Two cases of intoxication with new synthetic opioid, U-47700.

BACKGROUND: Novel substances often referred to as "designer drugs" have emerged as drugs of abuse, and recognition of these is difficult as routine blood and urine screening tests do not detect these agents. U-47700 is a synthetic selective µ-opioid agonist that can be bought online for as little as $40 per gram. We report two patients presenting after insufflation of U-47700, with subsequent confirmation of this substance in urine samples. CASE DETAILS: A 26-year-old man and 24-year-old woman insufflated a substance they believed to be "synthetic cocaine." The man was found down with cyanosis and agonal respirations. He was intubated and taken to hospital where he recovered well with supportive care. The woman presented with anxiety, tremors and drowsiness and was admitted for observation. Urine samples from both patients were analyzed using GC/MS/MS and LC/QToF, and U-47700 was isolated in both cases. No other opioids were detected. DISCUSSION: These cases are concerning because U-47700 is a relatively new agent that is easy to obtain over the internet and has the potential to cause significant morbidity and mortality.

Risk factors for positive mantoux tuberculin skin tests in children in San Diego, California: evidence for boosting and possible foodborne transmission.

OBJECTIVES: Source case finding in San Diego, California, rarely detects the source for children with tuberculosis (TB) infection or disease. One third of all pediatric TB isolates in San Diego are Mycobacterium bovis, a strain associated with raw dairy products. This study was conducted to determine risk factors for TB infection in San Diego. DESIGN: Case-control study of children /=10 mm) Mantoux skin test (TST) were matched by age to 1 to 2 children with negative TST from the same clinic. We assessed risk factors for TB infection through parental interview and chart review. RESULTS: A total of 62 cases and 97 controls were enrolled. Eleven cases and 25 controls were excluded from analysis because of previous positive skin tests. Compared with controls, cases were more likely to have received BCG vaccine (73% vs 7%, odds ratio [OR] 44), to be foreign born (35% vs 11%, OR 4.3), and to have eaten raw milk or cheese (21% vs 8%, OR 3.76). The median time between the most recent previous TST and the current test was 12 months for cases and 25 months for controls. Other factors associated with a positive TST included foreign travel, staying in a home while out of the country, and having a relative with a positive TST. There was no association between contact with a known TB case. In a multivariable model, receipt of BCG, contact with a relative with a positive TST, and having a previous TST within the past year were independently associated with TB infection. CONCLUSIONS: We identified several new or reemerging associations with positive TST including cross border travel, staying in a foreign home, and eating raw dairy products. The strong associations with BCG receipt and more recent previous TST may represent falsely positive reactions, booster phenomena, or may be markers for a population that is truly at greater risk for TB infection. Unlike studies conducted in nonborder areas, we found no association between positive TB skin tests and contact with a TB case or a foreign visitor. Efforts to control pediatric TB in San Diego need to address local risk factors including consumption of unpasteurized dairy products and cross-border travel. The interpretation of a positive TST in a young child in San Diego who has received BCG is problematic.

Tuberculosis cases reported among migrant farm workers in the United States, 1993-97.

Migrant farm workers (MFWs) are considered a high-risk group for tuberculosis. MFW tuberculosis cases reported to the Centers for Disease Control and Prevention represented 1 percent of all reported tuberculosis cases from 1993 to 1997. Most of these cases (70 percent) were reported from Florida, Texas, and California. MFW tuberculosis cases were more likely to be male, foreign-born, or Hispanic and to have a history of alcohol abuse and homelessness than were non-MFWs. Most (79 percent) foreign-born MFWs were from Mexico. HIV status was poorly reported, with results available for only 28 percent of MFW and 33 percent of non-MFW cases. Of the MFWs tested, 28 percent were HIV infected, whereas 34 percent of non-MFWs were HIV infected. Twenty percent of MFWs move or are lost to follow-up before completing therapy; these cases pose a management challenge for the nation's tuberculosis control efforts.

