Office of Nuclear Safety

BACKGROUND: Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients. METHODS: After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography. RESULTS: The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 +/- 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs. CONCLUSIONS: The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.

BACKGROUND: Because of the high prevalence of obstructive sleep apnea (OSA) and its adverse impact on perioperative outcome, a practical screening tool for surgical patients is required. This study was conducted to validate the Berlin questionnaire and the American Society of Anesthesiologists (ASA) checklist in surgical patients and to compare them with the STOP questionnaire. METHODS: After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. The scores from the Berlin questionnaire, ASA checklist, and STOP questionnaire were evaluated versus the apnea-hypopnea index from in-laboratory polysomnography. The perioperative data were collected through chart review. RESULTS: Of 2,467 screened patients, 33, 27, and 28% were respectively classified as being at high risk of OSA by the Berlin questionnaire, ASA checklist, and STOP questionnaire. The performance of the screening tools was evaluated in 177 patients who underwent polysomnography. The sensitivities of the Berlin questionnaire, ASA checklist, and STOP questionnaire were 68.9-87.2, 72.1-87.2, and 65.6-79.5% at different apnea-hypopnea index cutoffs. There was no significant difference between the three screening tools in the predictive parameters. The patients with an apnea-hypopnea index greater than 5 and the patients identified as being at high risk of OSA by the STOP questionnaire or ASA checklist had a significantly increased incidence of postoperative complications. CONCLUSIONS: Similar to the STOP questionnaire, the Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening. The STOP questionnaire and the ASA checklist were able to identify the patients who were likely to develop postoperative complications.

BACKGROUND: Although automated closed-loop control systems may improve quality of care, their safety must be proved under extreme control conditions. This study describes a simulation methodology to test automated controllers and its application in a comparison of two published controllers for Bispectral Index (BIS)-guided propofol administration. METHODS: A patient simulator was developed to compare controllers. Using input scripts to dictate patient characteristics, target BIS values, and the time course of surgical events, the simulator continuously monitors the infusion pump under control and generates BIS values as a composite of modeled response to drug, perceived stimulation, and random noise. The simulator formats the output stream of BIS data as input to the controller under test to emulate the serial output of the actual BIS monitor. A published model-based controller and a classic proportional integral derivative controller were compared when using the BIS value as a controlled variable. Each controller was tested using a set of 10 virtual patients undergoing a fixed surgical profile that was repeated with BIS targets set at 30, 50, and 70. Controller performance was assessed using median (absolute) prediction error, divergence, wobble, and percentage time within BIS target range metrics. RESULTS: The median prediction error was significantly smaller for the proportional integral derivative controller than for the model-based controller. The median absolute prediction error was smaller for the model-based controller than for the proportional integral derivative controller for each BIS target, reaching statistical significance for targets 30 and 50. CONCLUSIONS: When simulating closed-loop control of BIS using propofol, the use of a patient-individualized, model-based adaptive closed-loop system with effect site control resulted in better control of BIS compared with a standard proportional integral derivative controller with plasma site control. Even under extreme conditions, the modeled-based controller exhibited no behavioral problems.

Summary. A classification of fungi into biosafety categories is proposed, and the criteria for attribution to biosafety levels (BSL) are briefly discussed. The list differs from previous publications on this topic mainly by stressing (ecological) criteria derived from the fungi rather than host factors, and in including all species accepted in the recent medical literature. Zusammenfassung. Es wird eine Einteilung der Pilze in Sicherheitsgruppen vorgeschlagen. Die Kriterien der Zuordnung zu den Sicherheitsgruppen (BioSafety Levels, BSL) werden diskutiert. Die Liste unterscheidet sich von früheren Veröffentlichungen zu dem Thema hauptsächlich durch Akzentuierung der (ökologischen) Eigenschaften der Pilze und weniger der Wirtsfaktoren sowie dadurch, daß alle in der jüngeren medizinischen Literatur akzeptierten Pilzarten aufgenommen sind.

Isotopically dated corals from the central New Hebrides and New Georgia Island Group, Solomon Islands, indicate that both forearcs underwent rapid late Quaternary subsidence that was abruptly replaced by hundreds of meters of uplift at rates up to ∼8 mm/yr, while total plate convergence was only a few kilometers. Two mechanisms that might account for these rapid reversals in vertical motion include (1) a “displacement” mechanism in which the forearc is displaced upward by the volume of an object passing beneath on the subducting plate (as the object moves deeper and vacates the base of the forearc, the forearc subsides to near its original position) and (2) a “crustal shortening” mechanism in which the forearc thickens and uplifts because of horizontal shortening when a large object impinges on the forearc and abruptly increases interplate coupling on the shallow end of the main thrust zone. Rapid subsidence follows when the impinging object is broken or otherwise decoupled, shallow interplate coupling becomes weak, and the uplifted forearc extends and subsides. The displacement mechanism surely plays a role on timescales over which plates converge tens of kilometers, but it fails to explain the geographic pattern, short time frame, and abruptness of the change from subsidence to uplift that we observe. The crustal shortening mechanism is preferred because it allows the observed abrupt uplift when an object impinges on a forearc and causes locking of a shallow segment of the interplate thrust zone.

