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Sharing the journey of developing an ePortfolio assignment, this article focuses on the design process, implementation, and benefits of the ePortfolio as a capstone project for a bachelor's degree program using a constructivist approach. Integrating constructivist educational practices (e.g., student-centered learning, autonomy, self-regulation, mental relationships, and reflection) in the ePortfolio project design deepens student learning, offers a useful means for assessment of student learning through the degree program, and provides students with validation of their learning and development as professionals. Explaining the process of the implementation of the project in the capstone course, this article shows how students can co-construct knowledge in the context of a sociomoral atmosphere. The ePortfolio project serves as an instrument for student assessment and deepening of learning, and beyond graduation, it serves as a valuable tool for professional advancement.

We used a cluster-randomized controlled trial to examine the impacts of a technology- and game-based social-emotional program, the "Adventures Aboard the S.S. GRIN" ("Adventures"), on students' social skills development. Eighty-eight third-grade classrooms (N = 1645 third-grade students) across four California public school districts were randomized to treatment or control. Analysis of student demographic data indicated that 49% were male, 51% were female, approximately one-third were Latinx, and about 50% qualified for free and reduced lunch. Two-level hierarchical linear model analysis results indicated that "Adventures" had significant and meaningful impacts on students' social-emotional learning (SEL) skills. The findings of Adventures shine new lights on a growing effort to support all students, including those identified by their teachers as having social-emotional challenges. It also expands our knowledge about the potential role of technology in addressing SEL competencies.

School closures because of natural phenomena, such as COVID-19, underscore long-standing gaps in access to science education in the United States of America, particularly for young students. When educators have to pivot to deliver virtual instruction, it is important to identify feasible remote learning strategies for science content across formal and informal learning environments. This article discusses two evaluation studies of a multiplatform science learning program was originally developed for an in-person, formal learning environment that was modified based on infrastructure, preparations, and resource availability to meet the needs of distance learning in formal and informal learning environments due to COVID-19.

Many local governments have adopted digital innovations and advanced technologies, including Artificial Intelligence, the Internet of things, and big data to address unprecedented problems, improve the processes and procedures of their services, and enhance citizen engagement. Yet, there are considerable variations in the adoption of digital innovation among local communities, and such variations lead to inequality in access to digital technologies among individuals, households, and other groups of different demographic and socioeconomic levels. Drawing on insights from institutional theory, this study examines whether community wealth, education level, and the presence of an independent IT department matter for a city's level of engagement with digital innovation and technologies. It examines a dataset obtained from the 2023 Local Digital innovation Survey with California city governments. A set of logistic regression analyses provide evidence that community wealth/education and independent IT departments play significant roles in influencing California city governments' level of engagement with digital innovation and technologies. [ABSTRACT FROM AUTHOR]

An incomplete Freund's adjuvant elicited an overt pathogenesis in vaccinated mice following the intranasal challenge of A/California/07/2009 (H1N1) virus despite the induction of a higher specific antibody titer than other adjuvanted formulations. Aluminum hydroxide adjuvants have not induced any pathogenic signs in a variety of formulations with glycolipids. A glycolipid, α-galactosyl ceramide, improved a stimulatory effect of distinct adjuvanted formulations on an anti-influenza A antibody response. In contrast to α-galactosyl ceramide, its synthetic analogue C34 was antagonistic toward a stimulatory effect of an aluminum hydroxide adjuvant on a specific antibody response. The aluminum hydroxide adjuvant alone could confer complete vaccine-induced protection against mortality as well as morbidity caused by a lethal challenge of the same strain of an influenza A virus. The research results indicated that adjuvants could reshape immune responses either to improve vaccine-induced immunity or to provoke an unexpected pathogenic consequence. On the basis of these observations, this research connotes the prominence to develop a precision adjuvant for innocuous vaccination aimed at generating a protective immunity without aberrant responses. [ABSTRACT FROM AUTHOR]

Background Orthopedic patients report pain as their main symptom complaint. Subjective pain experience is correlated with self-reported psychological state, such as distress. Purpose This study tests whether scores from a measure of mindful attention are associated with subjective pain levels and whether psychological distress scores function as a mediation path. Methods During routine visits to a single orthopedic clinic in East Los Angeles, California, 525 patients were recruited to participate in the study. Participants reported on measures of pain (Universal Pain Assessment Tool [UPAT]), mindful attention (Five-Facet Mindfulness Questionnaire [FFMQ]), and psychological distress (Depression, Anxiety, Stress Scale [DASS]). We used Pearson correlations to examine relationships between FFMQ and UPAT scores and mediation analyses to test indirect effects of DASS scores as a mediation path. Results The average age of the sample was 54 years (range 18–98 years), 61% were male, and 64% were non-Hispanic White individuals. The locations of injury were the shoulder (72%), elbow (21%), and clavicle or wrist (7%). Ninety-one percent reported mild or greater pain in the prior 2 weeks (mean   =   4.2 ± 2.5, range 0–10), and 49% reported mild or more severe distress symptoms (DASS: 13.0 ± 11.5). FFMQ scores inversely predicted UPAT scores (β = –0.22, P  < .01), mediated through DASS scores. DASS subscale scores for depression (β = –0.10, P  = .02) and stress (β = –0.08, P  = .04) but not anxiety (β = –0.03, P  = .33) produced significant indirect effects. FFMQ acting-with-awareness and non-judging subscales had the largest effect on depression and stress DASS subscale scores. Conclusions We find statistical support to suggest that distress—particularly depressed mood and stress—mediates the association between mindful attention and pain intensity among orthopedic patients. A disposition of mindful attention might counter distress ailments that exacerbate subjective pain, and this has possible implications for mindfulness training interventions offered to orthopedic patients. [ABSTRACT FROM AUTHOR]

