Does inadequate diet during childhood explain the higher high fracture rates in the Southern United States?

SUMMARY: Southern states have the highest age-adjusted hip fracture rates among older adults in the United States. Regional hip fracture rates in the United States in 1986-1993 correlate with death rates from rickets in the 1940s. Historical patterns of bone nutrition early in life might explain contemporary geographic patterns in bone fragility. INTRODUCTION: State of residence early in life is a better predictor of the risk of hip fracture after age 65 than state of current residence. Therefore, the geography of rickets mortality in the United States before 1950 was compared with the geography of hip fracture rates among older adults in the United States during 1986-1993. METHODS: Vital statistics data for the US white population for 1942-1948 allowed calculation of the ratio of deaths from rickets to live births for each geographic division of the USA. These ratios were correlated with previously published, standardized hip fracture rates among whites 65-89 years old during 1986-1993 by census division. RESULTS: During 1942-1948, the rickets mortality ratio among whites was 3.11 in the South, 1.91 in the Northeast, 1.75 in the Midwest, and 1.04 in the West. The correlation of mortality with risk of hip fracture was 0.71 (p = 0.03) for both sexes combined and 0.86 (p = 0.01) for women. CONCLUSIONS: Inadequate nutrition during skeletal formation early in life might explain the higher incidence of hip fracture among older adults in the South.

Self-reported falls and fall-related injuries among persons aged>or=65 years--United States, 2006.

PROBLEM: In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown. METHOD: To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey. RESULTS: Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day. DISCUSSION: This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity. SUMMARY: The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions. IMPACT ON INDUSTRY: Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.

Seasonality of reported poison exposures.

Review of 3,381 records from New Hampshire Poison Center for July through September 1981 and January through March 1982 revealed no seasonal difference in the total number of calls. A significant predominance in the summer reports was noted for plants, pesticides, envenomations, and acetaminophen exposures. During the winter a predominance was noted for aspirin, vitamins, cold and cough remedies, liniments, foods, and calls with no specific agent identified.

Prevalence of lead poisoning among two-year-old children in Vermont.

OBJECTIVES: The recent redefinition of childhood lead poisoning by the Centers for Disease Control and Prevention means that many more children are considered lead poisoned than previously. The primary purpose of this study was to determine how many 2-year-old children had lead levels of 10 micrograms/dL or more in a rural state. METHODS: Random samples of 334 children drawn from the birth certificate file and 350 children from Vermont Medicaid rosters submitted capillary blood specimens that were confirmed by venous tests if lead levels were 10 micrograms/dL or more. RESULTS: Participation rates were 63.9% in the birth certificate group and 66.4% in the Medicaid group. In the birth certificate sample, the percentages of children with confirmed lead levels 10 micrograms/dL or more, 15 micrograms/dL or more, and 20 micrograms/dL or more were 9.0 (95% confidence interval [CI], 6.2-12.6), 2.7 (95% CI, 1.2-5.0), and 1.5 (95% CI, 0.5-3.4), respectively. In the Medicaid sample, the corresponding percentages were 14.9 (95% CI, 11.4-19.2), 5.1 (95% CI, 3.1-8.0), and 2.0 (95% CI, 0.8-4.1), respectively. The percentage of children in the state's most urban county with lead levels of 10 micrograms/dL or more was significantly less than that in the rest of the state in both samples. CONCLUSIONS: The prevalence of elevated lead levels in 2-year-old children may be significant in rural states with old housing stock. Medicaid-enrolled children represent a readily identifiable high-risk group.

Diarrhea associated with adherent enteropathogenic Escherichia coli in an infant and toddler center, Seattle, Washington.

During November 1983, the Seattle-King County Department of Public Health investigated an outbreak of diarrhea associated with enteropathogenic Escherichia coli, serogroup 0111:K58, in an infant and toddler day-care center. Of the 25 children in the center, ranging in age from 4 to 30 months (median age 11 months), diarrhea occurred in 14 characterized by watery, greenish stools. The median duration of diarrhea was 12 days. Two of the ill children were hospitalized because of severe dehydration. Stool cultures from the children diagnosed initially did not yield the common bacterial pathogens, parasites, or rotavirus. Stool cultures from 11 of 14 ill children and two of 11 well children (P less than .005), however, yielded an E coli serogroup, 0111:K58, which was not invasive or toxigenic by standard tests. The source of the organism was not identified. Although this organism has been recognized as a cause of diarrhea in newborn nurseries, this is the first published report of a documented outbreak of enteropathogenic E coli-induced diarrhea in a day-care center in the United States.

