Epidemiologic characteristics of human tularemia in the southwest-central states, 1981-1987

From 1981 through 1987, a total of 1,041 cases of tularemia in humans were reported in Arkansas, Kansas, Louisiana, Missouri, Oklahoma, and Texas; this represents 60% of the cases reported in the United States during this same time period. The state of Arkansas reported the highest total (420 cases). Annual incidence rates per one million population ranged from 36.3 in Arkansas to less than 5.0 in Kansas, Louisiana, and Texas. Epidemiologic data were available for 1,026 cases. The majority of cases were white (88%) and male (75%). May, June, and July were the months of onset of symptoms for 52% of the cases. For the cases with known exposure history, 63% reported an attached tick and 23% had exposure to rabbits. Other animals associated with human infection were squirrels, cats, and raccoons. The case-fatality ratio was 2%. Public health efforts to prevent human tularemia cases in the six southwest-central states should focus on reducing exposure to ticks.

Physical activity on the job and cancer in Missouri

We conducted a series of case-control studies to investigate the risks of 16 cancer types in relation to occupational physical activity. These studies were based on Missouri Cancer Registry data for 17,147 White male cancer patients registered between 1984 and 1989. Colon cancer risk was increased for both the moderate (odds ratio (OR) = 1.1; 95% confidence interval (CI) = 1.0, 1.3) and low (OR = 1.2; 95% CI = 1.0, 1.5) activity levels. Similar elevations were observed for prostate cancer at the moderate (OR = 1.1; 95% CI = 1.0, 1.3) and low (OR = 1.5; 95% CI = 1.2, 1.8) levels of activity, and for cancer of the testis at the low activity level (OR = 2.2; 95% CI = 1.3, 3.7). An opposite trend (p less than 0.01) was noted for lung cancer, which showed decreased risk at the moderate (OR = 0.9; 95% CI = 0.8, 1.0) and low (OR = 0.8; 95% CI = 0.6, 0.9) activity levels. These associations suggest that further study of the relationship between physical activity and site-specific cancer risk is warranted.

Human immunodeficiency virus (HIV) sero-prevalence in sexually transmitted disease clinic populations

Two HIV sero-prevalence surveys conducted during 1989 in public sexually transmitted disease clinics in the Kansas City SMSA tested 1,561 males and 1.043 females. There were 23 sero-positive males; no sero-positive females. The rate for males using the Missouri clinic was nearly triple that of males using the Kansas clinic. Among males the sero-prevalence rate for white males was 8.4 times that for black males. Of the 14 HIV sero-positive males for whom risk factor information was available, 12 were gay or bisexual and two were heterosexual intravenous drug users.

Secular trends in psychiatric diagnoses of suicide victims

Post-mortem psychiatric diagnoses are compared in two cohorts of male suicides from St. Louis (1956-1957) (Robins, 1981) and San Diego (1981-1982) (Rich et al., 1986). Similar structured interviews and diagnostic criteria had been used in both assessments. Substance/alcohol abuse has remained the major diagnosis in suicides under age 60. Rates of depressive disorder alone have decreased overall, due mostly to decreased rates in the elderly. Thus, depression occurs more frequently in younger ages. Comorbid depression and substance/alcohol abuse has also increased in younger ages. Implications in terms of the so-called 'cohort effect' are discussed.

Missouri leads the nation: and that needs to change

In Missouri, legislation to control tobacco use severely lags behind other states who have beaten us to the punch by passing such laws. It is time to make some changes, and you can help.

Lincomycin injections for upper respiratory tract infections: a comparison of findings in a rural clinic with analysis of a national data base

A review of the records of patients attending a rural family practice clinic indicated that 13% had received "cold shots" (lincomycin with or without chlorpheniramine). The providers who assumed management of the clinic when the previous physician retired judged these injections inappropriate, but patients believed that they were effective and expected to continue to receive them. This study included 51 consecutive patients seen in the clinic for treatment of a cold and compared those who expected an injection with those who did not. Thirty-four patients (67%) expected an injection but instead received education about upper respiratory tract infections and symptomatic treatment. Half of these patients (17) were not satisfied with this alternative, and 10 reportedly went to another provider for an injection. Compared with patients who did not expect an injection, patients who did were older (P less than .001), had longer duration of symptoms (P less than .02), and were more likely to have tried nonprescription remedies (P less than .001). Analysis of the 1985 National Ambulatory Medical Care Survey indicates that the administration of lincomycin is not uncommon (an estimated 800,000 injections were given in 1985) and that lincomycin is more likely to be administered by a rural solo physician practicing in the north central or southern regions of the United States.