Two intervention approaches designed to address the multifaceted academic and cognitive difficulties of low-income children who enter pre-K with very low math knowledge were tested in a randomized experiment. Blocking on classroom, children who met screening criteria were assigned to a Math + Attention condition in which the Pre-Kindergarten Mathematics Tutorial (PKMT) intervention was implemented (4 days/week for 24 weeks) in addition to 16 adaptive attention training sessions, a Math-Only condition using the PKMT intervention, or a business-as-usual condition. Five hundred eighteen children were assessed at pretest and posttest. There was a significant effect of the PKMT intervention on a broad measure of informal mathematical knowledge and a small but significant effect on a measure of numerical knowledge. Attention training was associated with small effects on attention, but did not provide additional benefit for mathematics. A main effect of state on math outcomes was associated with a stronger, numeracy-focused Tier 1 mathematics curriculum in one state. Findings are discussed with respect to increasing intensity of math-specific and domain-general interventions for young children at risk for mathematical learning difficulties.

This article utilizes a multilevel intersectional framework to analyze how Asian immigrant women workers in state-funded care provisioning make sense of and contest the relations of servitude that have long plagued low-paid domestic work. Our research, which draws on in-depth interviews with Chinese, Korean, and Filipina/o/x women in California's In-Home Supportive Services program, shows that workers across all three groups face coercive labor conditions in private homes that severely constrain their ability to refuse excessive demands on their time and tasks, including when care is publicly funded and means tested, provided by paid relatives, managed by the state, and regulated under union collective-bargaining agreements. Yet, our comparative analysis also shows that workers from different groups have varying understandings of what constitutes servitude and how it can be challenged, especially when care receiver–employers are similarly marginalized and are part of workers' families and ethnic communities. Meso-level institutions such as labor markets, immigrant networks, community organizations, and labor unions play a significant role in mediating workers' subjective understandings and group-level responses to ongoing conditions of de facto servitude. [ABSTRACT FROM AUTHOR]

Background: We used a genome‐wide discovery approach to identify methylation markers associated with metastasis in men with localized prostate cancer (PCa), as better identification of those at high risk of metastasis can inform treatment decision‐making. Methods: We identified men with localized PCa at Kaiser Permanente California (January 1, 1997–December 31, 2006) who did not receive curative treatment and followed them for 10 years to determine metastasis status. Cases were chart review‐confirmed metastasis, and controls were matched using density sampling. We extracted DNA from the cancerous areas in the archived diagnostic tissue blocks. We used Illumina's Infinium MethylationEPIC BeadChip for methylation interrogation. We used conditional logistic regression and Bonferroni's correction to identify methylation markers associated with metastasis. In a separate validation cohort (2007), we evaluated the added predictive utility of the methylation score beyond clinical risk score. Results: Among 215 cases and 404 controls, 31 CpG sites were significantly associated with metastasis status. Adding the methylation score to the clinical risk score did not meaningfully improve the c‐statistic (0.80–0.81) in the validation cohort, though the score itself was statistically significant (p < 0.01). In the validation cohort, both clinical risk score alone and methylation marker score alone are well calibrated for predicted 10‐year metastasis risks. Adding the methylation score to the clinical risk score only marginally improved predictive risk calibration. Conclusion: Our findings do not support the use of these markers to improve clinical risk prediction. The methylation markers identified may inform novel hypothesis in the roles of these genetic regions in metastasis development. [ABSTRACT FROM AUTHOR]

A prominent finding in recognition memory is that studied items are associated with more variability in memory strength than new items. Here, we test 3 competing theories for why this occurs--the "encoding variability," "attention failure", and "recollection" accounts. Distinguishing among these theories is critical because each provides a fundamentally different account of the processes underlying recognition memory. The encoding variability and attention failure accounts propose that old item variance will be unaffected by retrieval manipulations because the processes producing this effect are ascribed to encoding. The recollection account predicts that both encoding and retrieval manipulations that preferentially affect recollection will affect memory variability. These contrasting predictions were tested by examining the effect of response speeding (Experiment 1), dividing attention at retrieval (Experiment 2), context reinstatement (Experiment 3), and increased test delay (Experiment 4) on recognition performance. The results of all 4 experiments confirm the predictions of the recollection account and are inconsistent with the encoding variability account. The evidence supporting the attention failure account is mixed, with 2 of the 4 experiments confirming the account and 2 disconfirming the account. These results indicate that encoding variability and attention failure are insufficient accounts of memory variance and provide support for the recollection account. Several alternative theoretical accounts of the results are also considered.