International trends in rates of hypospadias and cryptorchidism.

Researchers from seven European nations and the United States have published reports of increasing rates of hypospadias during the 1960s, 1970s, and 1980s. Reports of increasing rates of cryptorchidism have come primarily from England. In recent years, these reports have become one focus of the debate over endocrine disruption. This study examines more recent data from a larger number of countries participating in the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS) to address the questions of whether such increases are worldwide and continuing and whether there are geographic patterns to any observed increases. The ICBDMS headquarters and individual systems provided the data. Systems were categorized into five groups based on gross domestic product in 1984. Hypospadias increases were most marked in two American systems and in Scandinavia and Japan. The increases leveled off in many systems after 1985. Increases were not seen in less affluent nations. Cryptorchidism rates were available for 10 systems. Clear increases in this anomaly were seen in two U.S. systems and in the South American system, but not elsewhere. Since 1985, rates declined in most systems. Numerous artifacts may contribute to or cause upward trends in hypospadias. Possible "real" causes include demographic changes and endocrine disruption, among others.

The return of thalidomide: are birth defects surveillance systems ready?

In the 1960s, thalidomide caused limb deficiencies in thousands of infants worldwide. The limb deficiencies were frequently of the intercalary type. As a result, numerous countries started birth defect surveillance programs. In 1967, the Centers for Disease Control (CDC) started the Metropolitan Atlanta Congenital Defects Program (MACDP), a population-based surveillance system, to provide early warning against new teratogens. Recent studies have shown that thalidomide may be beneficial for a range of conditions, including cancer and AIDS, and it may once again become widely available. Here, we examine the ability of MACDP to detect an increase in the birth prevalence of limb deficiency as an early warning of fetal exposure to thalidomide. We calculated base rates for all limb deficiencies, for bilateral nonsyndromic intercalary or preaxial deficiencies, and for all nonsyndromic intercalary limb deficiencies among Atlanta infants born from 1968 through 1993. We used relative risk estimates from previous studies and a range of pregnancy exposure rates for thalidomide. We tested the statistical power of MACDP to detect subtle changes in the birth prevalence of these defects using Poisson and cumulative sum (CUSUM) techniques. The base rates for all limb deficiencies, for bilateral intercalary or preaxial deficiencies, and for all intercalary limb deficiencies, were 0.53, 0.035, and 0.022/1,000, and the estimated relative risks were 175, 4,570, and 8,180, respectively. We varied the assumed rate of exposure to thalidomide from 1/10,000 to 5/100. With a 1/1,000 exposure rate, both Poisson and CUSUM techniques will detect a rate change in intercalary limb deficiency in about 6 months of monitoring, and a rate change in bilateral intercalary or preaxial deficiencies in about 12 months of monitoring. When monitoring all limb deficiencies, a pregnancy exposure rate of 3.5% or less would go unnoticed by the Poisson method and would take more than 50 years for the CUSUM method to signal an alarm with a 1/1,000 exposure rate. However, for rates of exposure less than 1/1,000, a progressively longer period of time or larger sample are needed to detect a rate change by both methods. Our findings highlight the importance of enlarging the monitored population and correct case classification in birth defects surveillance.

An evaluation of the Vermont worksite smoking law.

In view of the fact that the impact of statewide smoking laws on private worksite policies and the smoking behavior of employees has not been evaluated, two cross-sectional surveys were performed in Vermont to measure compliance with such a law: a random-digit telephone survey of employees and a subsequent mail survey of their employers. Employers were not aware that one of their employees had been surveyed. Roughly half (56 percent) of the employees and 66.5 percent of their employers described policies that are in compliance. Among all employers who described policies in compliance with the law, 68.1 percent of their employees also described compliant policies. Among all employees who described non-compliant policies, 48.8 percent had employers who described compliant policies. Overall, employees and employers agreed on how their policies stood with respect to compliance in 67.6 percent of cases. The prevalence and amount of smoking at work declined after the institution of the law but so did the prevalence and amount of smoking at home. Changes toward more restrictive policies were associated with reductions in cigarette consumption at work, but not with quitting. The study suggests that a large fraction of worksite smoking policies may not comply with a statewide worksite smoking law. The proportion of companies complying with such a law may be overestimated if information on compliance is obtained only from employers.

