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The article presents abstracts of scientific presentations at the Annual Meeting of the Association of Academic Physiatrists (AAP) in Sacramento, California on February 16-20, 2016 on topics including anterior cruciate ligament (ACL) injury, traumatic spinal cord injury, and botulinum toxin injections.

Background: Mobility is a vital function of human life. Nurses have an essential role in preventing hospitalized patient complications through movement and ambulation. Purpose: This study examined the integration, accuracy, and precision of a paper-based mobility/ambulation tool into an electronic health record (EHR) to assess inpatient mobility/ambulation status. Methods: This multisite mixed-methods study was a time-series correlational evaluation of a mobility/ambulation tool into the EHR. Results: Sustainability data revealed strong correlations between nurse responses and EHR levels (r = 0.602; scores r = 0.624). Cronbach's α values were 0.737 and 0.761. Nurses' anecdotes supported the findings. Conclusion: Findings revealed that the EHR-Mobility Ambulation Tool is a valid, reliable, and stable tool. EHR-generated scores can assist in reducing charting burden, care planning, and inform the interdisciplinary health team at all patient care stages. Tool adoption could potentially assist nurses plan interventions suitable to maintain or increase hospitalized patients' mobility status and contribute to discharge planning. [ABSTRACT FROM AUTHOR]

The important goals of Magnet® hospitals are to create supportive professional nursing care environments. A recently published paper found little difference in work environments between Magnet and non-Magnet hospitals. The aim of this study was to determine whether work environments, staffing, and nurse outcomes differ between Magnet and non-Magnet hospitals. A secondary analysis of data from a 4-state survey of 26,276 nurses in 567 acute care hospitals to evaluate differences in work environments and nurse outcomes in Magnet and non- Magnet hospitals was conducted. Magnet hospitals had significantly better work environments (t = -5.29, P < .001) and more highly educated nurses (t = -2.27, P < .001). Magnet hospital nurses were 18% less likely to be dissatisfied with their job (P <.05) and 13% less likely to report high burnout (P < .05). Magnet hospitals have significantly better work environments than non-Magnet hospitals. The better work environments of Magnet hospitals are associated with lower levels of nurse job dissatisfaction and burnout. [ABSTRACT FROM AUTHOR]

Introduction and objective: Advance care planning (ACP) communication and documentation are often inadequate, leading to care that is inconsistent with patients' preferences and moral dilemmas for family members. Nurses are patient advocates optimally positioned to initiate ACP but many feel that they lack the training and skills to navigate these conversations. The objective of this project was to increase nurses' capacity to engage in ACP. Methods: This project used the JBI audit and feedback method to implement evidence into practice. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used to incorporate ACP into nursing workflow. Eight audit criteria were created based on a JBI evidence summary. Compliance was measured by reviewing ACP notes from electronic health records and online survey responses. A baseline audit was followed by educational presentations and development of posted materials. Three follow-up audits examined sustainability. Results: Compliance with the best practice recommendation for nurses to engage in ACP discussions increased from 55% to 80%. There was improvement from zero ACP notes at baseline (0% compliance) to 12 ACP notes in the final audit. Of these notes, 42% included all best practice elements and 92% included patients' treatment preferences. Conclusions: Development of an integrative nursing education plan for ACP empowers nurses to engage in vital conversations. Informing nurses of their scope of practice, defining terms and expectations, and encouraging them to attempt and document conversations will benefit patients. Future initiatives would benefit from incorporating practical opportunities without real-life implications and providing continued support to cohorts. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to compare a cell phone based physical activity diary with a paper physical activity diary and to examine the reliability and validity of the cell phone diary. Researchers evaluated the diaries with 25 men and 25 women between the ages of 45 and 65. They concluded that a cell phone-based physical activity diary is equivalent to a paper diary, is acceptable to users and is a relatively reliable and valid approach to self-reported physical activity.

Purpose: The purposes of this study is first, to investigate intensive care patients' perceptions of stressors; second, to investigate the health care provider's perception of what constitutes a stressor from the patient's perspective; and third, to describe how health care providers manage their patients' stressors. This was a mixed-methods study; the quantitative section replicated Cornock's 1998 study of stress in the intensive care unit (ICU), with difference in sampling to include all health care providers in the ICU, in addition to nurses. The qualitative section added information to the current literature by describing how health care providers manage their patient's stressors. This article reports the quantitative findings of this study, as the qualitative section is presented in a separate article. Background and Significance: It is important to describe ICU patients' stressful experiences to assess patient's stressors, provide holistic care to eliminate stressors, and provide feedback to health care providers. There is a need to describe the clinical practice related to stress perception and management of stressors in the critical care environment. Methodology: A mixed-methods comparative descriptive design was used for the quantitative section, and a phenomenological approach guided the qualitative section. Lazarus and Folkman's theory formed the bases for integrating all variables investigated in this study. The sample included 70 ICU patients and 70 ICU health care providers. After consenting to participate in this study, subjects were given a demographic form and a paper-based tool, the Environmental Stressors graphic data form Questionnaire. Questionnaires were filled out by subjects anonymously in the ICU and returned to the researcher in the same setting. Findings: Descriptive statistics were analyzed using SPSS data analysis software. The top 3 most stressful items ranked by the patients included "being in pain," followed by "not being able to sleep" and "financial worries"; on the other hand, health care providers perceived "being in pain" followed by "not being able to communicate" and "not being in control of yourself" as the top 3 stressors perceived by their patients. Implications for Practice: The findings of this study are crucial and may inform nursing assessments and care of the ICU patient. In addition, this information may encourage the ICU staff to manipulate and redesign the ICU environment to be less stressful. Also, the findings of this study guided the development of an ICU stressor control policy. [ABSTRACT FROM AUTHOR]