Throughout the world, measuring "learning outcomes" is viewed by many stakeholders as a relatively new method to judge the "value added" of colleges and universities. The potential to accurately measure learning gains is also a diagnostic tool for institutional self-improvement. This essay discussed the marketisation of learning outcomes tests, and the relative merits of student experience surveys in gauging learning outcomes by analyzing results from the University of California's Undergraduate Experience Survey (Student Experience in the Research University Survey: SERU-S). The SERU-S includes responses by seniors who entered as freshmen on six educational outcomes self-reports: analytical and critical thinking skills, writing skills, reading and comprehension skills, oral presentation skills, quantitative skills, and skills in a particular field of study. Although self-reported gains are sometimes regarded as having dubious validity compared to so-called "direct measures" of student learning, the analysis of this study reveals the SERU survey design has many advantages, especially in large, complex institutional settings. Without excluding other forms of gauging learning outcomes, we conclude that, designed properly, student surveys offer a valuable and more nuanced alternative in understanding and identifying learning outcomes in the broad tapestry of higher education institutions. We discuss the politics of the learning outcomes race, the validity of standardized tests like the Collegiate Learning Assessment (CLA), and what we can learn from student surveys like SERU-S. We also suggest there is a tension between what meets the accountability desires of governments and the needs of individual universities focused on self-improvement.

The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82–6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations. [ABSTRACT FROM AUTHOR]

PURPOSE Delivering cancer care by high-functioning multidisciplinary teams promises to address care frag-mentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system. METHODS 4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes. RESULTS We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency. CONCLUSION 4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care. [ABSTRACT FROM AUTHOR]

5 Background: Insurance prior authorization (PA) is pervasive in modern oncology treatment, with both Medical and Radiation Oncology ranked among the top 5 in a survey of PA burdens across all medical specialties. The cumbersome process delays patient care and increases provider friction, with a major contributor being the perceived lack of transparency regarding PA decisions. Challenges arise because policies are often located behind portal logins, are inaccessible within the clinical workflow, or are too broad to capture patient nuances. We hypothesized that integrating automated insurance authorization software into the clinical workflow would enhance transparency to payer policies. Additionally, we investigated whether these policies could predict whether authorizations would be issued. Methods: We tracked radiation medicine treatment PA requests at a multisite academic healthcare network. Cases were tracked utilizing a standard clinical EMR. We concurrently implemented InsightRT (Siris Medical, Division of TurningPoint Healthcare), an EMR-integrated software system, to automate authorization documentation by capturing and transmitting patient and treatment characteristics. The online portal informed whether a prescribed treatment met the payer policy and tracked the approval process. A pilot subset of physicians was transitioned to using InsightRT. Results: A total of 1418 non-Medicare/Medicaid PA requests were tracked, with 1235 using the traditional clinical workflow and 183 utilizing InsightRT. The software system indicated 162 (88.5%) were "in policy" and only 2 prescriptions were eventually denied. Of the 21 (11.5%) prescriptions that were "Out of Policy" as indicated by the software, only 1 was denied. Sensitivity and specificity of Insight RT policy determination was 98.8% and 97.6% respectively. Overall, there were 43 denials across a total of 1418 cases with payer review only downgrading or changing 4 cases out of 1418, or 0.3%. The other 39 denials were overturned, with 23 (59%) by peer-to-peer (P2P), and 16 (41%) by documentation review. Conclusions: Automated insurance prior authorization provides increased transparency to the provider with high sensitivity and specificity. However, improvements to payer policies and processes are needed to decrease unnecessary burden and delays to care, as the true impact of PA is limited to 0.3% in this cohort. All cases from 12/23 - 5/24. All Cases from non Medicare/Medicaid 1418 Cases processed in InsightRT 183 Cases processed in EMR and not InsightRT 1235 Denials 43 Overturned denials that went to P2P 23 Overturned denials that only needed clinical documentation 16 Cases with confirmed P2P that were downgraded 4 The True Impact of PA - % of all cases changed due to PA 0.30% [ABSTRACT FROM AUTHOR]