Maternal smoking and birth defects: validity of birth certificate data for effect estimation.

OBJECTIVES: The authors sought to assess the validity of birth certificate data for estimating the association between maternal smoking and birth defects. The US standard birth certificate includes check boxes for maternal smoking and for 21 congenital anomalies. The sensitivity and specificity of birth certificate data have been studied, but previous studies have not addressed the validity of these data for estimating the association between birth defects and maternal smoking or other risk factors. METHODS: US public-use natality data (1997-1998) were used to calculate the prevalence ratio (adjusted for maternal age, race/ethnicity, and education) for the association between maternal smoking and 13 defects/defect categories. All analyses were restricted to 45 states, New York City, and the District of Columbia because they collect both maternal smoking and birth defect data. RESULTS: Maternal smoking was associated with an increased prevalence of hydrocephaly (adjusted prevalence ratio [PR] = 1.24; 95% confidence interval [CI] = 1.08, 1.43), microcephaly (PR 1.47; 95% CI 1.15, 1.88), omphalocele/gastroschisis (PR 1.37; 95% CI 1.22, 1.53), cleft lip/palate (PR 1.35; 95% CI 1.25, 1.45), clubfoot (PR 1.62; 95% CI 1.49, 1.75), and polydactyly/syndactyly/adactyly (PR 1.33; 95% CI 1.23, 1.43 ). Previous studies have indicated an association between maternal smoking and gastroschisis, oral clefts, and clubfoot with effect estimates of similar magnitude to this study. CONCLUSIONS: These findings suggest that birth certificate data may be useful for exploratory or corroborative studies estimating the association between birth defects and some risk factors recorded on birth certificates.

Outcomes of a diabetes education program.

This study is the first part of an evaluation of a model program of education on diabetes mellitus for diabetic outpatients, currently in progress in Washington State. The program consists of 16 hours of education, covering all aspects of self-care, with an emphasis on the prevention of unnecessary morbidity from poor control of the disorder or from infections. Eighty-eight percent of participants included in this study had not had formal diabetes education since receiving their diagnosis. The average duration of participants' diabetes was more than 7 years, and their average age was 55 years. Participants were evaluated just before and 3 months after the education program. During this interval, they made significant improvements in their knowledge of diabetes and their attitudes toward and skills in managing the disorder, as well as in their degree of satisfaction with control. Moreover, their random blood glucose and glycosylated hemoglobin (Hb Alc) levels were significantly lower at the 3-month followup. The authors suggest that outpatient education offers a significant improvement in diabetic control.

Is Helicobacter pylori a cause of infantile hypertrophic pyloric stenosis?

My hypothesis is that infantile hypertrophic pyloric stenosis (IHPS) is caused in some cases by Helicobacter pylori (HP) a bacterium commonly found in the human stomach. IHPS is an idiopathic condition of infancy. It occurs at about 5 weeks of age in 3 per 1000 newborns. Children with IHPS have structurally normal pylori at birth and do not resemble children with congenital anomalies. Some nonspecific evidence (temporal distribution, seasonality, familial clustering, leukocytic infiltrates, and increased risk with bottle feeding) are compatible with an infectious etiology. Some other epidemiologic features of IHPS, such as its strong male predominance, its racial and social class variation, and a possible drop in its incidence, are also features of HP infection. Clinical features of IHPS, such as vomiting, hematemesis, and esophagitis, are also consistent with HP. Finally, children with IHPS appear to be more likely to develop chronic conditions, such as peptic ulcers, now known to be caused by HP.

Relationship of opioid prescription sales and overdoses, North Carolina.