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indiana) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision- making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, the American Medical Society for Sports Medicine, and the American Bone Health Alliance. [ABSTRACT FROM AUTHOR]

The etiology of gliomas is not well understood. Some jobs might involve sustained and elevated exposures to carcinogens. This study compares lifetime job histories of 879 glioma cases diagnosed between August 1991 to April 1994 and May 1997 to August 1999 in the San Francisco Bay Area and 864 controls. Logistic analyses compared longest and ever held occupations of l year or more for all astrocytic and nonastrocytic cases and controls overall with adjustment for age, gender, and ethnicity and separately for men and women. Two-fold or higher or statistically significant elevated odds ratios were found overall and in men among those with longest held occupations, as firefighters, physicians, material moving equipment operators, and janitors; such elevated odds ratios were also observed for longest-held occupations among male motor vehicle operators and personal service workers and female messengers, legal/social service workers, electronic equipment operators, painters, and food processors. Odds ratios of 0.50 or less, but not statistically significant, were found for those with longest held jobs as writers/journalists, biological scientists, paper workers, mechanics, chemists, and photographers/photoprocessors. This study supports previously observed occupational associations and is one of the few studies with sufficient numbers to separately analyze occupations by gender. [ABSTRACT FROM AUTHOR]

The article focuses on the American College of Mohs Micrographic Surgery and Cataneous Oncology Bulletin. It presents information about the 28th Annual Clinical and Scientific Meeting of the college held on May 13 to 15, 1996 in California. Some of the new officers elected for the college are president is John A. Zitelli, vice president John W. Skouge and Secretary-Treasurer Hugh Greenway. The Distinguished Achievement Award was presented to John A. Zitelli and the Theodore Tromovitch Award was presented to Paul M. Salmon for their work. The article also presents abstracts of papers related to dermatology presented during the meeting.

Objective: To evaluate the outcomes of the first pregnancy after fertility-sparing surgery in patients treated for early-stage ovarian cancer., Methods: We performed a retrospective study of women aged 18-45 years with a history of stage IA or IC ovarian cancer reported to the California Cancer Registry for the years 2000-2012. These data were linked to the 2000-2012 California Office of Statewide Health Planning and Development birth and discharge data sets to ascertain oncologic characteristics and obstetric outcomes. We included in the case group ovarian cancer patients who conceived at least 3 months after fertility-sparing surgery. The primary outcome was preterm birth, and only the first pregnancy after cancer diagnosis was considered. Secondary outcomes included small-for-gestational-age (SGA) neonates, neonatal morbidity (respiratory support within 72 hours after birth, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, and intracranial or subgaleal hemorrhage), and severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Propensity scores were used to match women in a 1:2 ratio for the case group and the control group. Wald statistics and logistic regressions were used to evaluate outcomes., Results: A total of 153 patients who conceived after fertility-sparing surgery were matched to 306 women in a control group. Histologic types included epithelial (55%), germ-cell (37%), and sex-cord stromal (7%). Treatment for ovarian cancer was not associated with preterm birth before 37 weeks of gestation (13.7% vs 11.4%; odds ratio [OR] 1.23, 95% CI 0.69-2.20), SGA neonates (birth weight less than the 10th percentile: 11.8% vs 12.7%; OR 0.91, 95% CI 0.50-1.66), severe maternal morbidity (2.6% vs 1.3%; OR 2.03, 95% CI 0.50-8.25), or neonatal morbidity (both 5.9% OR 1.00, 95% CI 0.44-2.28)., Conclusion: Patients who conceived at least 3 months after surgery for early-stage ovarian cancer did not have an increased risk of adverse obstetric outcomes., Competing Interests: Financial Disclosure Paula C. Brady disclosed receiving funds from DynaMed for editing educational content. Larissa A. Meyer disclosed that money was paid to her institution from NCI (K07) and AstraZeneca. The other authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue., Objective: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals., Research Design: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges., Results: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month., Conclusion: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.

Clinic-based community health workers (cCHWs) are a growing workforce who can facilitate medical and social support services, particularly for patients with complex, chronic conditions. We assessed CHWs', employers', and patients' perceptions and readiness for CHW integration into clinical settings. We found varying levels of readiness between the groups, offset by conditional implementation concerns, such as need for clearer training, role delineation, expectations, and trust. Integrating CHWs as members of the complex care team holds promise for optimal patient engagement. Maximizing CHWs' potentials through readiness efforts can further support the triple/quadruple aims and goals for the Health Home Program.

The article presents a study which aims to examine various physiological responses during the Badwater Ultramarathon race held in extreme heat in Death Valley, California. The study includes four male athletes who completed the race with a mean finish time of 36 hours. The results suggest that it may be possible that a time threshold exists whereby success in longer duration events requires an ability to maintain a lower core body temperature.