332 Background: Receiving a cancer diagnosis and awaiting initial management recommendations is a stressful time. Distress should be recognized, documented, and treated promptly as part of quality oncologic care. The NCCN Distress Thermometer (DT) is a useful tool for patients to quantify their level of distress. This pilot study assesses the rate of distress screening at a high-volume academic healthcare network, before and after institutional quality improvement (QI) intervention. Methods: All patients seen for Radiation Medicine between 1/1/22 - 12/31/23 were reviewed. Rates of DT documentation at the time of consultation were assessed as the QI metric. Patients seen in 2022 served as a baseline of departmental compliance. The importance of distress assessment was formally introduced to physicians and advanced care practitioners (ACPs) in Q4 2022 during monthly departmental quality reports, with notice that a formal QI metric would be monitored beginning 1/1/23. Chi-square test was used to compare rates of DT documentation. Monthly departmental DT documentation rates were back presented to the physicians and ACPs during quality meetings. Results: 9391 patients were seen for radiation oncology consultation (2022 = 4311; 2023 = 5080). Baseline DT documentation was 51.0%. Initial compliance with the metric was below baseline, at 41.4% for Jan 2023. With continued feedback, education, and goal-setting, rates of DT use continually improved over Q1/Q2 2023 and remained relatively steady through the remainder of Q3/Q4 2023, reaching a monthly high of 89.8%. Overall DT documentation significantly improved for 2023 was 81.4% (χ2 = 977.9, p < 0.0001). The rates of DT documentation were relatively consistent based on diagnoses codes, though lower amongst consults seen for metastatic disease (84.0% vs 73.4%, χ2 = 24.28, p < 0.0001). Conclusions: Screening rates at consultation are modifiable and maintainable, but distress management remains a continuous quality improvement project as we explore services to address identified stressors and reassess distress levels at future visits. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes management and control remain poor in Asian Indians (AI) and is influenced by personal beliefs and cultural practices. Since AIs have a high prevalence of diabetes and are more likely develop complications earlier than any other ethnic group, understanding their beliefs and practices of diabetes management is essential. The purpose of this study was to examine and understand beliefs and practices about diabetes self-management in first-generation AI Hindus and Sikhs. Method: Interpretative phenomenology was used to interview 12 first generation AI participants with type 2 diabetes to elicit beliefs and daily self-management practices of diabetes. Interpretative and thematic analysis were completed. Results: Diabetes self-management was a balancing act influenced by Ayurvedic principles, allopathy and dietary practices; gender roles, insufficient knowledge and culturally inappropriate diabetes education. Discussion: Culturally appropriate strategies that incorporate Ayurvedic principles, dietary practices, gender roles should be developed to improve diabetes management. [ABSTRACT FROM AUTHOR]

Introduction: Asian Indians (AIs) have the highest prevalence rates (18.3%-29%) of diabetes in any minority group in the United States, yet little is known about their beliefs about what causes type 2 diabetes. The purpose of this study was to examine first generation AIs causal beliefs about type 2 diabetes. Method: Interpretative phenomenology was used to interview 12 first-generation AI participants with type 2 diabetes to elicit causal beliefs of their disease. Interpretative and thematic analysis were completed. Results: Beliefs about the causes of diabetes in AIs were influenced by a general familiarity with the disease, limited knowledge about causal and preventative factors of the disease, and gender specific roles and norms. Discussion: Health programs that aim to incorporate AI's cultural and health beliefs about the causes of diabetes are warranted. [ABSTRACT FROM AUTHOR]

Background/Objectives: Pediatric melanoma is rare and remains poorly characterized, especially in racial/ethnic minorities of whom Hispanics are the largest and fastest growing in the United States. The health care burden of melanoma in Hispanics, who often present with more advanced disease, is rising and has even been called an early epidemic in California. We sought to document key clinicopathologic features of melanoma in Hispanic pediatric patients and to compare these parameters to pediatric non‐Hispanic whites (NHWs) under the a priori hypothesis that Spitzoid melanomas occur in greater proportions in Hispanics. Methods: Single‐institution cross‐sectional study of pediatric melanoma cases (age < 20 years) with Hispanic stratification and comparison with matched Surveillance, Epidemiology, and End Results (SEER) data from the same time frame (1988‐2016). Results: Of our 61 institutional cases of pediatric melanoma, Hispanics (11), compared with NHWs (40), presented significantly younger (11.7 years, 95% CI: 2.77‐8.00 years; P =.001), with lower limb predominance (46%; P <.05), mostly Spitzoid melanomas (82%; P <.05), and thicker tumors (2.34 mm, CI: 0.26‐2.19 mm; P <.05). Similarly, SEER data (2499 cases) showed greater proportions of childhood/pre‐pubertal adolescent melanomas (<15 years), lower limb involvement, Spitzoid subtype (36.5% vs 22.5% in NHWs; P =.001), and advanced (regional/distant) disease stages in Hispanics (212) compared with NHWs (2197). Conclusions: Pediatric melanomas may present differently in Hispanics, and heightened awareness/lower threshold to biopsy high‐risk Spitzoid tumors on the lower limb may be warranted. Further investigations are needed to aid prevention and early detection in a vulnerable minority population less likely to seek outpatient dermatology specialty care. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) remains a pressing public health issue. Nationally, 1 in 5 women and 1 in 10 men have sustained severe physical violence from an intimate partner. Intimate partner homicides (IPH) are the most serious IPV outcome. This study examined documented IPH in Los Angeles County during 2017, analyzing if precipitating circumstances, victim demographics, victim/suspect relationship, and weapon type were related to how often a homicide was reported in online media stories. Cases were identified from the National Violent Death Reporting System (NVDRS), and standardized internet searches identified media articles associated with each case. Victim demographics from NVDRS and media articles were compared using Chi Square tests. Media report frequency, within different categorical predictor values, were examined using ANOVA models. 44 incidents were identified; averaging 5.2 articles per decedent. Univariate analyses showed significant difference in media reporting by poverty level (low versus high socioeconomic status) and presence of preceding argument. Multivariate analyses found significantly more media reports (p = 0.002) for incidents in which a preceding argument is reported, the victim was 30–39 years old and from a low socioeconomic status zip code. From our results certain characteristics of IPH are associated with greater media reporting. Promotion of consistent and responsible IPH media reporting guidelines is an opportunity to reinforce public health messaging and dispel myths. In turn, this will encourage the development of future policies and funding streams across the spectrum of preventing and stopping IPV. [ABSTRACT FROM AUTHOR]