Syphilis among HIV-infected mothers and their infants in Texas from 1988 to 1994.

BACKGROUND: Syphilis was investigated in a group of HIV-infected women and their infants. GOAL: To assess syphilis morbidity among HIV-infected women and their infants. Among women with syphilis during pregnancy, the risks for delivering an infant with congenital syphilis were assessed. STUDY DESIGN: Through the Pediatric Spectrum of HIV Disease project, Texas infants born to HIV-infected women were identified. After the infants were matched with their mothers, it was determined which had been reported as syphilis cases. RESULTS: In this study 18% of the HIV-infected mothers were reported as syphilis cases, most during pregnancy. Half of these mothers delivered infants (n = 49) with congenital syphilis. Inadequate prenatal care was the only significant risk for delivering an infant with congenital syphilis. The congenital syphilis rate among Texas infants of HIV-infected mothers was 48.8 per 1,000 live births. CONCLUSION: The congenital syphilis rate among Texas infants born to HIV-infected mothers was almost 50 times that of the general population.

Using DNA fingerprinting to detect transmission of Mycobacterium tuberculosis among AIDS patients in two health-care facilities in Puerto Rico.

BACKGROUND: Fourteen cases of tuberculosis (TB) in Puerto Rico, diagnosed from April 1993 to April 1995, had the same DNA fingerprint, documenting disease caused by the same strain of Mycobacterium tuberculosis. The 14 cases were retrospectively investigated for epidemiologic links. METHODS: Records were reviewed and staffs of the TB program, hospital/clinic, and AIDS residential facilities were interviewed. RESULTS: Half of the AIDS cases were epidemiologically related, providing evidence of TB transmission in an emergency department, an AIDS inpatient ward, and an AIDS residential facility. DNA fingerprinting allowed detection of M tuberculosis transmission, but contact investigators could have documented it sooner. Factors contributing to transmission included delayed diagnosis, prolonged infectiousness, inadequate discharge planning and infection control procedures, and poor communication between health-care facilities. CONCLUSIONS: The numbers of AIDS residential facilities are increasing and must understand proper monitoring of TB patients and infection control measures that prevent transmissions.

Immunization status of children born to human immunodeficiency virus (HIV)-infected mothers in two Texas cities.

BACKGROUND: Because HIV-infected and HIV-exposed children are at risk of acquiring infectious diseases, they should be immunized. METHODS: We abstracted charts at pediatric HIV clinics in Dallas and San Antonio, matched the children to birth certificates and assessed up-to-date immunization status. RESULTS: Of the 178 children, 108 (61%) were up to date for the diphtheria-tetanus-pertussis (DTP), polio, and measles-mumps-rubella (MMR) series. In multivariate analysis, predictors of delayed immunization included maternal high-risk sexual partners and infant antiretroviral therapy. CONCLUSION: In this population of children born to HIV-infected mothers, immunizations were up to date in 61%, a figure that exceeds or equals immunization levels for other Texas children. Texas falls short of the recommended goal of 90% immunization for children of HIV-infected mothers and healthy children.

Tuberculosis screening in private physicians' offices, Pennsylvania, 1996.

OBJECTIVE: To assess tuberculin skin testing practices of physicians after community-wide screening of 1400 children exposed to a pediatrician with active tuberculosis (TB). DESIGN: A self-administered questionnaire. SETTING: Medium-sized city in eastern Pennsylvania. PARTICIPANTS: Pediatricians and family practitioners seeing pediatric patients. MAIN OUTCOME MEASURES: Percentages of physicians who followed published recommendations for placement and reading of TB skin tests published by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC). RESULTS: Questionnaires were completed by 60/80 (75%) physicians. The 60 physicians had practiced a mean of 17 years (range 3-38 years), and only one did not do TB skin testing for pediatric patients. The 59 physicians doing TB skin testing reported routinely tuberculin testing more than 900 children per month. Only 8/59 (14%) physicians followed published guidelines for placement and reading of tuberculin tests. Those physicians screened 158 (17%) of the pediatric patients undergoing TB skin testing in a typical month. CONCLUSION: In this community where a highly publicized TB case prompted massive pediatric screening, most physicians seeing children in private practice do not follow standard TB skin testing guidelines. Increased understanding of how private-practice physicians learn about and decide to use recommended standards are needed if tuberculin tests are to be correctly performed and TB appropriately diagnosed.