Objective: An Automated Data Entry Process Technology tool was developed to free nurses from data entry tasks, thus creating time for patient care and other activities associated with improvements in performance and job satisfaction., Background: Manually transferring data from patient measurement devices to electronic health records (EHRs) is an intensive, error-prone task that diverts nurses from patient care while adversely affecting job performance and employee satisfaction., Methods: Performance improvement analytics were used to compare matched sets of manual and automated EHR data entries for 1933 consecutive vital signs records created by 49 RNs and certified nursing assistants in a 23-bed medical-surgical unit at a large tertiary hospital. Performance and quality effects were evaluated via nurses' responses to a postintervention survey., Results: Data errors decreased from approximately 20% to 0; data transfer times were reduced by 5 minutes to 2 hours per measurement event; nurses had more time for direct patient care; and job satisfaction improved., Conclusion: Data entry automation eliminates data errors, substantially reduces delays in getting data into EHRs, and improves job satisfaction by giving nurses more time for direct patient care. Findings are associated with improvements in quality, work performance, and job satisfaction, key goals of nursing leaders.

The article discusses research which was conducted to investigate the effect a single remote voluntary contraction (RVC) had on performance in women soccer players. Researchers evaluated 14 players who performed three maximal effort kicks and three maximal effort throw-ins with and without RVC. They found that RVC does not appear to enhance or negate kick or throw-in velocity in women soccer players.

Objective: To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates., Methods: This is a cross-sectional study of the 2015-2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs., Results: Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92)., Conclusion: Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Objective: The aim of this paper was to identify shapes of the curves between weekly working hours (WWH) and mental health status (MHS) and determine WWH for the best MHS in 13 occupations., Methods: This cross-sectional study applied public data of the 2015 to 2016 California Health Interview Survey. Restricted cubic spline regression was used to determine non-linear trends., Results: A statistically significant nearly V-shaped curve was demonstrated between WWH and MHS in total population, men and management, business and finance occupations. WWH for the best MHS were 42, 45, and 46 hours, respectively., Conclusion: These results suggest MHS be susceptible to WWH in total population, men and management, business and finance occupations. WWH for the best MHS for relevant populations could provide evidence for better work hours regulations in California.

Background: Clinical screening for basic social needs-such as food and housing insecurity-is becoming more common as health systems develop programs to address social determinants of health. Clinician attitudes toward such programs are largely unexplored., Objective: To describe the attitudes and experiences of social needs screening among a variety of clinicians and other health care professionals., Research Design: Multicenter electronic and paper-based survey., Subjects: Two hundred fifty-eight clinicians including primarily physicians, social workers, nurses, and pharmacists from a large integrated health system in Southern California., Measures: Level of agreement with prompts exploring attitudes toward and barriers to screening and addressing social needs in different clinical settings., Results: Overall, most health professionals supported social needs screening in clinical settings (84%). Only a minority (41%) of clinicians expressed confidence in their ability to address social needs, and less than a quarter (23%) routinely screen for social needs currently. Clinicians perceived lack of time to ask (60%) and resources (50%) to address social needs as their most significant barriers. We found differences by health profession in attitudes toward and barriers to screening for social needs, with physicians more likely to cite time constraints as a barrier., Conclusions: Clinicians largely support social needs programs, but they also recognize key barriers to their implementation. Health systems interested in implementing social needs programs should consider the clinician perspective around the time and resources required for such programs and address these perceived barriers.

Objective: To document the terminology patients hear during the treatment course for a nonviable pregnancy and to ask patients their perceived clarity and preference of terminology to identify a patient-centered lexicon., Methods: We performed a preplanned substudy survey of English-speaking participants in New York, Pennsylvania, and California at the time of enrollment in a randomized multisite trial of medical management of first-trimester early pregnancy loss. The six-item survey, administered on paper or an electronic tablet, was developed and piloted for internal and external validity. We used a visual analog scale and quantified tests of associations between participant characteristics and survey responses using risk ratios., Results: We approached 155 English-speaking participants in the parent study, of whom 145 (93.5%) participated. In the process of receiving their diagnosis from a clinician, participants reported hearing the terms "miscarriage" (n=109 [75.2%]) and "early pregnancy loss" (n=73 [50.3%]) more than "early pregnancy failure" (n=31 [21.3%]) and "spontaneous abortion" (n=21 [14.4%]). The majority selected "miscarriage" (n=79 [54.5%]) followed by "early pregnancy loss" (n=49 [33.8%]) as their preferred term. In multivariable models controlling for study site, ethnicity, race, history of induced abortion, and whether the current pregnancy was planned, women indicated that "spontaneous abortion" and "early pregnancy failure" were significantly less clear than "early pregnancy loss" (53/145, adjusted risk ratio 0.12, 95% CI 0.07-0.19 and 92/145, adjusted risk ratio 0.38, 95% CI 0.24-0.61, respectively, as compared with 118/145 for "early pregnancy loss"). "Miscarriage" scored similarly to "early pregnancy loss" in clarity (119/145, adjusted risk ratio 1.05, 95% CI 0.62-1.77)., Conclusion: The terminology used to communicate "nonviable pregnancy in the first trimester" is highly variable. In this cohort of women, most preferred the term "miscarriage" and classified both "miscarriage" and "early pregnancy loss" as clear labels for a nonviable pregnancy. Health care providers can use these terms to enhance patient-clinician communication., Clinical Trial Registration: ClinicalTrials.gov, NCT02012491.

