-control study investigated the relation between cigarette smoking and histologic subtypes of adult leukemia in Missouri in 1984-1990. Among males, elevated risks associated with ever smoking were observed for acute nonlymphocytic leukemia (odds ratio (OR) = 1.5; 95% confidence interval (CI) 1.1-2.0) and acute myelocytic leukemia (OR = 1.5; 95% CI 1.1-2.1). Females also showed an increased risk of acute nonlymphocytic leukemia associated with ever smoking (OR = 1.4; 95% CI 1.0-1.9), with an increasing trend in risk by level of smoking (p less than 0.01). Attributable risk estimates of the proportion of acute nonlymphocytic leukemia caused by smoking were 33 percent in males and 29 percent in females. Elevations in risk were not apparent for chronic forms of leukemia. The findings support the hypothesis that some types of leukemia may be etiologically related to cigarette smoking.

Medications and multiple falls in elderly people: the St Louis OASIS study

The purpose of this study was to identify associations between the use of commonly taken medications and groups of medications and the risk of falls in elderly people living in the community. A stratified random sample of 1358 persons aged 65 years and over was selected from the 15,000 members of an educational organization for functionally independent, community-dwelling elderly people in St Louis, Missouri. Twenty-seven per cent of subjects reported at least one fall in the past year and 8% reported two or more falls. After adjusting for potential confounders (including age, sex, relevant medical conditions, health status, cognitive impairment, use of alcohol, depression and use of other medications), the following medications were found to be important risk factors for multiple falls: diazepam [odds ratio (OR): 3.7, 95% confidence interval (CI): 1.5-9.3], diltiazem (OR: 1.8, 95% CI: 0.8-4.1), diuretics (OR: 1.8, 95% CI: 1.2-2.8) and laxatives (OR: 2.1, 95% CI: 1.0-4.5). We conclude that caution is needed before prescribing diuretics and psychotropics, especially diazepam, for elderly people. The safety of diltiazem in this age group should be assessed further.

Minor malformations, hyperactivity, and learning disabilities

Standardized minor malformation scores have been reported to predict and identify children with attentional problems and hyperactivity. The reason why this marker works for only a subset of children with attention deficit hyperactivity disorder remains unclear. The dysmorphology scores on all children presenting for a multidisciplinary team evaluation of developmental disorders were examined for diagnostic correlations after children with chromosomal disorders and recognized dysmorphic syndromes were excluded. For 1233 subjects, the mean minor malformation score was 2.94 (SD = 2.05). A significant association between minor malformation scores and IQ (mean = 80.95, SD = 23.67) was accounted for by the group with IQs greater than 100 exhibiting the higher dysmorphology scores. An analysis of variance revealed no significant association between minor malformation scores and hyperactivity or attention deficit disorder. Indeed, the presence of an attention deficit disorder yielded lower mean dysmorphology scores. When the minor malformation scores were compared for those subgroups of children with and without specific learning disabilities, the learning-disabled subjects had significantly higher dysmorphology scores. Minor dysmorphic features do not relate to the presence or absence of attentional problems or hyperactivity in referred children. Rather they appear to characterize that subpopulation of children with attention deficit disorder and learning disabilities as well as a group of learning-disabled children without attentional disorders.

Clinical, hematologic, and survival data from cats infected with feline immunodeficiency virus: 42 cases (1983-1988)

A retrospective study of stored feline serum samples was done to determine the infection rate of feline immunodeficiency virus in cats in central Missouri. Infected cats were compared with uninfected cats subjected to the same selection criteria on the basis of signalment, clinical signs, and CBC abnormalities. A significant incidence of virus infection was found in male cats. Neither age nor breed predilection could be identified. Infected cats were more likely to be anemic and leukopenic because of neutropenia. Cellulitis and neoplasia were more common in infected cats. A spectrum of disease severity was seen in infected cats ranging from no clinical signs to signs of severe chronic inflammatory disease. Infected cats were more likely to have clinical disease. Mean survival of infected cats was 24.4 months from the time of diagnosis.