Tuberculin skin test screening practices among US colleges and universities.

CONTEXT: Concern about transmission of Mycobacterium tuberculosis on college campuses has prompted some schools to institute tuberculin skin test screening of students, but this screening has never been evaluated. OBJECTIVE: To describe tuberculin skin test screening practices and results of screening in colleges and universities in the United States. DESIGN AND SETTING: Self-administered mail and telephone questionnaire in November and December 1995 to a stratified random sample of US 2-year and 4-year colleges and universities. MAIN OUTCOME MEASURES: Type of tuberculin screening required; types of schools requiring screening; number and rate of students with positive skin test results and/or diagnosed as having tuberculosis. RESULTS: Of the 3148 US colleges and universities, 624 (78%) of 796 schools surveyed responded. Overall, 378 schools (61%) required tuberculin screening; it was required for all new students (US residents and international students) in 161 (26%) of 624 schools, all new international students but not new US residents in 53 (8%), and students in specific academic programs in 294 (47%). Required screening was more likely in 4-year vs 2-year schools, schools that belonged to the American College Health Association vs nonmember schools, schools with immunization requirements vs schools without, and schools with a student health clinic vs those without (P<.001 for all). Public and private schools were equally likely to require screening (64% vs 62%; P=.21). In the 378 schools with screening requirements, tine or multiple puncture tests were accepted in 95 (25%); test results were recorded in millimeters of induration in 95 (25%); and 100 (27%) reported collecting results in a centralized registry or database. Of the 168 (27%) of 624 schools accepting only Mantoux skin tests and reporting results for school years 1992-1993 through 1995-1996, 3.1% of the 348 368 students screened had positive skin test results (median percentage positive, 0.8%). International students had a significantly higher case rate for active tuberculosis than US residents (35.2 vs 1.1 per 100000 students screened). CONCLUSIONS: Widespread tuberculin screening of students yielded a low prevalence of skin test reactors and few tuberculosis cases. To optimize the use of limited public health resources, tuberculin screening should target students at high risk for infection.

Violence and threats of violence experienced by public health field-workers.

CONTEXT: Public health workers may work with clients whose behaviors are risks for both infectious disease and violence. OBJECTIVE: To assess frequency of violent threats and incidents experienced by public health workers and risk factors associated with incidents. DESIGN: Anonymous, self-administered questionnaires. SETTING: Texas sexually transmitted disease (STD), human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), and tuberculosis (TB) programs. PARTICIPANTS: Questionnaires were completed by 364 (95.5%) of 381 public health workers assigned to the programs. The STD program employed 131 workers (36%), the HIV/AIDS program, 121 workers (33%), and the TB program, 112 workers (31%). MAIN OUTCOME MEASURES: The frequencies with which workers had ever experienced (while on the job) verbal threats, weapon threats, physical attacks, and rape, and risk factors associated with those outcomes. RESULTS: A total of 139 (38%) of 364 workers reported 611 violent incidents. Verbal threats were reported by 136 workers (37%), weapon threats by 45 (12%), physical attacks by 14 (4%), and rape by 3 (1%). Five workers (1%) carried guns and/or knives while working. In multiple logistic regression, receipt of verbal threats was associated with worker's male sex (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.5-4.0), white ethnicity (OR, 2.4; 95% CI, 1.4-4.1), experience of 5 years or longer (OR, 2.2; 95% CI, 1.3-3.8), weekend work (OR, 1.8; 95% CI, 1.1-3.1), and sexual remarks made to the worker by clients (OR, 2.0; 95% CI, 1.2-3.5). Receipt of weapon threats was associated with worker's male sex (OR, 5.7; 95% CI, 2.4-15.3), white ethnicity (OR, 4.0; 95% CI, 1.8-9.3), age of 40 years or older (OR, 2.5; 95% CI, 1.1-5.8), work experience of 5 years or longer (OR, 2.7; 95% CI, 1.2-6.0), rural work (OR, 3.6; 95% CI, 1.3-10.1), being alone with the opposite sex (OR, 3.7; 95% CI, 1.6-9.7), and interaction with homeless clients (OR, 5.2; 95% CI, 1.7-18.8). Physical attacks were associated with sexual remarks made to the worker by clients (OR, 4.2; 95% CI, 1.4-13.9). No risk factors predicting rape were identified. CONCLUSIONS: Violence directed toward public field-workers is a common occupational hazard. An assessment of what situations, clients, and locations pose the risk of violence to public health workers is needed.

