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Leptospirosis is a zoonotic disease with symptoms in humans and animals, ranging from subclinical to serious and fatal. The disease occurs worldwide, but there is limited recognition of the public and animal health risks it poses in the southern United States. A systematic review of the frequency of animal leptospirosis in 17 states and jurisdictions covering the southern continental United States was performed to advance our understanding of the pathogen's distribution and identify transmission patterns that could be targeted for prevention efforts. Fifty-two articles, spanning >100 years, met the analysis criteria. A wide range of techniques were used to measure seroprevalence and isolate the bacteria. The assessment identified exposure to Leptospira spp and Leptospira spp infection among a diverse range of species, spanning 22 animal families within 14 states, suggesting that the pathogen is distributed throughout the southern region. Disease frequency trends were assessed among animals in various habitats (all habitats, nonwild habitats, and wild habitats). The frequency of Leptospira spp detection in animals in wild habitats increased slightly over time (<0.2%/year). We identified reports of 11 human leptospirosis illness clusters and outbreaks in the southern United States. Exposure to potentially contaminated surface waters were documented for at least seven of the events, and interactions with infected or likely infected animals were documented for at least six of the events. This analysis highlights the need for stronger partnerships across the public and animal health fields to enhance diagnostics, surveillance, and reporting. The early identification of leptospirosis in animals may serve as an indicator of environmental contamination and trigger prevention measures, such as vaccinating companion animals and livestock, use of potable water, and the wearing of waterproof protective clothing near water that may be contaminated.

Objectives: Uric acid (UA) control may be insufficient in chronic kidney disease (CKD) patients in the current era. It is unclear, however, whether this is the result of environmental effects, patient anthropometrics or insufficient dosing of medical therapy (allopurinol)., Methods: We have collected data on multiple clinical and laboratory parameters of 114 CKD clinic patients attending the nephrology clinic of the University of Mississippi Medical Center with an estimated glomerular filtration rate <45 mL · min -1 · 1.73 m 2 . We assessed the correlates of UA levels and the allopurinol doses along with achieved serum UA and urine pH., Results: The cohort consisted of middle-aged to elderly patients with a mean (± standard deviation) age of 62.1 (11.6) years; 45.6% were female, 68.4% were African American and 47.4% had a history of gout. The mean UA level was 7.7 (2.49) mg/dL (range 3.1-16), allopurinol dose was 192 (99) mg/day (range 50-450) and estimated glomerular filtration rate was 23.8 (11.3) mL · min -1 · 1.73 m 2 . While the overall serum bicarbonate level was 25 (3.2) mEq/L, urine pH was <6 in 60.5% of the cohort. Significant univariate correlates of the administered doses of allopurinol were weight ( r 0.317, P = 0.001), body mass index (BMI; r 0.313, P = 0.001), and female sex ( r - 0.198; P = 0.035). Achieved UA levels correlated directly with BMI ( r 0.201, r = 0.036) but inversely with the allopurinol dose ( r -0.196; P = 0.036). During logistic regression analysis with stepwise selection, only weight (β 0.313, P = 0.001) and sex (β -0.190, P = 0.039) proved to be predictive of the allopurinol dose; as for the achieved UA level, only BMI (β 0.271, P = 0.006) and the allopurinol dose (β -0.258; P = 0.009) had a significant effect., Conclusions: In patients with advanced CKD, conventional dosing recommendations for allopurinol are unlikely to suffice in reaching target serum UA goals. In our cohort, larger-than-usual allopurinol doses were well tolerated.

Objectives: This study examined the association between social support and health-related quality of life (HRQoL) among low-income women in the southeastern region of the United States., Methods: Analysis was performed on data from a community needs assessment survey that was designed to explore social determinants of health and QoL indicators using a community-based participatory research approach. The study sample comprised 132 women aged 18 years old and older. Bivariate analysis and logistic regressions with bootstrapping were performed., Results: Social support was predictive of physical and mental HRQoL in a contrasting fashion, suggesting a complex relation. Other social determinants of global HRQoL independent of social support status include marital and employment status, maternal age, and income. Our results also demonstrate complex interaction patterns across race, social support, and HRQoL., Conclusions: The linkage between social support and HRQoL may not be a simple relation, as previously assumed. Rather, it is characterized by multifaceted interactions through which social determinants of health modulate the impact of social support on HRQoL. These are new findings.

