Montana Department of Public Health and Human Services

Objectives Although trauma clinical guidance has the potential to improve patient outcomes significantly, it is applied inconsistently across the USA today. Work is needed to improve guidance application among those who treat traumatic injury, including emergency medicine (EM) clinicians. A priority step of such improvement is the visual design of clinical directives, as it can markedly influence EM clinicians’ satisfaction and subsequent usage of guidance. This qualitative study aims to analyze EM clinicians’ needs and preferences for the visual design of trauma clinical guidance. Methods As part of a larger exploratory sequential mixed-methods study exploring trauma clinical guidance barriers and facilitators, we conducted semistructured video conference interviews during August and September 2024 with EM clinicians. Participants were selected through purposeful criteria and snowball sampling to ensure diverse representation across professional and personal characteristics. Interviews were audio recorded and analyzed through rapid qualitative content analysis. Results 12 EM clinicians completed interviews, providing feedback on their preferences for the visual design of trauma clinical guidance. Clinicians emphasized the need for simple guidance that can be easily used in a time-pressured setting. Dynamic features such as expandable or “clickable” content can provide deeper explanations of guidance concepts without compromising usability. Flowsheets and visual aids can clarify guidance recommendations. Clinicians asked that recommendations be specific and action-oriented. Conclusion When designing trauma clinical guidance, authors should promote visual design characteristics that prioritize simplicity, dynamic features, visual aids, and specificity. Level III

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders’ inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area’s overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents’ best chance for surviving an opioid overdose.

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), implemented in 2015, has more codes than ICD-9-CM for events involving cannabis. We examined cannabis indicator trends across the transition from ICD-9-CM to ICD-10-CM in Colorado, where state law regulates adult cannabis use. Using 2011 to 2018 data from hospital and emergency department (ED) discharges, we calculated monthly rates per 1000 discharges for two indicators: (1) cannabis use disorders and (2) poisoning and adverse effects of psychodysleptics. Immediate, point-of-transition (level) and gradual, post-transition (slope) changes across the ICD-9-CM to ICD-10-CM transition were tested using interrupted time series models adjusted for legalisation, seasonality and autocorrelation. We observed a level increase and slope increase in the rate of ED discharges with cannabis use disorders. Hospital discharges with cannabis use disorders had a negative slope change after the transition and no level change. ED discharges with poisoning and adverse effects of psychodysleptics showed an increase in slope after the transition. No effects of the transition were observed on hospital discharges with poisoning and adverse effects of psychodysleptics. Shifts in the level and slope of cannabis indicator rates after implementation of the new coding scheme suggest the use of caution when interpreting trends spanning the ICD-9-CM to ICD-10-CM transition.

Abstract Opioid misuse takes an enormous toll on the health and economy of the U.S., costing 130 lives per day, and an estimated 157 billion dollars per year. Mitigating the epidemic requires better information on the mix of drugs being used in a community and when and where drug use concentrates. Many widely used data sources, such as national population surveys, have a two-year lag before the data are available, and underestimate the prevalence of drug use because they rely on self-reported information about a stigmatized behavior. For rural populations, the data gap is compounded by privacy policies that suppress key information (for example, opioid-related death rates) in small populations. Municipal wastewater testing is an innovative approach to assessing community-level drug use that can provide near real-time, cost-effective, and unbiased measures of drug use. Importantly, wastewater-based data cannot reveal who is using a particular drug, mitigating privacy concerns. The methodology is routinely used across Europe and Australia as part of a holistic multi-indicator monitoring and alert system. When combined with geospatial mapping and advanced analytics, wastewater-based data can help locate geographic hotspots of use and provide an early warning for new substances entering into a community. We conducted a pilot study to compare temporal trends in estimates of per-capita drug use between wastewater-based data and other local data sources in two municipalities (one urban, one rural) in Montana. In the first phase of our study (Bishop et al, 2020, manuscript is in submission to Sci Total Environ), we optimized testing to estimate per-capita drug use in wastewater in an urban and rural municipality. Here, we report the value of these data for public health officials to predict rather than react to changes in drug use patterns. We also illustrate how rural populations can use the methodology to assess the impacts of local law enforcement efforts and evaluate the effectiveness of programs, such as the prescription take-back program, to improve public health and safety.