Use of Texas birth certificate data to predict measles immunization status.

Inadequate immunization has been a major cause of epidemic measles, but risk factors for inadequate immunization are poorly characterized. By using measles data bases and computerized birth certificate files, we identified a retrospective cohort of 1,070 Texas-born children who were aged 15 months to 10 years when they had measles during the 1988 to 1991 epidemics. We used measles and birth certificate data, including prenatal care and demographic information, to determine immunization status and risk factors for inadequate measles immunization. Risk factors predicting lack of immunization in children with measles in stepwise logistic regression were black ethnicity, urban residence, poor prenatal care, preschool age, and an unknown father. Birth certificates contain information that can predict inadequate measles vaccination and should be evaluated prospectively.

Recommendations for treatment of chancroid, 1993.

Since the 1989 Sexually Transmitted Diseases Treatment Guidelines were published by the Centers for Disease Control and Prevention, changes in the efficacy of the recommended and alternative regimens for the treatment of Haemophilus ducreyi infections have been described. Among recommended agents, erythromycin remains effective, and although a single dose of ceftriaxone appears to remain effective in the United States, limited data from Kenya have shown that this regimen has been associated with treatment failures. Of alternative treatment regimens, trimethoprim-sulfamethoxazole has been associated with widespread failure, but little work has been done to further evaluate the efficacy of the amoxicillin/clavulanic acid and ciprofloxacin regimens. Of the new antimicrobials, azithromycin has been very effective in the United States, but the efficacy of this drug elsewhere has not been thoroughly evaluated. Fleroxacin has been very effective in Kenya. Data from Africa indicate that patients who are infected with the human immunodeficiency virus do not respond to therapy as well as patients who are not, and patients who are uncircumcised may not respond as well to therapy as do patients who are circumcised.

Purified protein derivative tuberculin and delayed-type hypersensitivity skin testing in migrant farm workers at risk for tuberculosis and HIV coinfection.

OBJECTIVE: To assess the joint use of purified protein derivative (PPD) and delayed-type hypersensitivity (DTH) antigens in screening individuals of unknown HIV serostatus for tuberculosis (TB) preventive therapy eligibility. DESIGN: Population-based survey. METHODS: A group of migrant farm workers were screened for HIV and skin-tested with PPD, tetanus toxoid (TET), Candida albicans (CAN) and mumps (MUM) antigens by the Mantoux method. Anergy was defined as a < or = 2 mm reaction to all four antigens. Eligibility for preventive therapy was defined as a reaction of > or = 5 mm to PPD among HIV-seropositive individuals, > or = 10 mm among HIV-seronegatives, or anergy. RESULTS: A total of 253 out of 271 individuals had sufficient data for analysis. Of these, 15 (5%) were HIV-seropositive; 183 (75%), 175 (72%) and 157 (65%) reacted to TET, CAN, and MUM, respectively, and 113 (47%) were eligible for preventive therapy [108 (44%) PPD-positive, five (2%) anergic]. Use of PPD alone was 95% sensitive for detecting preventive therapy eligibility; PPD plus one DTH antigen was more sensitive (99%) but less specific (range, 69-85%); PPD plus two DTH antigens was most specific (CAN + MUM, 84%; TET + MUM, 93%; and TET + CAN, 100%). CONCLUSIONS: In this population with 5% HIV seroprevalence, testing for anergy did not significantly increase the detection of preventive therapy eligibility. The use of two DTH antigens is very sensitive and specific. These results support the recommendation of joint PPD and anergy testing for the screening of HIV-seropositive individuals. Our data also suggest, however, that for individuals whose HIV serostatus is unknown, anergy testing should be considered as a screening tool only if the prevalence of anergy is expected to exceed the prevalence of PPD positivity.