Objective: To compare the maternal mortality rate (MMR) in the Mississippi Delta region of the United States with that of the non-Delta region states., Methods: Analyzed data come from national birth certificate and death certificate data for 1999-2007. Data were aggregated for analysis by region, counties of the Delta Regional Authority, non-Delta regions of the eight Delta states, and the 42 non-Delta states. The MMR was calculated using birth data as the denominator and maternal mortality data as the numerator., Results: During the 9 years of the study, there were more than 36 million births in the United States and 5002 reported maternal deaths. The national MMR was 13.5/100,000 (95% confidence interval [CI] 13.1-13.9/100,000). The MMR reported in the non-Delta states was 13.6/100,000 (95% CI 13.2-14.0/100,000); in the non-Delta counties of the Delta states, the MMR was 13.1/100,000 (95% CI 12.1-14.0/100,000); and the MMR was 18.5/100,000 (95% CI 16.1-20.9/100,000) in Delta counties. The odds of maternal death in Delta counties is 1.39 times (95% CI 1.22-1.59) higher compared with non-Delta counties or non-Delta states. There was no statistically significant difference between the MMR in non-Delta states and the MMR in non-Delta counties of Delta states. After controlling for maternal race/ethnicity, age, marital status, and education in a multivariable model, the MMR in the Delta counties compared with non-Delta counties and non-Delta states remains significantly increased (odds ratio 1.16, 95% CI 1.01-1.32)., Conclusions: Overall, maternal mortality is significantly greater in the Delta region of the United States compared with the non-Delta portion. After controlling for maternal race/ethnicity, age, marital status, and education, the odds of maternal death remains 16% higher in the Delta region of the United States compared with the non-Delta United States.

Objective: Type 2 diabetes is a common disease, afflicting more than 20 million Americans. Psychiatric disorders, particularly depression, have been previously correlated with diabetes., Methods: The objectives of this study were to determine the frequency of psychiatric illnesses in a type 2 pediatric diabetic cohort and to examine if there were any significant demographic differences between diabetic children with psychiatric disorders and diabetic children without psychiatric disorders. A retrospective chart review was performed on patients from two southeastern children's hospitals., Results: In our study, 26.2% (67 of 256) of diabetic patients were diagnosed with neuropsychiatric disorders (NPD). A comparison between gender frequencies of affected and unaffected patients suggested a statistical difference (P = 0.009). It appears that pediatric diabetic males are affected with NPD to a greater extent than females. Patients diagnosed with neurological disorders showed a body mass index average of 39.03, which was statistically different from non-diagnosed NPD patients (P = 0.0313)., Conclusions: To our knowledge, this is the first report to demonstrate the frequency of psychiatric disorders in a cohort of pediatric type 2 diabetics in the southeastern US. This study provides information regarding children afflicted with type 2 diabetes mellitus and the frequency of neuropsychiatric morbidities. This information may be useful for crafting future health policies and quality improvement interventions.

The southern and eastern margins of the range of the brown recluse spider run through the southeastern quadrant of the United States. Populations vary from abundant in states such as Arkansas and west and central Kentucky and Tennessee to absent in the Atlantic seaboard states. The diagnosis of loxoscelism should be restricted to areas of the southeastern United States where brown recluse spiders are both common and widespread. Better knowledge of the local presence of recluse spiders in one's area, along with the list of differential diagnoses for dermonecrosis, will allow medical personnel in the south to better assess the probability of spider involvement in a necrotic skin lesion. In North America, there are two groups of spiders proven to be medically important: the widow spiders (genus Latrodectus) and the recluse spiders (genus Loxosceles). The widow spiders are a known entity, because their distinctive coloration makes them readily identifiable by nonarachnologists. Also, the physiological mechanism of the venom, the antivenom to counter it, and the symptoms are known, causing misdiagnosis to rarely occur. In contrast, recluse spiders are almost at the other end of the spectrum. They are readily misidentified or confused with harmless spiders, and the physiological mechanism of the venom is still being elucidated. Furthermore, no antivenom is commercially available, and the brown recluse's infamy causes many skin lesions of nonarachnid origin to be misdiagnosed as brown recluse spider bites.

Objectives: Children with chronic medical conditions (CMCs) are considered to be at increased risk for influenza and its related complications. Despite this, influenza immunization rates in the United States for children with CMCs in the primary care setting remain between 7-10%. This was a survey study looking at the barriers to influenza immunization among children with CMCs other than asthma. We examined caregiver knowledge and perceptions regarding influenza vaccine in addition to assessing other barriers, such as availability and perceived safety of the vaccine., Methods: The study was conducted during the fall-winter influenza seasons of 2002-2003 and 2003-2004 at five academic institutions across the southeastern US. Convenience samples of 100-150 families attending pediatric subspecialty clinics were surveyed., Results: A total of 794 surveys were completed. Controlling for disease, failure to recommend vaccination was significantly associated with failure to get the vaccine (P < 0.0001). Of the children who did not receive the vaccine, 61% of their parents believed that the vaccine itself could give influenza, 54% cited other safety concerns, and 30% thought it did not work. Among vaccine recipients, 163 (43%) reported that the primary care provider had given the vaccine, whereas 171 (45%) reported that the vaccine had been given at the subspecialty clinic., Conclusion: This study highlights the importance of physician recommendation, as well as parental education, as some of the key elements crucial to the receipt of influenza vaccination in children with CMCs.