Oral water intoxication in infants. An American epidemic

Between 1975 and 1990, a total of 34 patients with water intoxication were treated at St Louis (Mo) Children's Hospital, 24 of these in the last 3 years, indicating a marked increase in incidence of this previously rare condition. Thirty-one were infants living in poverty who ingested excessive amounts of water offered at home by their caretakers. Exhaustion of the supply of infant formula was the most common reason given for this substitution. Infants were treated by a single infusion of hypertonic saline or a slow infusion of isotonic saline. Central pontine myelinolysis was not observed as a complication of hypertonic saline therapy. Modification of the Special Supplemental Food Program for Women, Infants, and Children to provide sufficient formula for the growing infant and better education of mothers as to the hazards of excessive water ingestion might reduce the incidence of this preventable and life-threatening condition.

Anal sphincter reconstruction: anterior overlapping muscle repair

Anal sphincter reconstruction for anal incontinence was performed in 55 women between 1973 and 1987 at The Jewish Hospital of St. Louis. The mean age was 34 years (range, 22-75 years). Incontinence was due to obstetric injury in 48 patients and to fistulotomy in 7 patients. Patients suffered from complete incontinence (41), incontinence of liquid stool and flatus (11), or incontinence of flatus only (3). All patients underwent an anterior overlapping sphincter muscle reconstruction, and one patient also had a posterior repair. Complete continence was restored in 28 patients, and partial continence was achieved in 24 patients. Only three patients remained totally incontinent. Clinical assessment did not accurately reflect functional outcome after 1 year of follow-up. No factor predicting outcome was found retrospectively. Clinical assessment of a patient's outcome may be inaccurate unless specific questions are asked. The use of a perineal drain reduced infection but did not affect outcome. Previous repair or associated rectovaginal fistula does not affect outcome. Sphincter injury owing to fistula disease may result in poor outcome after repair.

Meningococcal disease in the United States--1986. Meningococcal Disease Study Group

Active surveillance for invasive meningococcal disease was conducted during 1986 and 1987 in six areas of the United States with a total population of approximately 34 million persons. The incidence of meningococcal disease was 1.3:10(5). The highest incidence of disease among the surveillance areas was in Los Angeles County (1.65:10(5). Neisseria meningitidis serogroups B and C caused about equal amounts of disease, which reflects a recent increase in the incidence of group C disease. Group C caused more than half of the cases of meningococcal disease in Los Angeles and Tennessee but less than one-third of the cases in Missouri and Oklahoma. Multilocus enzyme electrophoresis demonstrated that a group of closely related isolates of N. meningitidis was prevalent in Los Angeles during the surveillance period and was associated with an increased incidence of meningococcal disease there.

Underestimates of student substance use by school personnel: a cause for concern?

The present study was designed to compare school personnel's (i.e., principals, counselors, teachers) estimates of student substance use with student self-reported data. Comparisons were made in 78 schools between 5431 student self-reports of tobacco, alcohol, and drug use and 170 school personnel's estimates of student substance use. The results indicated that a significant number of school personnel were unable to estimate student substance use. Personnel who did provide estimates typically underestimated the degree of substance use, in comparison to student self-reported substance use. School personnel did not significantly overestimate use in comparison to student self-reported substance use for any substance in any grade or geographic area. It is suggested that school personnel may resist the adoption of prevention programs because of a perceived lack of need due to underestimation of the substance use problem.

Fluid contamination during orthopaedic procedures. A study of incidence, location, and prevention

Certain orthopaedic procedures may expose health care providers to contamination of scrub clothing, personal undergarments, and/or skin by patients' body fluids. The incidence and site of fluid contamination were studied for an orthopaedic surgeon and his assistant during 54 orthopaedic operations from March through May 1989. Contamination was recorded in 35 of the cases (65%) for the surgeon, and in 37 (69%) for the assistant. The sites of contamination spanned the length of the lower extremities, with an overall 34% incidence above the knee. The surgeon and assistant then monitored fluid contamination during 43 cases from March through May 1990 while wearing water-impervious surgical pants. An additional 16 clinicians also tested these pants and answered questions regarding their comfort and utility. No cases of fluid contamination were recorded during the second phase of the study. The garment was reported to be comfortable and did not appear to add a heat factor, even with the use of lead aprons during fluoroscopic procedures.