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The reinforcement treatment for embankment using the fly ash deposits as the filling material for roadbed was clarified in this paper. Studies have shown that fly ash can be used as the filling material for embankment, but the subgrade bearing capacity from the original fly ash deposits cannot meet the requirements for operating. Fly ash has a good condition to run the dynamic consolidation for meeting the requirements of embankment compaction. The modulus of resilience and the California bearing ratio (CBR) of fly ash is close to that of general filling material for embankment. Fly ash also has the engineering properties of high void ratio and low cohesion. The maximum level of compaction of the fly ash deposits can be 93% and the bear capacity can be about twice over before after the treatment. [ABSTRACT FROM AUTHOR]

This study revisits the concept of environmental inequity in Southern California using the California Environmental Protection Agency's most recent data and spatial models. Empirical studies in the late 1990s documented the existence of environmental inequity among disadvantaged populations in the area, and we still found evidence of environmental inequity. However, our findings were more nuanced and subtler than previous results. The risk of being exposed to pollutants (e.g. ozone, PM2.5 and others) increases with a corresponding increase in Hispanic or Asian populations in a census tract. The risk of living near adverse environmental conditions (e.g. hazardous facilities, ground water threats and more) was less clear according to minority status. As the percentage of Hispanics in a census tract increases, the environmental risk increases only to a point, and then decreases. This finding suggests that, at present, some Hispanic communities enjoy better environmental conditions than do ethnically mixed communities, but the risk of being exposed to pollutants still increases with an increase in the percentage of Hispanics in a census tract. If policy needs to be developed and updated accordingly to reflect changing environments, this new evidence directs urban environmental inequity research to pay attention to ethnically mixed communities as well. [ABSTRACT FROM AUTHOR]

The article discusses a study that examined the feasibility of implementing a one-to-one telephone-based teacher-led mindfulness training before and after orthopedic surgery. Highlights include recruitment of patients from a Southern California orthopedic clinic in 2015, the Universal Pain Assessment Tool completed by participants to quantify pain level, and changes in measure scores from baseline to week 10.

Introduction: There have been conflicting data regarding the relationship between sepsis-bundle adherence and mortality. Moreover, little is known about how this relationship may be moderated by the anatomic source of infection or the location of sepsis declaration. Methods: This was a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock. The study included patients who presented to one of three Los Angeles County Department of Health Services (DHS) full-service hospitals January 2012 to December 2014. The primary outcome of interest was the association between sepsisbundle adherence and in-hospital mortality. Secondary outcome measures included in-hospital mortality by source of infection, and the location of sepsis declaration. Results: Among the 4,582 patients identified with sepsis, overall mortality was lower among those who received bundle-adherent care compared to those who did not (17.9% vs. 20.4%; p=0.035). Seventyfive percent (n=3,459) of patients first met sepsis criteria in the ED, 9.6% (n=444) in the intensive care unit (ICU) and 14.8% (n=678) on the ward. Bundle adherence was associated with lower mortality for those declaring in the ICU (23.0% adherent [95% confidence interval{CI} {16.8-30.5}] vs. 31.4% nonadherent [95% CI {26.4-37.0}]; p=0.063), but not for those declaring in the ED (17.2% adherent [95% CI {15.8-18.7}] vs. 15.1% non-adherent [95% CI {13.0-17.5}]; p=0.133) or on the ward (24.8% adherent [95% CI {18.6-32.4}] vs. 24.4% non-adherent [95% CI {20.9-28.3}]; p=0.908). Pneumonia was the most common source of sepsis (32.6%), and patients with pneumonia had the highest mortality of all other subsets receiving bundle non-adherent care (28.9%; 95% CI [25.3-32.9]). Although overall mortality was lower among those who received bundle-adherent care compared to those who did not, when divided into subgroups by suspected source of infection, a statistically significant mortality benefit to bundle-adherent sepsis care was only seen in patients with pneumonia. Conclusion: In a large public healthcare system, adherence with severe sepsis/septic shock management bundles was found to be associated with improved survival. Bundle adherence seems to be most beneficial for patients with pneumonia. The overall improved survival in patients who received bundle-adherent care was driven by patients declaring in the ICU. Adherence was not associated with lower mortality in the large subset of patients who declared in the ED, nor in the smaller subset of patients who declared in the ward. [ABSTRACT FROM AUTHOR]