OBJECTIVES: The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds). METHODS: Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives. RESULTS: The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds. CONCLUSIONS: The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.

A quasi-experimental design was used to test the outcomes of an exercise program directed towards Black and Hispanic college-age women. Forty-four women (36 Black, 7 Hispanic, and 1 Black/Hispanic) attended exercise classes three times per week for 16 weeks. At program completion, women were classified as either high attendees (n = 26) or low attendees (n = 18). Compared to low attendees, the high attendees had significantly higher exercise self-efficacy (p <.001), perceived benefits and barriers (p =.004), aerobic fitness, flexibility, muscle strength, and percentage of body fat (all p <.001). Daily activity levels improved significantly in the high attendance group following the program (p <.001) and at 8 weeks post-program completion (p =.01).

The objective of this study is to estimate the amount of and factors associated with out-of-pocket (OOP) payment for medical care under Taiwan's National Health Insurance (NHI) program. This research used two methods to collect original data. The first method consisted of using a sample household survey and household diary records to collect data on OOP payment prospectively over a two-month period from a random sample of 600 households in central Taiwan. Using the individual as the unit of analysis, we obtained a total of 1062 sample subjects. To ascertain the quality and accuracy of survey data, the claim records of the bureau of NHI were merged with the survey data. These data were analyzed by a two-part model, with a probit model for use of health care and an ordinary least-squares model for OOP payments. Results of this research indicate that on average an individual's annual OOP payment for medical care was euro 247, which is substantial, compared with the average euro 144 for per capita NHI earmarked tax. Finally, results of model estimation indicate that supplemental health insurance and household income were positively associated with any use of health care, while household income was also positively associated with OOP payment for health care.

Osteoarthritis (OA) is a disease of high prevalence that produces substantial morbidity and is a leading cause of physical and psychological disability and expense, including time lost from work, medical care, and disability support. Until recently, the focus of research into the pathophysiology of OA has been on articular cartilage and has not resulted in either biomarkers of OA activity or effective targets for disease-modifying therapy. The contemporary paradigm of OA considers involvement of all joint tissues. It has been shown that, in later-stage OA, bone blood flow and oxygen content are markedly reduced and have a deleterious effect on bone cells, inducing them to release proteins (cytokines) that contribute to the bone remodeling and cartilage breakdown seen in OA.

We describe the screening rates obtained in the first year of implementation of a universal domestic violence screening protocol by nurses in the urgent care clinic of a Canadian community health center. Rates were calculated using data extracted from electronic patient health records, and a random patient chart pull. Qualitative methods provided additional information. Screening rates were considerably higher and were maintained longer than those recorded in similar settings reported in the literature. Leadership, including monitoring of documentation rates, was key to maintaining higher than average rates. Asking all patients in urgent care settings about domestic violence may improve overall screening rates and play an important role in public education.

OBJECTIVE: This study assessed whether a simple, readily implemented four-symptom somatic screen would be able to effectively identify current posttraumatic stress symptoms in victimized populations. METHODS: The sample consisted of 622 Somali community-dwelling refugees who fled widespread violence and trauma occurring in East Africa during 1990-1992. Data were collected during 2000-2003 and included demographic characteristics, number of types of torture and nontorture trauma experienced earlier in Africa, and current self-rated posttraumatic stress symptoms, as measured by the Posttraumatic Stress Disorder Checklist (PCL). The sample was also assessed with the HADStress screen, which was developed for this study, to determine whether the screen was effective in detecting current posttraumatic stress symptoms. The HADStress screen assessed for the presence of four somatic symptoms: Headaches, Appetite change, Dizziness, and Sleep problems. All items were given equal weight. Possible scores on the screen range from 0 to 4, with higher scores indicating more somatic symptoms. RESULTS: Univariate analysis showed that persons who experienced more types of trauma (both torture and nontorture trauma) and persons who had higher PCL scores (indicating more current posttraumatic stress symptoms) had significantly higher HADStress scores. Negative binomial regression analysis showed that PCL scores were the most effective variable in predicting HADStress scores. On the Tukey-B post hoc analysis, a HADStress score of 0 or 1 was associated with a mean PCL score of less than 30, a score of 2 was associated with a mean PCL score of 40.28, and a score of 4 was associated with a mean PCL score of 51.07 (suggesting that over 50% of this group would have active posttraumatic stress disorder). CONCLUSIONS: A score of 2 or higher on the HADStress scale among refugees warrants additional evaluation for posttraumatic stress symptoms in clinical settings. For communitywide efforts at early recognition and treatment, a cutoff score of 4 may be more practical and cost-effective.