Outbreaks of syphilis in rural Texas towns, 1991-1992.

Between 1986 and 1990, rates of primary and secondary syphilis increased 134% in rural counties in the South. Reasons for the increases are speculative. During the 14 months ending in October 1992, outbreaks in four eastern Texas counties provided an opportunity to characterize syphilis in rural Texas. We reviewed records for 118 patients and 339 sex partners. Three outbreaks were concentrated in neighborhoods where crack cocaine dealers conducted business and exchange of sex for drugs or money was common; the fourth outbreak involved out-of-town prostitutes who visited undocumented alien workers. Among the 118 syphilis cases, 15 (13%) were primary, 35 (30%) were secondary. Most patients were black (105, 89%); the male-female ratio was 1:1. One woman gave birth to an infant with congenital syphilis. Almost half of the sex partners were infected. HIV pretest counseling was completed for only 55 patients (47%), and only 23 (19%) were tested for the human immunodeficiency virus. These four rural outbreaks of syphilis associated with crack cocaine and the exchange of sex for drugs or money mirror recent urban syphilis outbreaks. Patients in these rural syphilis outbreaks are at risk for HIV infection, but HIV testing has not been emphasized by public health workers.

Initial STD visits by adolescent females, Dallas County, Texas.

Sexually active adolescents are at high risk for unintended pregnancy and sexually transmitted diseases. We identified a cohort of 6089 women aged 13 to 21 years who in 1985 either delivered an infant at Parkland Hospital (3154) or used the outpatient clinics (2935). We reviewed those records and others in the Dallas County sexually transmitted disease (STD) clinic for the period 1983 through 1988 to determine the prevalence of visits to the Dallas County STD clinic by pregnant and nonpregnant adolescents, STD diagnoses at initial visit, whether STD visits and diagnoses varied by pregnancy status or ethnic background, and how the women were referred to the STD clinic. Similar percentages of nonpregnant (13%) and pregnant (11%) women had an STD visit, and most adolescents who visited the STD clinic had an STD diagnosis made. Gonorrhea and syphilis were the STDs diagnosed most frequently in both pregnant and nonpregnant adolescents. Regardless of pregnancy status, black adolescents were 7.3 times more likely to have an STD visit. Referral by a sexual partner was the second most common reason that adolescents sought STD care. Our study provides only minimal estimates of STDs among adolescents but indicates STDs, regardless of pregnancy status, are a more common medical problem than has been reported previously. Referral by sexual partners may be an important way to reach adolescents at risk for STDs.

Chancroid in the United States, 1981-1990: evidence for underreporting of cases.