Background: The HIV/AIDS epidemic in the U.S. South is undergoing a marked shift toward a greater proportion of new HIV/AIDS cases in women, African-Americans, and through heterosexual transmission., Methods: Using consecutive sampling, 611 participants were interviewed from eight Infectious Diseases clinics in five southeastern states in 2001 to 2002., Results: Sixty four percent of participants were African-American, 31% were female, and 43% acquired HIV through heterosexual sex; 25% had private health insurance. Eighty-one percent were on antiretroviral therapy, and 46% had HIV RNA viral loads (VL) <400. Women and racial/ethnic minorities were less likely to be on antiretrovirals and to have VL <400. Probable psychiatric disorders (54%) and history of childhood sexual (30%) and physical abuse (21%) were common., Conclusions: Prevention and care systems need to address the HIV epidemic's shift into poor, minority, and female populations. High levels of trauma and probable psychiatric disorders indicate a need to assess for and address these conditions in HIV clinical care.

Background: Women and minorities continue to account for a higher proportion of AIDS incidence and mortality than their male and white counterparts. This study examined whether race and gender were associated with antiretroviral use among HIV-infected individuals in the southeastern US., Methods: Multivariate regression analyses were used to identify whether race and gender predicted use of a protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI) from 1996 to 2000 among individuals receiving HIV primary care., Results: Female gender and nonwhite race were significantly associated with a lower likelihood of being prescribed a PI or NNRTI at baseline. At the follow-up measure three years later, fewer individuals of minority race and female gender were prescribed a PI or NNRTI; however, these differences had declined and were no longer statistically significant., Conclusions: Efforts are needed to improve prompt access to advances in HIV therapeutics for women and minorities and to address continued disparities in HIV care by race and gender.

Texas has more fatal crashes involving unlicensed drivers under age 15 than does any other US state. Numbers and rates of such crashes are also above the national mean in many southern and Southwest states. Data on fatal passenger vehicle crashes from 1999 through 2004 were obtained from the online Fatality Analysis Reporting System (FARS). During the study period, there were 51 fatal passenger vehicle crashes in Texas in which drivers were under age 15. These crashes accounted for 12.3% of the US total. Nine southern states, including Texas, together accounted for 44% of all fatal crashes involving drivers under 15. Unlicensed crash rates per million inhabitants were higher in Texas than in other states with comparable populations but were much lower than those in other southern, southwest, and north central states. While Texas has recently improved its compliance with proposed graduated licensing models, state law explicitly prohibits police from stopping drivers based solely on age-related probable cause. This restriction may be a major barrier to effective detection and interdiction of under-age unlicensed driving. Because of the relatively high number of fatal crashes involving drivers under age 15 occurring in Texas, preventive efforts targeted to this state could modestly reduce the national burden of deaths due to very young unlicensed drivers. Expanding these efforts to other southern and southwest states could further reduce numbers and rates of such crashes. Expanded use of graduated licensing and increased public awareness are likely to prove effective tools in this public health effort.

Background: The purpose of this study was to determine which patient-related factors are most strongly associated with having uncontrolled hypertension among outpatients., Methods: A sample of 300 outpatients with diagnosed hypertension from three different settings was reviewed, focusing on demographics, comorbidity, adherence, and treatment factors. Regression analyses were conducted to determine which factors were associated with poor BP control (> 140 mmHg systolic or > 90 mmHg diastolic)., Results: Those most strongly associated with blood pressure control were men (OR 2.04, 95% CI 1.17-3.55) living in a rural setting (OR 0.30, 95% CI 0.16-0.55). Age, race, total number of medicines, number of visits, and the number of comorbidities were not significantly associated with poor blood pressure control in this population., Conclusions: Being urban and male are strongly associated with uncontrolled hypertension. Public health blood pressure control efforts in the Southeast region should be directed toward this population.