This qualitative study examines the social environmental influences on smoking and cessation from the perspectives of Chinese smokers and household nonsmokers in California. Seven focus groups were conducted with 63 participants. Three culturally influenced levels of potential intervention emerged from constant comparative analysis. At the individual level, participants focused more on irritating odor than health harms of exposure and had inaccurate beliefs about harms of smoking and cessation. At the relational level, peers kept smokers connected to pro-smoking norms. There was conflict in the home about smoking and failed cessation, but smokers recognized the benefits of cessation for family harmony and children's health. Physicians encouraged cessation but this tended to be insufficient to prompt action unless a smoker felt ill. At the societal level, participants recognized changes in social acceptability and environmental regulation of smoking upon immigration. Better implementation of smokefree policies, plus culturally nuanced strategies for equipping both nonsmokers and smokers to become smokefree, are needed. [ABSTRACT FROM AUTHOR]

Background: Little is known about the care that adolescent and young adult (AYA) patients with cancer receive at the end of life (EOL). Objective: To examine care in the last month of life among AYA patients with cancer. Design: Medical record review of the last 30 days of life. Setting/Subjects: One hundred eleven AYA patients aged 15-39 years at death with either stage I-III cancer and evidence of cancer recurrence or stage IV cancer at diagnosis. Patients received care in Kaiser Permanente Southern California, an integrated healthcare delivery system, and died from 2007 to 2010. Measurements: Use of intensive measures, including chemotherapy in the last 14 days of life and emergency room visits, hospitalizations, and intensive care unit admissions in the last 30 days; documented care preferences; symptom prevalence and treatment; advance care planning; hospice use; and location of death. Results: One hundred seven patients (96%) had documented care preferences in the last month of life. At first documentation, 72% of patients wished for life-prolonging care, 20% wished for care focused on comfort, and 8% were undecided. Forty-seven percent of patients had documented changes in preferences in the last month, with 40% wishing for life-prolonging care when preferences were last noted before death, 56% preferring comfort, and 4% undecided. Seventy-eight percent of patients received at least one form of intensive EOL care, including 75% of those who preferred comfort measures at last documentation. Conclusions: Many AYA patients enter the last month of life wishing for life-prolonging care. While most ultimately wish for comfort, intensive care is prevalent even among such patients. [ABSTRACT FROM AUTHOR]

Older Chinese immigrants are a growing population in the United States who experience multiple healthcare communication barriers such as limited English proficiency and low health literacy. Each of these obstacles has been associated with poor health outcomes but less is known about their effects in combination. This study examined the association between healthcare communication barriers and self-rated health among older Chinese immigrants. Cross-sectional survey data were obtained from 705 Chinese American immigrants ages 50-75 living in San Francisco, California. Communication barriers examined included spoken English proficiency, medical interpreter needs, and health literacy in written health information. The study sample (81 % females, mean age = 62) included 67 % who spoke English poorly or not at all, 34 % who reported needing a medical interpreter, and 37 % who reported 'often' or 'always' needing assistance to read health information. Two-thirds reported poor self-rated health; many reported having access to racial-concordant (74 %) and language-concordant (86 %) healthcare services. Both poor spoken English proficiency and low health literacy were associated with poor self-rated health, independent of other significant correlates (unemployment, chronic health conditions, and having a primary doctor who was ethnic Chinese). Results revealed that spoken English proficiency and print health literacy are independent communication barriers that are directly associated with health status among elderly Chinese American immigrants. Access to racial- or language-concordant health care services did not appear to resolve these barriers. These findings underscore the importance of addressing both spoken and written healthcare communication needs among older Chinese American immigrants. [ABSTRACT FROM AUTHOR]