Chancroid, a bacterial sexually transmitted disease (STD) characterized by genital ulceration, has reemerged in the United States during the last decade. From 1950 to 1980, cases were infrequently reported. After an epidemic in California in 1981, however, the numbers of cases increased, peaking in 1987 at 5,035. Despite a subsequent decline in numbers of reported cases to 4,223 in 1990, new areas continue to report outbreaks. Interpreting chancroid surveillance data is difficult because confirmatory culture media are not commercially available. In addition, states may not require that unconfirmed or even confirmed cases be reported. To determine if chancroid is more widely distributed than surveillance figures indicate, CDC contacted STD clinics in 115 health departments, located in 32 states, the District of Columbia, and Puerto Rico--areas chosen because they had reported five or more cases of chancroid in any single year during 1986-1990--to determine if cases might be occurring but not reported. Only 16 of the 115 clinics had culture media available for Haemophilus ducreyi, and only nine had laboratory facilities complete enough to definitively diagnose chancroid, syphilis, or genital herpes, the most common STDs characterized by genital ulcers. Five or more clinically likely cases occurring in 1990 were identified in 24 states, seven more than surveillance figures indicated. Surveillance can be improved if a) states utilize the definitions for chancroid cases adopted for use in 1990 and b) microbiology laboratories utilize enhanced diagnostic methods.

Diagnosis and therapy for common sexually transmitted diseases.

During the past decade, as the human immunodeficiency virus (HIV) has appeared, sexually transmitted diseases (STDs) have resurged to epidemic proportions, and STDs have been shown to facilitate transmission of HIV, the diagnosis and treatment of STDs have increased in importance for all clinicians. This article's recommendations for treatment of STDs that might more commonly be seen in a dermatology practice are based on the 1989 Sexually Transmitted Disease Treatment Guidelines of the Centers for Disease Control. Clinicians are encouraged to address actively prevention and treatment of sexual partners, a very important part of the management of STDs.

Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988.

Family practice physicians and pediatricians in Dallas County, Texas, were surveyed to determine how recent vaccine price increases have changed immunization referral patterns. A total of 73% of responding physicians referred some pediatric patients for immunization in 1988. Public health clinics were the largest referral source with more responding pediatricians (84.4%) referring patients than did responding family practitioners (66.5%). Referrals to the clinics were most often made when patients were unable to afford immunizations in a private practice setting. Between 1979 and 1988, the number of responding pediatricians and family practitioners making immunization referrals increased by 193% and 391%, respectively. The percentages of children referred for immunization increased by 693% during the same decade. It was suggested by our survey of Dallas County physicians that a new influx of patients are using public sector immunizations, potentially creating additional financial stress for public health programs. In addition, this shift to the public sector may undermine the health departments' ability to provide new vaccines or protect greater numbers of children with immunization.

Mechanism of fasting-induced suppression of acetaminophen glucuronidation in the rat.

These studies have revealed the occurrence of important relationships among nutritional status, hepatic intermediary metabolism, acetaminophen glucuronidation and susceptibility to hepatotoxicity. During an acute fast hepatic metabolism of glucose is altered profoundly. The altered metabolic poise of the fasted liver appears to favor higher G6P'-ase activity relative to UDPG pyrophosphorylase activity, resulting in decreased production of UDPG secondary to depleted glycogen levels. Although the rate of gluconeogenesis is enhanced and maintains UDPG levels at approximately 60% of those in fed animals, the decreased production of UDPG limits the rate of UDPGA synthesis for glucuronidation of high doses of acetaminophen. Since glucuronidation is the major pathway of clearance of these high doses of the drug, UDPG synthesis is rate-limiting for acetaminophen elimination; the resulting prolongation of the drug half-life is associated with increased amount of reactive metabolite formed and potentiation of liver injury. Glucuronidation is also the major pathway of clearance in the human overdose situation and if UDPG production occupies a similar rate-determining role, then enhancement of UDPG production might be of significant value in the therapy of acetaminophen overdosage. Thus, determination of factors which control UDPG production in the liver under different physiological (nutritional/hormonal) conditions has both fundamental and practical value.

Root canal procedure for disarming nonhuman primates.

Nonhuman primates were disarmed by shortening their canine teeth. These teeth were cut off near the gingival level, the entire pulpal tissue removed and the canal filled with a formulated paste which was radiopaque, adhesive and germicidal. The teeth were sealed with a commercial alloy. This endodontic procedure was a quick, practical one-step method for permanently disarming nonhuman primates.