BACKGROUND: In the United States, fatal drug overdoses have tripled since 1991. This escalation in deaths is believed to be driven primarily by prescription opioid medications. This investigation compared trends and patterns in sales of opioids, opioid drug overdoses treated in emergency departments (EDs), and unintentional overdose deaths in North Carolina (NC). METHODS: Our ecological study compared rates of opioid sales, opioid related ED overdoses, and unintentional drug overdose deaths in NC. Annual sales data, provided by the Drug Enforcement Administration, for select opioids were converted into morphine equivalents and aggregated by zip code. These opioid drug sales rates were trended from 1997 to 2010. In addition, opioid sales were correlated and compared to opioid related ED visits, which came from a Centers for Disease Control and Prevention syndromic surveillance system, and unintentional overdose deaths, which came from NC Vital Statistics, from 2008 to 2010. Finally, spatial cluster analysis was performed and rates were mapped by zip code in 2010. RESULTS: Opioid sales increased substantially from 1997 to 2010. From 2008 to 2010, the quarterly rates of opioid drug overdoses treated in EDs and opioid sales correlated (r=0.68, p=0.02). Specific regions of the state, particularly in the southern and western corners, had both high rates of prescription opioid sales and overdoses. CONCLUSIONS: Temporal trends in sales of prescription opioids correlate with trends in opioid related ED visits. The spatial correlation of opioid sales with ED visit rates shows that opioid sales data may be a timely way to identify high-risk communities in the absence of timely ED data.

Emergency department visits involving nonmedical use of selected prescription drugs in the United States, 2004-2008.

This report, adapted from the lead article in the June 10, 2010, issue of Morbidity and Mortality Weekly Reports, describes the alarming increase in overdose deaths involving prescription drugs. Oxycodone, hydrocodone, and methadone were the drugs most highly implicated. Data were derived from the federal Drug Abuse Warning Network (Dawn). Other drugs commonly used in managing pain patients, including benzodiazepines and muscle relaxants, also were implicated.

United States pedestrian fatality rates by vehicle type.

OBJECTIVE: To describe the relation between motor vehicle type and the risk of fatally injuring a pedestrian. DESIGN: The risk of killing a pedestrian was measured as the number of pedestrian fatalities per billion miles of vehicle travel by each vehicle type in the US in 2002 as reported by the National Highway Traffic Safety Administration's Fatality Analysis Reporting System. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Rates for each vehicle type by sex, age, and rural/urban roadway type and rate comparisons using relative risks (RR) and 95% confidence intervals (CIs). RESULTS: Passenger cars and light trucks (vans, pickups, and sport utility vehicles) accounted for 46.1% and 39.1%, respectively, of the 4875 deaths, with the remainder split among motorcycles, buses, and heavy trucks. Compared with cars, the RR of killing a pedestrian per vehicle mile was 7.97 (95% CI 6.33 to 10.04) for buses; 1.93 (95% CI 1.30 to 2.86) for motorcycles; 1.45 (95% CI 1.37 to 1.55) for light trucks, and 0.96 (95% CI 0.79 to 1.18) for heavy trucks. Compared with cars, buses were 11.85 times (95% CI 6.07 to 23.12) and motorcycles were 3.77 times (95% CI 1.40 to 10.20) more likely per mile to kill children 0-14 years old. Buses were 16.70 times (95% CI 7.30 to 38.19) more likely to kill adults age 85 or older than were cars. The risk of killing a pedestrian per vehicle mile traveled in an urban area was 1.57 times (95% CI 1.47 to 1.67) the risk in a rural area. CONCLUSIONS: Outcomes reflect the ways in which a vehicle's characteristics (mass, front end design, and visibility) and its degree of interaction with pedestrians affect its risk per mile. Modifications in vehicle design might reduce pedestrian injury. The greatest impact on overall US pedestrian mortality will result from reducing the risk from the light truck category.

Fatal logging injuries in Washington state, 1977 to 1983.

The logging fatalities in Washington state during the years 1977 to 1983 were analyzed using death certificates and the investigations of the Washington Department of Labor and Industries. Each source identified more than 92% of the 135 fatalities. The annual injury mortality rate for logging was approximately 2/1,000 workers. Loggers were killed by falling trees in 34% of fatalities and by equipment in 24% of fatalities. None of the 12 men killed in vehicle rollovers were wearing seat belts. Risk was greatest for tree fellers and choker-setters. Risk was also greatest during the morning, during the first two days of the workweek, and during the month of June. Size of logging company was inversely related to risk of injury, with the smallest companies having mortality ratios ten times higher than the largest companies. The study suggests that routinely collected occupational data on injuries and employment can be combined to identify high-risk categories in specific industries and thereby target inspection activities or suggest new regulations addressing specific occupational hazards.

The relation between small size for gestational age and the sex ratio of children with birth defects.