Background: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California., Methods: This study used data from the 2011-2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented)., Results: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos., Conclusions: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

Background: State and local public health agencies collect and use surveillance data to identify outbreaks, track cases, investigate causes, and implement measures to protect the public's health through various surveillance systems and data exchange practices., Purpose: The purpose of this assessment was to better understand current practices at state and local public health agencies for collecting, managing, processing, reporting, and exchanging notifiable disease surveillance information., Methods: Over an 18-month period (January 2014-June 2015), we evaluated the process of data exchange between surveillance systems, reporting burdens, and challenges within 3 states (California, Idaho, and Massachusetts) that were using 3 different reporting systems., Results: All 3 states use a combination of paper-based and electronic information systems for managing and exchanging data on reportable conditions within the state. The flow of data from local jurisdictions to the state health departments varies considerably. When state and local information systems are not interoperable, manual duplicative data entry and other work-arounds are often required. The results of the assessment show the complexity of disease reporting at the state and local levels and the multiple systems, processes, and resources engaged in preparing, processing, and transmitting data that limit interoperability and decrease efficiency., Conclusions: Through this structured assessment, the Centers for Disease Control and Prevention (CDC) has a better understanding of the complexities for surveillance of using commercial off-the-shelf data systems (California and Massachusetts), and CDC-developed National Electronic Disease Surveillance System Base System. More efficient data exchange and use of data will help facilitate interoperability between National Notifiable Diseases Surveillance Systems.

SLAC, a high-energy (GeV) electron accelerator facility, performs experimental and theoretical research using high-energy electron and/or positron beams that can produce secondary neutron and gamma radiation when beam losses occur. Radioactive gas production (mainly C, N, O, Ar) and release is one of the environmental protection program issues. U.S. DOE Order 458.1 requires that 40 CFR 61 Subpart H's NESHAP requirements be followed. These regulations prescribe a total dose limit of 0.1 mSv y to the Maximally Exposed Individual (MEI) of the general public, a requirement for a continuous air monitoring system if a release point within a facility can cause > 1 × 10 mSv y to the MEI, and a requirement for periodic confirmatory measurements for minor sources which give releases that contribute ≤ 1 × 10 mSv y to the MEI. At SLAC, all air release points for current operations are evaluated to be minor sources. This paper describes SLAC's evaluation following NESHAP requirements; measurements using the Air Monitoring Station (AMS) as periodic confirmatory measurements are also discussed.

Lawrence Livermore National Laboratory uses CAP88-PC Version 1.0 modeling software to demonstrate compliance with the Code of Federal Regulations Title 40 Part 61 Subpart H (National Emission Standards for Emissions of Radionuclides Other Than Radon From Department of Energy Facilities). Annual air emissions from both well characterized stack sources and difficult to characterize diffuse sources must be assessed. This paper describes a process that uses a mathematical optimization routine to find a set of estimated diffuse source terms that together with the measured stack source terms provides a best fit of modeled air concentrations to measured air concentrations at available sampling locations. The estimated and measured source terms may then be used in subsequent CAP88-PC modeling to estimate dose at the off-site maximally exposed individual. LLNL has found this process to be an effective way to deal with the required assessment of diffuse sources that have otherwise been difficult to assess.

The National Ignition Facility (NIF) at Lawrence Livermore National Laboratory is the world's largest and most energetic laser system for inertial confinement fusion (ICF) and experiments studying high energy density (HED) science. The NIF is a 192-beam, Nd-glass laser facility that is capable of producing 1.8 MJ, 500 TW of ultraviolet light, and over 50 times more energetic than other existing ICF facilities. The NIF construction began in 1997, and the facility, which was completed in 2009, is now fully operational. The facility is capable of firing up to 192 laser beams onto a target placed at the center of a 10-m-diameter spherical target chamber. Experiments involving the use of tritium have been underway for some time. These experiments present radiological issues: prompt neutron/gamma radiation, neutron activation, fission product generation, and decay radiation. This paper provides an introduction to the NIF facility and its operation, describes plans for the experimental program, and discusses radiological issues associated with the NIF's operations.

The National Ignition Facility at Lawrence Livermore National Laboratory is the world's largest and most energetic laser system for inertial confinement fusion and experiments studying high energy density science. Many experiments performed at the National Ignition Facility involve radioactive materials; these may take the form of tritium and small quantities of depleted uranium used in targets, activation products created by neutron-producing fusion experiments, and fission products produced by the fast fissioning of the depleted uranium. While planning for the introduction of radioactive material, it was recognized that some of the standard institutional processes would need to be customized to accommodate aspects of NIF operations, such as surface contamination limits, radiological postings, airborne tritium monitoring protocols, and personnel protective equipment. These customizations were overlaid onto existing work practices to accommodate the new hazard of radioactive materials. This paper will discuss preparations that were made prior to the introduction of radioactive material, the types of radiological work activities performed, and the hazards and controls encountered. Updates to processes based on actual monitoring results are also discussed.

