Risk Stratification With Coccidioidal Skin Test to Prevent Valley Fever Among Inmates, California, 2015.

Two California state prisons (A and B) have very high rates of coccidioidomycosis (Valley Fever). The prison health care service sought to improve their prevention strategy by risk stratification with a newly available spherulin-based Coccidioides delayed-type hypersensitivity test. Of the 36,789 voluntarily screened inmates, 4.7% experienced adverse reactions. A positive test (8.6% of those tested) was independently associated with (1) incarceration at prisons A and B, (2) admission to prison from a Coccidioides-endemic county, (3) length of stay at prisons A and B, and (4) increasing age. These findings suggest that the test is safe and performing well at risk stratification; the prison system now restricts inmates with negative tests from prisons A and B. This novel use of the test might benefit other coccidioidomycosis prevention programs.

Reversal of elevated international normalized ratios and bleeding with low-dose recombinant activated factor VII in patients receiving warfarin.

STUDY OBJECTIVE: To assess the effectiveness of using low-dose recombinant activated factor VII (rFVIIa) to reverse the effects of warfarin in critically ill patients with major bleeding events. DESIGN: Prospective observational study. SETTING: Intensive care unit of a 500-bed university-affiliated hospital. PATIENTS: Sixteen nonhemophiliac patients who had been receiving warfarin and had an acute major bleeding event. INTERVENTION: Patients received rFVIIa 1.2 mg for reversal of anticoagulation. MEASUREMENTS AND MAIN RESULTS: Patients were identified from clinical pharmacology consult service electronic tracking records, and their data were cross-checked with the pharmacy information system. Information collected for each patient included extent of bleeding and magnitude of elevation in international normalized ratio (INR). A mean +/- SD dose of rFVIIa 16.3 +/- 4.1 microg/kg (range 11-25 microg/kg) reduced the mean INR from 2.8 +/- 1.6 (range 1.44-6.34) to 1.07 +/- 0.27 (range 0.86-1.92, p<0.001). A rapid onset of response for achieving a desirable hemostatic effect was observed in 14 of the 16 patients. CONCLUSION: Low-dose rFVIIa appears to be an effective, rapid reversal modality for major bleeding events in the presence of warfarin and an elevated INR. The agent's response is quicker than that expected with fresh frozen plasma combined with vitamin K. In emergency situations, rFVIIa 1.2 mg can be used to reverse the anticoagulant effect of warfarin and other vitamin K antagonists without inducing a hypercoagulable state; the product, however, is expensive.

Perceptions of state public health officers and state veterinarians regarding risks of bioterrorism in the United States.

OBJECTIVE: To assess perceptions of state public health officers and state veterinarians in the United States regarding the risks of bioterrorism and determine the degree of support provided for activities related to bioterrorism. DESIGN: Cross-sectional survey. SAMPLE POPULATION: State public health officers and state veterinarians. PROCEDURE: A questionnaire was sent between April and June 2001 to the state public health officer and state veterinarian in each of the 50 states and the District of Columbia. RESULTS: Perceptions of the risk of bioterrorism attacks were similar for state public health officers and state veterinarians. Veterinarians perceived the risks associated with foot-and-mouth disease and Newcastle disease to be higher than did physicians. State veterinarians perceived the risks associated with an anthrax hoax, brucellosis, and ricin toxicosis to be lower than did state public health officers. Risk posed by agents that affected animals exclusively was perceived to be higher than risk posed by agents that affected humans exclusively and zoonotic agents. Number of full-time-equivalent positions devoted to bioterrorism surveillance and percentage of the budget devoted to bioterrorism activities were significantly lower for offices run by state veterinarians than for offices run by state public health officers. State veterinarians were significantly less likely to have knowledge of bioterrorism incidents within their state or district than were state public health officers. CONCLUSIONS AND CLINICAL RELEVANCE: Provision of additional resources to state veterinarians and explicit integration of their expertise and surveillance capabilities may be important to effectively mitigate the risk of bioterrorism.

Identification of barriers to adaptation of battlefield technologies into civilian trauma in California.