Readers are invited to submit letters for publication in this department. Submit letters online at http://joem.edmgr.com. Choose “Submit New Manuscript.” A signed copyright assignment and financial disclosure form must be submitted with the letter. Form available at www.joem.org under Author and Reviewer information. Reply: We thank Drs Miller, Loewen, Szeinuk, and Noonan for their comments and insights regarding the burden of asbestos-related disease (ARD) among current and former Libby residents, as well as on our publication.1 We agree with Dr Loewen's observation that local physicians may not have noted ARD in this cohort of screening participants. This could have resulted in under-ascertainment of nonmalignant, ARD mortality. (Note that we reported results for asbestosis, a nonmalignant disease defined as interstitial pneumonitis and fibrosis caused by inhalation of asbestos.2) Still, the asbestosis SMRs we reported ranged from 82 (among workers categorized as “other asbestos occupation”) to 558 (among household contacts) in comparison with a national reference population. These SMRs clearly indicate a striking excess of nonmalignant ARD in the screening cohort. We also agree that the results from our analysis only represent the cohort of participants in the Agency for Toxic Substances and Disease Registry and Montana Department of Public Health and Human Services screening programs; across the decades in which the Libby vermiculite operation was active, there were likely other persons exposed to Libby amphibole asbestos who did not participate in those screening programs (possibly due to, as suggested, out-migration from Libby, or other factors). We further agree that mortality studies in general benefit from pairing death certificate data with objective clinical measurements. In this case, expert interpretations of chest radiographs were available for the majority of participants. As noted, CT has greater sensitivity than chest radiographs to asbestos-related changes,2 but were not used in our analysis due to CT data being unavailable for the majority of the screening cohort. Finally, that the majority of the cohort may have been too young (more than 50% were younger than 50 years of age at the time of screening) to have developed ARD indicates that continued monitoring of Libby residents and further mortality updates should be considered to detect trends in ARD. The continued work of Drs Miller, Loewen, Szeinuk, and Noonan and others offers insights about the natural history of disease among Libby patients.

Public health laboratories (PHLs) provide essential services in the diagnosis and surveillance of diseases of public health concern, such as tuberculosis. Maintaining access to high-quality laboratory testing is critical to continued disease detection and decline of tuberculosis cases in the United States. We investigated the practical experience of sharing tuberculosis testing services between PHLs through the Shared Services Project. The Shared Services Project was a 9-month-long project funded through the Association of Public Health Laboratories and the Centers for Disease Control and Prevention during 2012-2013 as a one-time funding opportunity to consortiums of PHLs that proposed collaborative approaches to sharing tuberculosis laboratory services. Submitting PHLs maintained testing while simultaneously sending specimens to reference laboratories to compare turnaround times. During the 9-month project period, 107 Mycobacterium tuberculosis complex submissions for growth-based drug susceptibility testing and molecular detection of drug resistance testing occurred among the 3 consortiums. The median transit time for all submissions was 1.0 day. Overall, median drug susceptibility testing turnaround time (date of receipt in submitting laboratory to result) for parallel testing performed in house by submitting laboratories was 31.0 days; it was 43.0 days for reference laboratories. The median turnaround time for molecular detection of drug resistance results was 1.0 day (mean = 2.8; range, 0-14) from specimen receipt at the reference laboratories. The shared services model holds promise for specialized tuberculosis testing. Sharing of services requires a balance among quality, timeliness, efficiency, communication, and fiscal costs.

The U.S. Diabetes Prevention Program (DPP) showed that lifestyle participants who achieved ≥7% weight loss and ≥150 min/week physical activity experienced the greatest reduction in type 2 diabetes incidence. Demographic, clinical, and program factors that are related to achieving both these lifestyle goals have seldom been explored in community-delivered DPP programs. The purpose of this investigation is to examine factors associated with concurrent achievement of weight loss and physical activity goals in a 12-month community DPP lifestyle intervention. Adults [n=223; age=58.4 (SD=11.5); BMI=33.8 (SD=6.0)] with glucose or HbA1c values in the pre-diabetes range and/or metabolic syndrome risk factors enrolled from one worksite and three community centers in the Pittsburgh, PA metropolitan area between January 2011 and January 2014. Logistic regression analyses determined the demographic, clinical and program adherence factors related to goal achievement at 6, 12, and 18 months. Participants achieving both intervention goals at 6 months (n=57) were more likely to attend sessions [Adjusted Odds Ratio (AOR) =1.48], self-weigh (AOR=1.19), and self-monitor behaviors (AOR=1.18) than those meeting neither goal (n=35; all p<0.05). Baseline BMI (AOR=0.87, p<0.01), elevated glycemic status (AOR=0.49, p<0.05), and female sex (AOR=0.52, p<0.05) were inversely related to goal achievement at 6 months. Meeting either lifestyle goal at 6 months had the strongest association with meeting both goals at 12 and 18 months. Our study supports the importance of early engagement, regular attendance, self-monitoring, and self-weighing for goal achievement. Dissemination efforts should consider alternative approaches for those not meeting goals by 6 months to enhance long-term success.

Clonal VGII subtypes (outbreak strains) of Cryptococcus gattii have caused an outbreak in the US Pacific Northwest since 2004. Outbreak-associated infections occur equally in male and female patients (median age 56 years) and usually cause pulmonary disease in persons with underlying medical conditions. Since 2009, a total of 25 C. gattii infections, 23 (92%) caused by non–outbreak strain C. gattii, have been reported from 8 non–Pacific Northwest states. Sixteen (64%) patients were previously healthy, and 21 (84%) were male; median age was 43 years (range 15–83 years). Ten patients who provided information reported no past-year travel to areas where C. gattii is known to be endemic. Nineteen (76%) patients had central nervous system infections; 6 (24%) died. C. gattii infection in persons without exposure to known disease-endemic areas suggests possible endemicity in the United States outside the outbreak-affected region; these infections appear to differ in clinical and demographic characteristics from outbreak-associated C. gattii. Clinicians outside the outbreak-affected areas should be aware of locally acquired C. gattii infection and its varied signs and symptoms.