The early 20th century Southerner lived in a disease environment created by a confluence of poverty, climate and the legacy of slavery. A deadly trio of pellagra, hookworm and malaria enervated the poor Southerner--man, woman and child--creating a dull, weakened people ill equipped to prosper in the modem world. The Northern perceptions of the South as a backward and sickly region were only compounded by the realization that her population was malnourished, infected by worms, and continually plagued by agues and fevers. As historian John Duffy concluded, "As a chronically debilitating disease, it [malaria] shared with the other two the responsibility for the term 'lazy Southerner".

Objectives: Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes., Methods: A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina., Results: Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness., Conclusions: In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HIV/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed.

Background: PROTEKT US (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin in the United States) was established in 2000 to monitor antimicrobial resistance among respiratory tract pathogens across the United States., Methods: During 2000 to 2001, 75 southern US centers collected 3,867 Streptococcus pneumoniae, 1,455 Streptococccus pyogenes and 1,042 Haemophilus influenzae., Results: Overall, 46.1% of S. pneumoniae isolates were nonsusceptible to penicillin, 35.8% were resistant to erythromycin, and 0.5% were resistant to fluoroquinolones. Against S. pneumoniae the most active agents were telithromycin (99.7% susceptible), linezolid (99.8%) and the fluoroquinolones (levofloxacin 99.4%, gatifloxacin 99.5%). The prevalence of erythromycin-resistant S. pyogenes isolates was 4.5%. Telithromycin, at concentration of < or = 1 mg/L, inhibited 99.9% of S. pyogenes. The prevalence of beta-lactamase positive H. influenzae was 26.2%. Telithromycin was active (MIC90 4 mg/L) against H. influenzae, irrespective of beta-lactamase production., Conclusion: The prevalence of penicillin and macrolide resistance among respiratory tract pathogens from the southern United States is high. Fluoroquinolone resistance is low. Telithromycin is highly active against respiratory tract pathogens with reduced susceptibility to beta-lactams, macrolides, and fluoroquinolones.

Background: Obesity has reached epidemic proportions over the past 20 years., Methods: This study investigated the differences in rates of obesity and perceptions of health status between rural, urban, and suburban Southern women based on selected socioeconomic factors. Using data from a national health survey, the reports from 4,391 women aged 40 to 64 years were included in the study., Results: Significantly more rural women lived in poverty, reported a poorer health status, and had a greater prevalence of obesity. Urban women had the next highest obesity rate and a moderate health status. The healthiest group with the lowest obesity and poverty rates were suburban women., Conclusion: Obesity and poor overall health are closely related in rural women. The greatest challenge to health care providers is to provide appropriate community-based weight-management programs.

Background: This detailed study describes the demographic characteristics, behavioral characteristics, care-seeking behavior, and barriers to health care and social services for patients infected with the human immunodeficiency virus (HIV) in the Southeast., Methods: We conducted a cross-sectional study of Medicaid-eligible HIV-positive individuals (chart abstractions [N = 679], patient surveys [N = 487]) and care providers (N = 101) in North Carolina. Relative risks compare blacks, women, and respondents reporting substance abuse with their reference groups. Results are compared with those of a larger sample including persons from Alabama and South Carolina., Results: Forty-one percent of respondents did not receive care locally, and 69% of female respondents had young children at home. In the 12 months before the survey, 66% reported substance abuse; 49% reported multiple living situations; 11% had entered drug treatment; and 10% had difficulty with the law. The findings in North Carolina did not differ from those in Alabama and South Carolina. Mean indices from care provider surveys revealed low interagency knowledge and referrals., Conclusions: Patients have complex needs for both social services and health care. However, providers are not working together.

Tobacco use is associated with numerous illnesses and contributes to as many as 400,000 deaths in the United States each year. Most tobacco use in the United States is in the form of cigarette smoking, but smokeless tobacco use is particularly high in certain areas and within certain subpopulations. Among US adults, smokeless tobacco use is associated with low socioeconomic status, male sex, Native American race, and southern or rural residence. We review six studies among adults (> or = 18 years) describing the epidemiology of smokeless tobacco use in the southeastern United States. These studies indicate that the Southeast, with its strong ties to tobacco production, is an area that requires intensive tobacco cessation strategies targeting the use of smokeless tobacco as well as cigarettes.

Background: This study was done to define the seasonality of respiratory syncytial virus (RSV) epidemics in the southeastern United States., Methods: We tested 5,092 fresh nasal aspirates or washings, using the Kallestad Pathfinder enzyme immunoassay (EIA) or the Directigen RSV membrane EIA according to manufacturers' directions., Results: A total of 1,419 (27.9%) respiratory specimens, collected from pediatric patients between May 1993 and December 1996 at two large southeastern medical centers, were positive for RSV antigen by enzyme immunoassay. A persistent RSV epidemic was documented between July 1993 and December 1996. We defined an epidemic as 2 consecutive months in each of which > or = 10% of the specimens were positive and > or = 2 positive specimens detected. The highest percentages of positive specimens were detected in December of 1993, 1994, and 1996, to date, and November 1995., Conclusion: On the basis of our findings, we recommend health care workers consider RSV in the differential diagnosis of acute respiratory illness throughout the year in pediatric patients from the southeast United States.