Plasma exchange and vincristine in the treatment of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura associated with bone marrow transplantation

Hemolytic uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP) is a rare and often fatal complication of bone marrow transplantation (BMT). In this study, we report eight such cases (seven allo and one auto) treated with plasma exchanges (PE), vincristine (six patients), and discontinuation of cyclosporin A (in allo BMT). This complication occurred in 6.3% of 112 allogeneic BMT and in 0.7% of 146 autologous BMT. In seven patients, the BMT preparatory regimens consisted of cyclophosphamide, etoposide, and total-body irradiation (TBI). Among the eight patients with HUS/TTP, one allogeneic BMT patient with reversible renal failure, but without central nervous system (CNS) involvement, or systemic mycotic infection, responded completely and is without evidence of disease for a period of greater than 3.5 years. Three patients showed hematologic improvement, and four did not respond. The median duration of survival was 17 days. Six of the seven deaths occurred in a setting of systemic infection, progressive renal failure, and worsening of graft-versus-host reaction. In spite of hematologic improvement to PE and vincristine, BMT patients in whom HUS/TTP developed usually succumbed to complications.

Pericardial drainage: subxiphoid vs. transthoracic approach

The optimal management of effusive pericardial disease remains controversial. Subxiphoid drainage has been criticized for a high recurrence rate while transthoracic procedures (window or pericardiectomy) are more invasive operations with greater potential for morbidity. We compared subxiphoid (SX group) and transthoracic (TT group) drainage in 131 patients (age range from 1 month to 81 years) treated from 1979 to the present. The etiology of effusion included cancer (38), uremia (24), infection (27), radiation (9), and other (33) causes. The two groups had similar age and sex distribution, etiology, and fluid volume. There was no difference in the operative mortality between the two groups (SX 15%, TT 13%, p = NS). Patients undergoing thoracotomy for treatment of effusive pericardial disease had a higher incidence of respiratory complications as defined by the presence of pneumonia, pleural effusion, prolonged ventilation, and need for reintubation (SX 11%, TT 35%, p less than 0.005). This may account, in part, for the longer mean hospital stay in transthoracic group (14.4 vs. 11.4 days). Nine patients were lost to follow-up after hospital discharge. The remaining 104 hospital survivors were followed for between 1 month and 11 years (mean 34 months, cumulative of 297 patient years). Three patients in each group experienced fluid recurrence and all but one were successfully treated by needle aspiration or percutaneous catheter placement. Following discharge, no patient required reoperation for effusive or constrictive pericardial disease or died from tamponade. There were no significant differences in 5-year actuarial survival (SX 54%, TT 49%) or actuarial freedom from recurrence (SX 89%, TT 93%).(ABSTRACT TRUNCATED AT 250 WORDS)

The ecology of adolescent maltreatment: A multilevel examination of adolescent physical abuse, sexual abuse, and neglect

This study examined the individual characteristics, family relations, and stress/social support of 50 maltreated adolescents and their mothers. Dyads were divided into 4 demographically similar groups: neglect, physical abuse, sexual abuse, and nonmaltreatment control. Results show that adolescent neglect was primarily associated with extrafamilial difficulties and social isolation. Adolescent physical abuse was linked more with rigidity in family relations, poorer maternal understanding of child developmental skills, and adolescent externalizing behaviors. In contrast, adolescent sexual abuse was related to maternal emotional problems and adolescent internalizing behaviors. In general, each group of maltreated adolescents experienced lower levels of family cohesion, more attention problems, and more daily stress than did their nonmaltreated counterparts. Findings are consistent with an ecological model of adolescent maltreatment.