The National Ignition Facility at the Lawrence Livermore National Laboratory has implemented a protocol for evaluating and releasing material and equipment that is potentially "volumetrically contaminated" as a result of neutron activation and shown not to be "distinguishable from background." This protocol is an important element of the National Ignition Facility's operational program as the U.S. Department of Energy's (DOE) Order 458.1, Radiation Protection of the Public and the Environment, requires DOE approval of the process used to release volumetrically contaminated personal property and establishes a dose constraint of 10 µSv y(-1) (1 mrem y(-1)) for clearance of such items. The protocol uses process and historical knowledge to determine when material and equipment may be potentially impacted and field measurements to verify it has been impacted (i.e., is distinguishable from background). Material and equipment that do not meet the distinguishable-from-background criterion are considered to be non-impacted and outside the scope of the Order and may be released from radiological control. This paper provides the technical basis and methodology for determining whether or not there is radioactivity distinguishable from background in the evaluated material and equipment and documents that the measurement sensitivity exceeds the unrestricted release criteria specified in the American National Standards Institute report N13.12-1999, Surface and Volume Radioactivity Standards for Clearance. Pending DOE approval, this protocol could be used as the basis for releasing materials and equipment that exceed the distinguishable-from-background criterion and are below the specified threshold for unrestricted release.

The National Ignition Facility (NIF) is the world's largest and most energetic laser system. The facility has the potential to generate ionizing radiation due to the interaction between the laser beams and target material, with neutrons and gamma rays being produced during deuterium-tritium fusion reactions. To perform these experiments, several types of hazards must be mitigated and controlled to ensure personnel safety. NIF uses a real-time safety system to monitor and mitigate the hazards presented by the facility. The NIF facility Safety Interlock System (SIS) monitors for oxygen deficiency and controls access to the facility preventing exposure to laser light and radiation from the Radiation Generating Devices. It also interfaces to radiation monitoring and other radiological monitoring and alarm systems. The SIS controls permissives to the hazard-generating equipment and annunciates hazard levels in the facility. To do this reliably and safely, the SIS has been designed as a fail-safe system with a proven performance record now spanning over 10 y. This paper discusses the SIS, its design, implementation, operator interfaces, validation/verification, and the hazard mitigation approaches employed in the NIF. A brief discussion of the Failure Modes and Effect Analysis supporting the SIS will also be presented. The paper ends with a general discussion of SIS do's and don'ts and common design flaws that should be avoided in SIS design.

Lawrence Livermore National Laboratory must control potentially activated materials and equipment in accordance with U.S. Department of Energy (DOE) Order 458.1, Radiation Protection of the Public and the Environment, which requires DOE approval of the process used to release volumetrically contaminated personal property and establishes a dose constraint of 10 µSv y(-1) (1 mrem y(-1)) for clearance of such property. The National Ignition Facility at Lawrence Livermore National Laboratory developed a technical basis document and protocol for determining the radiological status of property that is potentially activated from exposure to neutron radiation produced via fusion of tritium and deuterium. The technical basis included assessment of the neutron energy, the type of materials potentially exposed and the likely activation products, and the sensitivity of radiation detectors used to survey the property. This paper evaluates the National Ignition Facility technical basis document for applicability to the release of property from Lawrence Livermore National Laboratory's various accelerator facilities considering the different types of particles accelerated, radiations produced, and resultant activation products. Extensive process knowledge regarding the accelerators' operations, accompanied by years of routine surveys, provides an excellent characterization of these facilities. Activation studies conducted at the Stanford Linear Accelerator and the High Energy Accelerator Research Organization in Japan corroborate that the long-lived radionuclides produced at accelerator facilities are of the same variety produced at the National Ignition Facility. Consequently, Lawrence Livermore National Laboratory concludes that the release protocol developed for the National Ignition Facility can be used appropriately at all its accelerator facilities.

The National Ignition Facility (NIF) has been designed to accommodate some challenging radiological conditions. The high prompt neutron source (up to 1.6 × 10(19) neutrons per shot) results in the need for significant fixed shielding. Concrete shielding approximately 2 m thick is used for the primary (target bay) shield. Penetrations in this shield, including those required for 192 laser beams, utilities, diagnostics, and 19 shielded personnel access doors, make the design challenging. An additional 28 shield doors are part of the secondary shield. In addition, the prompt neutron pulse results in activated air within the target bay, requiring special ventilation considerations. Finally, targets can use a number of hazardous and radioactive materials including tritium, beryllium, and depleted uranium (the latter of which results in the generation of small quantities of fission products). Frequent access is required to the associated potentially contaminated volumes for experimental setup, facilitating the need for local exhaust ventilation to manage these hazards. This paper reviews some of these challenges, design considerations, and the engineering solutions to these design requirements.

Operation of the NIF requires a large and varied number of routine and infrequent activities involving contaminated and radioactive systems, both in servicing online equipment and offline refurbishment of components. Routine radiological operations include up to several dozen entries into contaminated systems per day, multiple laboratories refurbishing radiologically impacted parts, handling of tens of curies of tritium, and (eventually) tens of workers spending most of their day working in radiation areas and handling moderately activated parts. Prior to the introduction of radioactive materials and neutron producing experiments (capable of causing activation), very few of the operating staff had any radiological qualifications or experience. To support the full NIF operating program, over 600 radiological workers needed to be trained, and a functional and large-scale radiological protection program needed to be put in place. It quickly became evident that there was a need to supplement the LLNL site radiological protection staff with additional radiological controls technicians and a radiological protection staff within NIF operations to manage day-to-day activities. This paper discusses the approach taken to stand up the radiological protection program and some lessons learned.