Summary: Vitamin D is hypothesized to suppress inflammation. We tested total and free vitamin D metabolites and their association with inflammatory markers. Interleukin-6 levels were lower with higher 25-hydroxyvitamin D. 1,25-dihydroxyvitamin D and free 25OHD associations mirrored those of 25OHD. However, associations for the two metabolites diverged for tumor necrosis factor alpha (TNF-α) soluble receptors. Introduction: Vitamin D is hypothesized to suppress inflammation, and circulating 25-hydroxyvitamin D (25OHD) and inflammatory markers are inversely correlated. However, total serum 25OHD may not be the best indicator of biologically active vitamin D. Methods: We tested serum total 25OHD, total 1,25(OH)D, vitamin D binding protein (DBP), and estimated free 25OHD and free 1,25(OH)D associations with inflammatory markers serum interleukin-6 (IL-6), TNF-α and their soluble receptors, interleukin-10 (IL-10), and C-reactive protein (CRP) as continuous outcomes and the presence of ≥2 inflammatory markers in the highest quartile as a dichotomous outcome, in a random subcohort of 679 men in the Osteoporotic Fractures in Men (MrOS) study. Results: IL-6 was lower in men with higher 25OHD (−0.23 μg/mL per standard deviation (SD) increase in 25OHD, 95 % confidence intervals (CI) −0.07 to −0.38 μg/mL) and with higher 1,25(OH)D (−0.20 μg/mL, 95 % CI −0.0004 to −0.39 μg/mL); free D associations were slightly stronger. 25OHD and DBP, but not 1,25(OH)D, were independently associated with IL-6. TNF-α soluble receptors were inversely associated with 1,25(OH)D but positively associated with 25OHD, and each had independent effects. The strongest association with ≥2 inflammatory markers in the highest quartile was for free 1,25(OH)D (odds ratios (OR) 0.70, 95 % CI 0.54 to 0.89 per SD increase in free 1,25(OH)D). Conclusions: Associations of 1,25(OH)D and free 25OHD with IL-6 mirrored those of 25OHD, suggesting that 1,25(OH)D and free D do not improve upon 25OHD in population-based IL-6 studies. However, associations for the two metabolites diverged for TNF-α soluble receptor, warranting examination of both metabolites in studies of TNF-α and its antagonists. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to examine treatment patterns for chemotherapy-induced anemia (CIA) between calendar periods when the changes in the US prescribing information, for erythropoiesis-stimulating agents (ESAs) took place.Methods: Patients diagnosed with breast, lung, colorectal, ovarian, or gastric cancer (2000-2012) who developed grade 2+ CIA (hemoglobin (Hb) <10 g/dl) were identified from Kaiser Permanente Southern California Health Plan. We estimated the proportions of CIA episodes with ESA use, red blood cell (RBC) transfusion, or prescription nutritional supplements in three calendar periods: January 1, 2000-December 31, 2006 (P1), January 1, 2007-March 24, 2010 (P2), and March 25, 2010-June 30, 2013 (P3). Multivariable regressions were used to test the differences of CIA treatment approaches and Hb concentration prior to CIA treatment across these calendar periods.Results: The proportions of CIA episodes with ESA use were 28 % in P1, 21 % in P2, and 3 % in P3. For RBC transfusion, they were 8 % in P1, 14 % in P2 and 16 % in P3. The trend of decreasing ESA use and increasing transfusion use were statistically significant. Relative to P1, the odds ratio (OR) was 0.69 (95% CI: 0.55, 0.86) for P2 and 0.08 (0.30, 0.88) for P3 for ESA use. For RBC transfusion, OR was 2.00 (1.56, 2.56) for P2 and 2.37 (1.88, 3.00) for P3. Use of prescription nutritional supplement was rare across calendar periods. There was a decreasing trend of Hb concentration prior to ESA use (p value <0.01), but no difference in Hb concentrations prior to transfusion.Conclusion: In the management of CIA, use of ESA has decreased over time, while use of RBC transfusion has increased. [ABSTRACT FROM AUTHOR]

Objective: Complementary and integrative health (CIH) use among Hispanic adults with colorectal cancer (CRC) diagnosis is not well documented. Understanding the prevalence and patterns of CIH use among Hispanics offers insights to uncover potential needs for clinical services. Design: Participants were age 21 years or older with a first-time diagnosis of CRC from population-based cancer registries in California. In-person and/or telephone-based interviews were administered to collect data on CIH use. Demographic and clinical diagnosis data were abstracted from medical records. Descriptive statistical and logistic regression was used to analyze the frequencies and associations between selected patient characteristics and CIH use. Results: Among 631 Hispanic patients, 40.1% reported ever using CIH. Herbal products/dietary supplements were used most often (35.3%), followed by bodywork (16.5%), mind-body practices (7.8%), and homeopathy (6.7%). About 60% of participants reported CIH use to address specific health conditions; however, most patients did not discuss CIH use with their physicians (76.3%). Women reported higher CIH use than did men (45.1% versus 35.9%; odds ratio, 1.49 [95% confidence interval, 1.07-2.08]; p = 0.02). CIH use did not differ by clinical stage, time since diagnosis, or preferred language. Conclusions: CIH use is prevalent among Hispanic patients with CRC, especially women. Little communication about CIH use occurs between participants and their healthcare providers. Efforts aimed at improving integrative oncology services provide an opportunity to address such gaps in healthcare service. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the efficacy of an in-language intervention of 2 lectures plus printed materials versus printed materials alone on knowledge and adherence to nutrition and physical activity guidelines among older Chinese Americans in San Francisco, California. Methods. From August 2010 to September 2013, we randomized 756 Chinese Americans aged 50 to 75 years to either lectures plus print (n = 361) or print (n = 357). Clusters were the participants recruited by each lay health worker. Intervention outcomes were changes in knowledge of recommended vegetable intake, fruit intake, and physical activity level and adherence to those recommendations from pre- to 6 months postintervention. Results. The retention rate was 99%. At baseline, knowledge and adherence to recommendations were low. Print yielded increases in knowledge of recommended vegetable intake and physical activity level and adherence to fruit intake and physical activity recommendations. Lectures plus print had significant increases in all 6 outcomes. In multivariable models, lectures plus print was superior to print for knowledge of vegetable (adjusted odds ratio [AOR] = 12.61; 95% confidence interval [CI] = 6.50, 24.45) and fruit (AOR = 16.16; 95% CI = 5.61, 46.51) intake recommendations and adherence to vegetable intake recommendations (AOR = 5.53; 95%CI = 1.96, 15.58). Conclusions. In-language print materials, alone and combined with lectures, increased nutrition and physical activity knowledge and behaviors among older Chinese Americans. [ABSTRACT FROM AUTHOR]