The objectives of our study were to determine the prevalence of cervical intraepithelial neoplasia (CIN) in a southeastern human immunodeficiency virus (HIV)-positive population relative to an HIV-negative control group and to compare these findings with published reports from other geographic regions. Demographic, medical, and cytopathologic data were collected on 89 HIV-positive women receiving care at the Duke Adult Infectious Disease Clinic. Comparisons were made with 100 HIV-negative obstetric patients who delivered at Duke and with published reports from other regions of the United States and abroad. Cervical intraepithelial neoplasia was present in 43 (49%) of 87 HIV-positive women compared with 23% of the 100 HIV-negative patients. Two of the HIV-positive patients had invasive cancer. Comparison of these patients with patients from other geographic regions revealed similar odds ratios for the presence of CIN in HIV-positive patients compared with HIV-negative patients. These results suggest a significantly increased risk for cervical dysplasia in HIV-positive women in this southeastern population.

Geographic variations in adverse health outcomes have long been recognized in the United States, with specific focus on the southeastern region of the country. Cerebrovascular disease mortality rates have identified the Southeast as the "stroke belt" for decades, though rates are also high for other hypertension-related diseases including ischemic heart disease, diabetes, and end-stage renal disease. The increased cerebrovascular disease mortality in the Southeast has prompted intervention and research efforts. This paper provides a descriptive profile of the hypertensive end-organ diseases in this area to guide research efforts and to gauge changes in health outcomes and risks. In addition to mortality from stroke, this assessment identified excessive risks from diabetes, ischemic heart disease, and end-stage renal disease for some states in the Southeast. Trend variations in health outcomes were also detected.

Pulmonary signs and symptoms may provide important differential clues to the diagnosis of tick-borne illness incurred in the southern United States.

Prostate cancer screening has assumed increased importance with increasing mortality from this cancer. Newer diagnostic tests such as measurement of prostate-specific antigen (PSA) have improved detection of early prostate cancer. To determine practice patterns of prostate cancer screening, surveys were sent to 487 urologists (231 responses) and 542 family physicians (205 responses) in the Southeast inquiring about actual screening practices. In screening asymptomatic patients, the digital rectal examination was used by 99% of the urologists and 98% of the family physicians, with the mean age of screening initiation being 45 +/- 7 years for the urologists and 43 +/- 7 years for the family physicians. Serum PSA was used for screening asymptomatic patients by 98% of the urologists and 87% of the family physicians, with 49 +/- 4 years being the mean age of screening initiation for both specialties. Although differences in screening emerged, both physician groups approximated the recommended screening guidelines.

Using data collected by the National Center for Health Statistics, we examined the relationships between smoking-related beliefs and attitudes and smoking status for a sample of adolescents (N = 3,198) from southern states. Stepwise logistic regression was used to identify the best predictors of smoking prevalence. Results indicated that 8 of 13 variables in the logistic model significantly differentiated between smokers and nonsmokers. Smokers were more likely to believe that it is safe to smoke for only a year or 2 and that smoking helps reduce stress and boredom while promoting relaxation. Smokers also reported a higher tolerance than nonsmokers for being around other smokers, and reported their parents would not mind their smoking. The logistic model attained a predictive accuracy of 93.2%. The implication of these findings is that if smoking interventions targeted at adolescents address smoking-related beliefs and attitudes, there is an enhanced likelihood that such interventions will positively influence the smoking behavior of southern adolescents.

A previous national study indicated that the South dominated other regions of the United States in tobacco use. Using the results of the Teenage Attitudes and Practices Survey conducted by the National Center for Health Statistics, we examined the geographic and demographic differences of tobacco use among US adolescents. The sample consisted of teenagers in grades 7 through 12 nationwide (N = 6,599). Data were collected through telephone interviewing. The variables included demographics and measures of smoking or use of smokeless tobacco (chewing tobacco/snuff). Results indicated that the overall prevalence rate for smokeless tobacco use was 4.44%, but in the South it was 6.38%. The overall smoking prevalence rate was 13.31%, with no substantial difference among regions. Demographic variables such as sex, ethnicity, education, and poverty levels were also related to tobacco use prevalence. These geographic and demographic variations in tobacco use help target specific regions and populations in greatest need of intervention programs.