The National Ignition Facility (NIF) at the Lawrence Livermore National Laboratory (LLNL) in California is currently in operation with the goal to demonstrate fusion energy gain for the first time in the laboratory-also referred to as "ignition." Based on these demonstration experiments, the Laser Inertial Fusion Energy (LIFE) power plant is being designed at LLNL in partnership with other institutions with the goal to deliver baseload electricity from safe, secure, sustainable fusion power in a time scale that is consistent with the energy market needs. For this purpose, the LIFE design takes advantage of recent advances in diode-pumped, solid-state laser technology and adopts the paradigm of Line Replaceable Units used on the NIF to provide high levels of availability and maintainability and mitigate the need for advanced materials development. The LIFE market entry plant will demonstrate the feasibility of a closed fusion fuel cycle, including tritium breeding, extraction, processing, refueling, accountability, and safety, in a steady-state power-producing device. While many fusion plant designs require large quantities of tritium for startup and operations, a range of design choices made for the LIFE fuel cycle act to reduce the in-process tritium inventory. This paper presents an overview of the delivery plan and the preconceptual design of the LIFE facility with emphasis on the key safety design principles being adopted. In order to illustrate the favorable safety characteristics of the LIFE design, some initial accident analysis results are presented that indicate potential for a more attractive licensing regime than that of current fission reactors.

The National Ignition Facility (NIF) is a 192 laser beam facility that supports the Inertial Confinement Fusion program. During the ignition experimental campaign, the NIF is expected to perform shots with varying fusion yield producing 14 MeV neutrons up to 20 MJ or 7.1 × 10(18) neutrons per shot and a maximum annual yield of 1,200 MJ. Several infrastructure support systems will be exposed to varying high yield shots over the facility's 30-y life span. In response to this potential exposure, analysis and testing of several facility safety systems have been conducted. A detailed MCNP (Monte Carlo N-Particle Transport Code) model has been developed for the NIF facility, and it includes most of the major structures inside the Target Bay. The model has been used in the simulation of expected neutron and gamma fluences throughout the Target Bay. Radiation susceptible components were identified and tested to fluences greater than 10(13) (n cm(-2)) for 14 MeV neutrons and γ-ray equivalent. The testing includes component irradiation using a 60Co gamma source and accelerator-based irradiation using 4- and 14- MeV neutron sources. The subsystem implementation in the facility is based on the fluence estimates after shielding and survivability guidelines derived from the dose maps and component tests results. This paper reports on the evaluation and implementation of mitigations for several infrastructure safety support systems, including video, oxygen monitoring, pressure monitors, water sensing systems, and access control interfaces found at the NIF.

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white&#95;paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

Introduction: Validly interpreting scores based on patients' reports of their experiences using scales depends on a valid scoring system. The possibility exists that, although the creators of a scale intended to create a scale measuring a single construct, the questions may seem to measure more than one construct. However, the possibility also exists that the questions do generally measure one construct, but several "nuisance" constructs influence the measurement of the construct indirectly. Unidimensional, multidimensional, and bifactor analytical models offer a method for establishing scale dimensionality and subsequently developing valid scoring systems. In this paper, we take an applied perspective, discuss these models and their implications, and use real data to provide an example., Methods: We used unidimensional, multidimensional, and bifactor analyses to examine the measurement structure of the Consumer Assessments of Healthcare Providers and Systems Cultural Competence (CAHPS-CC) Survey. Participants came from a 2008 sample of 2 Medicaid managed care plans, in New York and California., Results: Both unidimensional and bifactor models failed to fit the data well. A multidimensional model, with 7 factors corresponding to 7 cultural competence domains fit the data well (root mean square error of approximation=0.064; Tucker-Lewis Index=0.98; comparative fit index=0.97)., Discussion: Results indicate that the CAHPS-CC does not seem to measure a single construct. Rather, the CAHPS-CC seems to measure 7 separable domains, suggesting the need for 7 separate scale scores. Our findings highlight the importance of conducting dimensionality analyses.

Objective: Healthcare reform will result in substantial numbers of newly insured, low-income adults with chronic conditions. This paper examines the costs of a chronic disease management program among newly insured adults with diabetes and/or hypertension., Research Design and Methods: Low-income adults with diabetes and/or hypertension were provided County-sponsored health insurance coverage and access to disease management. Health econometric methods were used to compare costs among participants in disease management to nonparticipants, both overall and in comparison between those who were newly insured versus previously insured under an alternative County-sponsored insurance product. Costs were also compared between those who qualified for County-sponsored coverage due to diabetes versus hypertension., Results: Annual inpatient costs were $1260 lower, and outpatient costs were $723 greater, among participants in disease management (P<0.001 each). Participants in disease management without previous County-sponsored coverage had higher pharmacy costs ($154, P=0.002) than nonparticipants; whereas participants with diabetes had marginally significant lower overall costs compared with nonparticipants ($-685, P=0.070)., Conclusions: Disease management was successful in increasing the use of outpatient services among participants. The offsetting costs of the program suggest that disease management should be considered for some newly insured populations, especially for adults with diabetes.