Objectives. We examined the trends and correlates of quadrivalent human papillomavirus vaccine (HPV4) initiation in insured boys during the periods before and after routine use recommendation. Methods. We grouped data from electronic medical records of boys aged 9 to 17 years from the Kaiser Permanente Southern California prepaid health plan into 3 open cohorts: permissive use: 2009 to 2010; anal cancer indication added: 2010 to 2011; and routine use: 2011 to 2013. We estimated adjusted risk ratios (ARRs) between demographics and vaccination initiation using Poisson regression. Results. HPV4 initiation increased across cohorts--1.6%, 3.4%, and 18.5%--with the greatest increase among boys aged 11 to 12 years in cohort 3. Initiation was associated with receiving influenza vaccination in the previous year in all cohorts (cohort 3: ARR = 1.48; 95% confidence interval [CI] = 1.46, 1.51) and with non-White race/ethnicity following routine recommendation (cohort 3, non-Hispanic Black: ARR = 1.18; 95% CI = 1.08, 1.30; Hispanic: ARR = 1.23; 95% CI = 1.17, 1.29; Asian/Pacific Islanders: ARR = 1.16; 95% CI = 1.11, 1.20). Conclusions. Routine use recommendation increased the uptake of HPV4 in boys. System-level interventions to encourage providers to routinely recommend HPV4 vaccination may help increase HPV4 uptake in boys. [ABSTRACT FROM AUTHOR]

Medication adherence is a major determinant of antiretroviral (ARV) treatment success and a significant challenge for HIV-positive patients, yet a well-defined adherence threshold to maintain virologic suppression on current ARV regimens remains unclear. The present study evaluated 1915 Kaiser Permanente Southern California HIV-positive patients on one of three regimen types: (1) emtricitabine-tenofovir-efavirenz (FTC-TDF-EFV); (2) emtricitabine-tenofovir (FTC-TDF) and raltegravir (RAL); and (3) FTC-TDF and a boosted protease inhibitor, either darunavir (DRV) or atazanavir (ATV), to compare virologic failure rates between patients with varying levels of adherence to the regimens. Medication possession ratios (MPRs) were calculated to determine adherence, and HIV RNA PCR levels drawn 12-18 months after the initial pharmacy claim for the measured drug were used to determine virologic failure, which was defined as two consecutive HIV RNA PCR measurements ≥200 copies/mL. Adherence was inversely related to virologic failure, with an 80-90% MPR threshold resulting in no more than 3.5% virologic failure rate. In comparison, ≥90% MPR yielded no more that 1.1% virologic failure rate. Although the gold-standard adherence threshold for older ARV regimens has been 95%, an 80-90% MPR appears sufficient to maintain virologic suppression in patients treated with these three ARV regimen types. [ABSTRACT FROM AUTHOR]

Salmonella arizonae (also called Salmonella subgroup IIIa) is a Gram-negative, non-spore-forming, motile, rod-shaped, facultatively anaerobic bacterium. S. arizonae strain RKS2983 was isolated from a human in California, USA. S. arizonae lies somewhere between Salmonella subgroups I (human pathogens) and V (also called S. bongori; usually non-pathogenic to humans) and so is an ideal model organism for studies of bacterial evolution from non-human pathogen to human pathogens. We hence sequenced the genome of RKS2983 for clues of genomic events that might have led to the divergence and speciation of Salmonella into distinct lineages with diverse host ranges and pathogenic features. The 4,574,836 bp complete genome contains 4,203 protein-coding genes, 82 tRNA genes and 7 rRNA operons. This genome contains several characteristics not reported to date in Salmonella subgroup I or V and may provide information about the genetic divergence of Salmonella pathogens. [ABSTRACT FROM AUTHOR]