OBJECTIVE: To characterize the adoption of routine battlefield medical techniques (tourniquets, hemostatic agents, and tactical combat casualty care into civilian prehospital trauma care and to identify the barriers to their use in the state of California through anonymous electronic survey of local emergency medical services agency (LEMSA) directors. RESULTS: The response rate for this survey was 50% (14/28). The majority of LEMSA directors (86%) were emergency medicine physicians. Tourniquets were used by 57% of respondents. The top three reasons cited for not using tourniquets included different injury patterns in civilian trauma, no proven benefit of use, and increased risk of complications. Hemostatic agents were used even less frequently in civilian practice (7%) but had similar barriers to use. Only 36% of LEMSA directors use tactical combat casualty care with tactical emergency medical services, but when used, respondents had higher usage of tourniquets. Overall lack of training, no proven benefit, and expense were the reasons cited for not incorporating military medical techniques. CONCLUSIONS: Tourniquets, hemostatic agents, and tactical medical care are the integral components of battlefield medicine and have been lifesaving in these settings. The barriers to this transition are multifactorial. Physicians familiar with these technologies should become advocates for their integration in civilian trauma patient care.

Poisoning hospitalization correlates with poison center call frequency.

INTRODUCTION: Poison Control Centers (PCCs) have been shown to reduce health expenditures by reducing emergency department and clinic visits. The effect or association of PCC call frequency on acute hospitalization rates for poisonings has not been studied extensively. METHODS: All nonfederal hospital discharges for acute poisoning principal diagnosis codes (960-979, 980-989, 9956X, 3030, and 005) in California between October 1999 and June 2002 were examined. Approximately 3.3% of the discharges had county/hospital information suppressed in the public-use database because of confidentiality criteria and were excluded from the analysis. U.S. Census Bureau population estimates for appropriate years by counties were also obtained. The 58 California counties were condensed to 48 counties and 3 "small-county" geographic groupings. Exposure calls by counties/groupings to the California Poison Control System(CPCS) for the same period were tabulated. RESULTS: In California, rates of hospital discharges for poisoning averaged 0.54/1000 person years with a range of 0.25/1000 person years (Central Counties) to 1.53/1000 person years (Del Norte County). Poison call rates averaged 8.5/1000 person years with a range of 4.9/1000 person years (Los Angeles County) to 19.6/1000 person years (Napa County). Poisoning discharges per 1000 person years positively correlated with PCC calls per 1000 person years (Spearman correlation 0.41, p = 0.0003). The average hospital length of stay (LOS) did not correlate with PCC call frequency or poisoning discharges per 1000 person years. CONCLUSION: The CPCS call frequency or county penetrance was not correlated with a reduction in the number of hospitalizations for poisoning nor was it associated with reduced average LOS in this study. Further study is needed to understand the etiology of the large differences in county rates of poisoning hospitalization and average LOS.

Regional variations in the use and awareness of the California Poison Control System.

PURPOSE: To investigate regional variations in public awareness and utilization of the services of Poison Control Centers (PCC) before and after an intervention. METHODS: This study examines call rates of different California regions based on the final five regional PCCs prior to the consolidation of these services under a single statewide California Poison Control System (CPCS) and interventions to increase utilization. Awareness surveys were performed before and after a media campaign that was directed primarily to the Los Angeles basin and to a lesser extent other high Hispanic concentration areas. Focus groups were also utilized to better define specific areas of poison knowledge and awareness of CPCS services. FINDINGS: Large differences in regional California call rates were seen, with the Los Angeles basin showing the lowest utilization of CPCS services compared with the rest of California. Significant seasonal variation in utilization was also found, with the highest average call rates observed in August and the lowest in February. Focus groups demonstrated that urban awareness of PCC was lower than suburban awareness, particularly in monolingual Hispanic households. An improvement was seen after the institution of a media education campaign that included use of Spanish language material and radio spots. Similar increases in call rates were also seen in Fresno county category, with a higher percentage of Hispanic population that was not as aggressively targeted by the awareness campaign. CONCLUSIONS: Significant regional variations in CPCS call rates were found and an increased awareness and utilization was seen in the Los Angeles basin after a directed media campaign compared with most areas of California. Further efforts to increase CPCS utilization in the Los Angeles region, primarily among urban monolingual Hispanics, are needed.