Purpose: This study reviews Asian immigration in California and the effect it has had on public health in the state in terms of genetic disease detection. This is documented in terms of the numbers of cases of thalassemia detected, including Hemoglobin (Hb) E/beta-thalassemia, beta-thalassemia major, and Hb H disease., Patients and Methods: California has been screening all newborns for hemoglobinopathies since 1990 and tests approximately 530,000 newborns per year. Samples are collected on filter paper during the first I to 2 days of life and sent to one of eight contract laboratories. The screening methodology is cation exchange high-performance liquid chromatography. Confirmatory testing is performed at Children's Hospital Oakland hemoglobin laboratory using a variety of methods., Results: Approximately five to seven cases each of Hb E/beta-thalassemia and beta-thalassemia major are detected annually. Most cases are of Southeast Asian origin. Prevalence rate of Hb E/beta-thalassemia among Southeast Asians is approximately 1 in 2,200 births. A pilot program for Hb H disease screening was successful and this disorder has now been incorporated in newborn screening, detecting approximately 40 cases per year., Conclusions: Increases in Asian immigration and births in the U.S., particularly California, have been dramatic during the past 10 years and have led to detection of previously rare diseases like Hb E/beta-thalassemia. It has also changed the way other thalassemic disorders are viewed, such as Cooley anemia, which previously affected mainly individuals of Mediterranean origin. Now, most affected patients are of Asian origin.

This paper presents the results of applying the case-specular method to two earlier studies of wire codes and childhood cancers (DA Savitz et al, Am J Epidemiol 1988;128:21-38, and SJ London et al, Am J Epidemiol 1991;9:923-937). The method compares the wire codes of case residences with the wire codes of specular residences constructed by switching the location of the case residence across the center of the street. The method was designed to discriminate between the magnetic field hypothesis, which postulates that childhood cancer is affected by magnetic fields and that wire codes are a proxy for magnetic fields, and the neighborhood hypothesis, which postulates that childhood cancer is affected by some characteristics of the neighborhood other than magnetic fields and that wire codes are a proxy for those characteristics. Although the results from the two applications of the method have limited precision, they support the results originally reported (odds ratios of around 2 for very high current configuration residences and childhood cancers) and do not support suggestions that the associations are due to confounding by socio-economic and neighborhood factors. The results leave open the question of whether or not control selection bias could have influenced the original associations, because there was no convincing evidence that the control-specular matrices were symmetric.

Background: Health plans commonly face the conflicting demands of trying to provide access to novel technologies, including new classes of medications, while trying to contain costs. These demands are particularly acute for California's Medicaid program, known as Medi-Cal, which is responsible for delivery of medical care to an unusually large population of mentally ill individuals in the context of a culturally diverse environment. To meet the challenge, Medi-Cal has instituted a formal process for technology assessment of new and existing pharmaceutical products known as the Therapeutic Class Review (TCR)., Objective: The purpose of this paper is to describe the information produced for Medi-Cal in the TCR process for antidepressant medications and the individual petition review of antipsychotic medications, and to synthesize our experience in a series of policy recommendations designed to improve the quality of coverage decisions., Outcome: A collaborative process between Medi-Cal and Lilly resulted in a substantive body of new evidence regarding the needs of Medi-Cal recipients, the quality of current treatment, and prospects regarding the cost-effectiveness of introducing newer treatments., Conclusion: Medi-Cal has a formal process for evaluating new medicines. This process allows researchers to understand the needs of those who make coverage decisions. We recommend increasing routine epidemiologic surveillance, including service use, and clinical trials that include aspects of usual medical care early in the drug development process.

Due to the lack of information regarding how US workers protect themselves from ultraviolet radiation, this study explored solar protection behaviors among three groups of outdoor workers. This cross-sectional research involved two separate studies. Study 1 consisted of observations of 312 outdoor workers, and Study 2 was a paper and pencil survey (n = 240). For each data set, occupational groups were compared on ultraviolet radiation protection. Observational data indicated that 50.4% of the workers had adequate protection. Across occupational groups, the ranking from highest to lowest levels of protection was consistent for both data sets. Face and lower arms were consistently the least protected sites. The pattern of findings suggests the importance of assessing protection of individual body sites, as well as composite protection.

The Final Focus Test Beam (FFTB) is a new beam line at the Stanford Linear Accelerator Center designed to test new beam optics concepts, hardware, and techniques necessary to achieve and measure the small spot sizes required for future generations of high-energy e+e- linear colliders. The FFTB takes a 47 GeVc-1, 1 kW electron beam at the end of the Stanford Linear Accelerator Center linear accelerator and transports it to the FFTB beam dump. A radiation protection system was designed and installed for the FFTB with the primary goal that the integrated dose equivalent outside the shielding resulting from beam loss would not exceed 10 mSv y-1. This system is comprised of shielding, a beam containment system and a personnel protection system. This paper presents various aspects of radiation safety at Stanford Linear Accelerator Center that were considered in the design of the FFTB radiation protection system. Beam tests were conducted in which the performance of various beam containment devices and the shielding effectiveness were evaluated. Preliminary results from these tests are presented.

A research demonstration pilot project for hospitalized adult and pediatric long-term ventilator-dependent patients was conducted by Kaiser Permanente Southern California Region from 1985 until 1992. The purpose of the pilot project was to investigate if home care was a realistic alternative to continued hospital care. Many aspects of home care as compared to hospital care were studied. The results of the quality of life and quality of care study in addition to cost data are presented in this paper. Standardized questionnaire tools were used to obtain patient data from the perspective of the patient, as well as others providing direct patient care. Respondents were asked to measure perceptions of quality of life and quality of care at home versus at the hospital in regard to health status, life satisfaction, emotional well-being, caregiver ability, and professional care and services. Quality of care was found to be similar to hospital care. Quality of life was judged to be better at home.