BACKGROUND: Infants with birth defects are more likely to be born small for gestational age (SGA) than are other infants. This study describes a relation noted between the percentage SGA and the percentage male among children with various defect types. The data source was case records collected by the Metropolitan Atlanta Congenital Defects Program, a population-based, active surveillance system, during 1968 through 1998. METHODS: The study calculated the correlation between the percentage male and the percentage SGA for isolated cases of 44 different defect types for male-dominant and female-dominant defects separately. RESULTS: The correlation coefficient was -0.47 (P < 0.01) for male-dominant defects and 0.20 (P > 0.05) for female-dominant defects. Male-dominant defects were more likely to show less than 15% SGA and more likely to show the strongest risk differences by sex. CONCLUSIONS: These results are consistent with genetic causation of strongly skewed sex ratios, at least among male-dominant defects. Review of the literature suggests that defects with sex ratios closer to 1 are likely to have lower recurrence risks and therefore are less likely to be inherited than are other defects with skewed sex ratios. Sex ratios closer to 1 and a high percentage SGA may be markers of acquired or environmental birth defects.

Fatal injuries in the construction industry in Washington State.

Two hundred thirty-one deaths occurred in the construction industry in Washington State between 1973 and 1983, an average annual mortality rate of 27.5 per 100,000 workers. Falls, cave-ins, and electrocutions resulting from heavy equipment (boom type) contacting overhead power lines together accounted for 45.4% of the fatalities. Heavy construction had a death rate twice that of the other two construction subgroups (building and special trades construction). There was a significant trend towards increasing mortality with decreasing company size (p = 0.03). Drilling machine operators, welders, flamecutters, reinforcing-iron workers, and heavy-equipment operators had the highest proportionate mortality ratios (PMRs). PMRs for workers generally increased with age. Many of these fatal construction injuries would not have occurred had existing safety regulations been observed.

Sex differences in the prevalence of human birth defects: a population-based study.

BACKGROUND: Sex differences in the prevalence of several human birth defects have often been reported in the literature, but the extent of sex differences for most birth defects is unknown. To determine the full extent of sex differences in birth defects in a population, we examined population-based data from the Metropolitan Atlanta Congenital Defects Program (MACDP). METHODS: MACDP records were analyzed for 1968 through 1995. We determined the sex-specific prevalence of all major birth defects, using the total number of live births by sex during these years as the denominator. For each specific defect, we calculated a relative risk with regard to sex on the basis of the ratio of prevalence among males to prevalence among females. Male-female relative risks were also determined for total major birth defects and for several broad categories of defects. RESULTS: The overall prevalence of major defects at birth was 3.9% among males and 2.8% among females. All but two of the major categories of birth defects (nervous system defects and endocrine system defects) had a higher prevalence among males. Defects of the sex organs were eight and one-half times more prevalent among males and accounted for about half of the increased risk of birth defects among males relative to females. Urinary tract defects were 62% more prevalent among males, and gastrointestinal tract defects were 55% more prevalent among males. Among specific defect types, twofold or greater differences in prevalence by sex were common. CONCLUSIONS: Our data indicate that sex differences in the prevalence of specific human birth defects are common, and male infants are at greater risk for birth defects than female infants. Several mechanisms have been proposed to account for these differences.

Survival of infants with spina bifida: a population study, 1979-94.

This study aimed to investigate the survival of infants born with spina bifida between 1979 and 1994 from the population-based Metropolitan Atlanta Congenital Defects Program (MACDP) and to identify clinical and demographic factors associated with survival. Survival status was obtained from MACDP records and the National Death Index. Survival rates were calculated using the Kaplan-Meier method. Risk factors potentially associated with survival were examined by the log-rank test. We assessed the independent effect of risk factors using the Cox proportional hazards model. Overall, 78.4% of children with spina bifida survived during the study period. Of the 235 infants born with spina bifida, 87.2% survived the first year of life. Survival to age 1 for the 1979-83, 1984-88 and 1989-94 birth cohorts was 82.7%, 88.5% and 91.0% respectively. In multivariable analysis, factors associated with increased mortality were low birthweight (<2500 g) (vs. > or =2500g, relative risk (RR) 2.3 [95% CI 1.1, 4.9]) and high lesions (vs. low lesions, RR 3.4 [95% CI 1.6, 7.1]). This study suggests a continuous improvement in survival among children born with spina bifida in Atlanta. Demographic and clinical factors are associated with length of survival. This information is useful for both clinicians and families who need to plan for the long-term care of these children.