Changes in characteristics of women who smoke during pregnancy: Missouri, 1978-88

The Missouri birth certificate has had a question, "cigarettes smoked per day?" since 1978; the current data base contains more than 800,000 records. A comparison of the Missouri data for married mothers with the National Natality Survey (NNS) data shows mainly consistent findings between the two data sets. The Missouri data, however, also provided information on the smoking status during pregnancy of unmarried women that is not available from the NNS. The Missouri data show a substantial difference in the smoking rates of married (23.2 percent) and unmarried (40.9 percent) women. The highest smoking rates during pregnancy are found among unmarried women, ages 20-24, with less than a high-school education, and those with a fourth or higher order child. There has been a relatively small overall drop in the smoking rate from 1978-80 to 1986-88 (31.1 percent versus 27.5 percent). However, blacks and teenagers have had very substantial drops in smoking rates. There has been only a slight decrease for other high-risk groups such as white unmarried women, women with less than a high-school education, and those having a fourth or higher order birth. Missouri started using the new national standard birth certificate in 1989 with a differently worded smoking question. The percentage of women smoking and those smoking less than one pack per day in 1989 went down more than would be expected from the trend data. It appears that the new birth certificate question will provide a lower estimate of the percentage of mothers who smoke cigarettes than was acquired from the previous version on the Missouri certificate. The births in Missouri for which mothers' rate of smoking was unknown increased nearly fourfold to 0.9 percent.

Vibrio infections in Kansas City

In August 1989, the Kansas City Health Department declared vibrio infections a reportable disease. The authors present a report discussing cases of vibriosis reported between 1980 and 1989.

Comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery

A surgeon-specific computer-generated monthly questionnaire was used to improve surveillance of surgical wound infections in outpatients as well as inpatients following discharge. From July 1988 through June 1989, 20,536 surgical procedures were performed at our medical center, of which 53% were for outpatients. The total wound infection rate was 0.63%: 0.13% in outpatients and 1.2% in inpatients (p less than .005). Of the infected wounds, 20% were reported by the survey alone and would have gone undetected by conventional surveillance methods (71.4% of outpatient and 13.8% of inpatient wound infections). As a whole, clean and clean-contaminated wounds in outpatients were much less likely to become infected than those in inpatients. Wound cultures were not obtained in 85% of infections reported by the survey alone, and were less likely to be obtained in outpatients. The average time spent by the infection control department on the survey was approximately two hours per week.

Age at death: a three hospital urban, suburban, and small town study

Comparison of the ages of patients dying at three interrelated St. Louis hospitals in 1988 has been used to study the results of similar high-quality acute hospital care when provided to dissimilar populations. The data presented by the authors leads them to conclude that in this era of mounting health costs, we have not, at least as recently as 1988, realized that an ounce of prevention if worth a pound of cure.

Racial differences in prevalence of phobic disorders

Few community-based field studies have examined racial differences in the prevalence of phobia disorders. Using data from two sites of a large epidemiologic survey, this study investigates risk factors associated with the one-month prevalence of phobia disorders from 2340 black and 3936 white respondents. Findings indicate that recent prevalence is higher for blacks than whites, with racial differences remaining even when demographic and socioeconomic factors are held constant. Additional significant risk factors for recent phobia pertained to site and being female, being young, and having low education attainment.

Improving perinatal outcome for rural Missouri

Improving perinatal outcome in rural Missouri as reflected by a lowering of the perinatal mortality rate is a realistic and achievable goal for the state. The authors present information and data with suggestions for reaching this goal.

As the twig is bent

The trauma of having no home imposes unique health problems on families, especially children. Homeless children are more subject to infectious diseases, are more in need of immunizations, and have more growth and developmental problems than children growing up in nurturing environments. A study of the homeless in St. Louis found that increasingly they are families headed by single women who had to leave their homes mainly because of overcrowding. A study of data obtained from healthcare clinics set up at shelters showed that the mean age of homeless children was 4.9 years; the mean number of months they had lacked a permanent residence was more than four. Healthcare screenings showed that chronic health problems, such as asthma and anemia and deficits in growth and development, were among the top 10 diagnoses. Less serious problems like colds and lice were more prevalent, however. Intelligence tests administered to homeless children showed that they had three times the cognitive and developmental problems that would be expected among children in general.

Racial differences in cancer mortality in Missouri

The discrepancy between black and white cancer mortality rates remains a cause of concern for the public health community. The authors discuss some of the factors that contribute to the problem and suggest that an organized local, state and national effort is necessary to find a solution.

The incidence of voice disorders

This report summarizes the log book for patients with voice disorders treated at Washington University in St. Louis between 1984 and 1988. Our experience with these 764 patients is expressed as the number of visits for each problem type.