This paper presents a technology assessment process based on systems engineering methodologies used in the aerospace and defense industries. Systems engineering, defined in the U.S. military manual for engineering management, is a logical sequence of activities and decisions transforming an operational need into a description of system performance parameters and a preferred system configuration. Like systems engineering, technology assessment is driven by a single, clear need. The objective of systems engineering is to design a new system configuration; technology assessment assesses existing technologies to address this need. A six-step technology assessment model based on systems engineering principles is presented, including: (1) needs assessment; (2) clinical feasibility analysis; (3) systems assessment; (4) approval; (5) implementation; and (6) follow-up/CQI.

This paper presents a meta-analysis of 22 studies of coffee use and myocardial infarction or coronary death. In the eight case-control studies, a fairly homogeneous increased risk was found among coffee users (geometric mean rate ratio of 1.42 for 5 cups per day vs none, with 95% confidence limits of 1.30, 1.55, homogeneity P-value of 0.89). The 14 cohort studies tended to exhibit lower but very heterogeneous rate ratios, with a trend toward larger rate ratios in studies with longer follow-up periods and later publication dates (geometric mean rate ratio of 0.92 for the five cohort studies published up to 1981, 1.27 for the nine cohort studies published in 1986 or later; overall homogeneity P-value of 0.0008). The evidence thus remains ambiguous regarding both the existence and size of a coffee effect, and although a rate ratio of over 1.5 for 5 cups per day appears unlikely, stronger effects for 10-cup-per-day drinkers cannot be ruled out.

"What is the major nursing administrative issue today?" The question was posed to a community of scholars in the masters program in nursing administration at the University of California, San Francisco. Using a modified nominal group approach, multiple issues were identified, explored, and prioritized. There was consensus that "doing more with less" is the most important issue and greatest of challenges. To explore this issue in depth, books relating to the topic were identified, read, and applied to nursing administrative practice. Before discussion, administrative briefings were written and distributed among the group. Previous readings and experience also contributed to the synthesis of ideas over the academic year, and the subsequent development of the following position paper.

Dental disease is a major health problem for all school-age children in the nation; for migrant children the problem is most severe. This paper presents strategies for the clinical nurse specialist (CNS) in the school setting in case management of migrant children with dental disease. The barriers migrant families face in obtaining health care are addressed. Leininger's transcultural care theory serves as a conceptual framework. Examples of how the CNS functions in the roles of clinician, educator, consultant, and researcher are given. The federally funded Migrant Education Program is described, along with a model dental program developed by a CNS. Suggestions for documenting the effectiveness of the CNS's role in cost containment and in influencing positive outcome measures of school-age children are presented.

Hospitals face a significant challenge to select and appropriately place clinically warranted, safe, and cost-effective medical devices. To meet this challenge, the Kaiser Permanente, Northern California Region developed a comprehensive medical device technology assessment and equipment planning program. This paper discusses the structure of the program, physician leadership and accountability, the role of clinical engineers and other support personnel, and the program's influence on strategic planning and policy development.

The purpose of this paper is to provide a systematic explanation of the use of traditional medicine among the native American population living in the San Francisco Bay area. Several hypotheses concerning the factors associated with this behavior are tested. These include tribal grouping, socioeconomic and sociocultural factors, as well as the relationship between traditional medicine and modern Anglo medicine. The analysis is based on a probability sample of 277 native American families, systematically drawn from a specially prepared list of 5,000 in three Bay area counties with the largest native American population (Alameda, San Francisco, and Santa Clara). Traditional medicine was used by almost one of three families in the sample and it is shown that use of traditional medicine, although related to sociocultural factors, did not detract from the use of modern Anglo medicine.

The health maintenance organization (HMO) can provide an alternative to the predominant form of health care delivery in the United States, fee-for-service. Although market penetration of the HMO is relatively low in most parts of the country, the HMO has achieved a significant market share in a number of states. This paper examines the competitive response of Blue Cross and Blue Shield to the introduction of the HMO in two geographic regions with significant HMO activity, northern California and Hawaii. The evidence obtained from extensive interviews indicates that Blue Cross and Blue Shield plans have responded to HMO competitive pressure by establishing their own HMOs and by altering traditional procedures. HMO competition has stimulated Blue Cross and Blue Shield to make greater cost control efforts and to offer larger benefit packages. These results can have important policy implications for the role that HMOs are to play in cost containment.

This paper presents the results of two studies that compared methods for measuring patient satisfaction with specific medical encounters. One form used six-point response scales ranging from "very satisfied" to "very dissatisfied" (S6 scale); the other used five-point scales ranging from "excellent" to "poor" (E5 scale). Forms were assigned randomly to outpatients in fee-for-service (N = 136) and prepaid systems of care (N = 363) and were compared in terms of response variability, reliability, and validity. In both studies, the E5 scales showed greater response variability and better predicted whether patients intended to return to the same doctor in the future, recommend the doctor to a friend, and comply with the medical regimen. Reliability was satisfactory and did not differ between methods. Results are discussed in terms of their implications for constructing visit-specific satisfaction rating scales.