Retrospective analysis of clinical data from 8 State/Territory Family Planning Organizations (FPO) was conducted to determine the reproductive health services used by young women. Between July, 1996 and June, 1997, a total of 185, 879 client visits were recorded at FPO clinics, of which 72,303 (39%) were by young clients. The results showed that young women tended to use a combined oral pill, postcoital pill and spermicides more than those older than 25 years (p<0.05). Young women were also more likely to use services for management of sexually transmitted disease (STD), counselling for HIV, STD and sexual assault (p<0.05). However, there were considerable differences among the 3 groups of women: Aboriginal clients, those who did not speak English at home, and those who were born outside Australia. This study confirms that young women are using FPO services especially for emergency/postcoital contraception, STD screening and counselling. FPOs need to continue their existing role of providing reproductive and sexual health services catering to the need of this special segment of the population.

A growing body of evidence indicates the baccalaureate degree is needed for dental hygiene (DH) graduates to address the changes in oral health delivery and health systems, develop the societal expectations of a professional, and practice to the full extent of their education. Transitioning from the associate to the baccalaureate as the minimum entry-level degree in DH will better prepare graduates to address the increasingly complex oral health care needs of the public. The higher degree prepares the dental hygienist to serve in roles that will improve access to high-quality care and allow for interprofessional collaboration as a part of a health care team. A higher entry-level degree is also needed to advance the public perception of DH and its recognition as a unique health care profession. However, reported student barriers to the entry-level baccalaureate degree include time and funding constraints, and the belief that the associate degree education is sufficient for clinical practice coupled with a lack of perceived value/benefit of the higher-level degree. This narrative literature review examines relevant policies, standards, and survey data to assess the support for the baccalaureate degree as minimum entry-level education in DH. As the roles for dental hygienists expand to meet the needs of the changing population demographics, the health care market demands for a baccalaureate degree educated dental hygienist will follow. More research is needed to document the value of the baccalaureate-prepared dental hygienist.

The commercial nuclear industry, the US Naval Nuclear Propulsion Program, and the DOE nuclear complex have used various models to operate and manage complex nuclear facilities in a safe manner. These models have focused primarily on operating parameters and design control. Using the idea of a safety envelope, the authors describe a new model that depicts the interrelationship of these and many other factors that contribute to nuclear safety. Management of nuclear facilities can use this model to establish and maintain a safety culture.< <ETX xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">&gt;</ETX>

This study was undertaken to determine the proportion of family planning organization clients who are from a non-English speaking background (NESB), to analyse the services they used, and to compare it to the services used by other clients. Analysis of clinic data sheets from the 8 State/Territory family planning organizations (FPO) was conducted. From a total of 185,879 client visits in FPO clinics between July, 1996 and June, 1997, 27,349 (14.7%) were from NESB. The proportion of clients with NESB was quite similar to that in the community. This means that in general, FPOs are reaching their share of clients with NESB. The patterns of reproductive health services used varied between NESB women compared to English speaking women.

AIMS: To estimate temporal trends in adolescents' current cigarette, alcohol and cannabis use in Europe by gender and region, test for regional differences and evaluate regional convergence. DESIGN AND SETTING: Five waves of the European School Survey Project on Alcohol and Other Drugs (ESPAD) from 28 countries between 1999 and 2015. Countries were grouped into five regions [northern (NE), southern (SE), western (WE), eastern Europe (EE) and the Balkans (BK)]. PARTICIPANTS: A total of 223 814 male and 211 712 female 15-16-year-old students. MEASUREMENTS: Daily cigarette use, weekly alcohol use, monthly heavy episodic drinking (HED) and monthly cannabis use. Linear and quadratic trends were tested using multi-level mixed-effects logistic regression; regional differences were tested using pairwise Wald tests; mean absolute differences (MD) of predicted prevalence were used for evaluating conversion. FINDINGS: Daily cigarette use among boys in EE showed a declining curvilinear trend, whereas in all other regions a declining linear trend was found. With the exception of BK, trends of weekly drinking decreased curvilinear in both genders in all regions. Among girls, trends in WE, EE and BK differed from trends in NE and SE. Monthly HED showed increasing curvilinear trends in all regions except in NE (both genders), WE and EE (boys each). In both genders, the trend in EE differed from the trend in SE. Trends of cannabis use increased in both genders in SE and BK; differences were found between the curvilinear trends in EE and BK. MD by substance and gender were generally somewhat stable over time. CONCLUSIONS: Despite regional differences in prevalence of substance use among European adolescents from 1999 to 2015, trends showed remarkable similarities, with strong decreasing trends in cigarette use and moderate decreasing trends in alcohol use. Trends of cannabis use only increased in southern Europe and the Balkans. Trends across all substance use indicators suggest no regional convergence.

In December 1991, equipment breakdowns resulted in a tritium release at the Department of Energy's (DOE's) Savannah River K-Reactor. A description of the event is presented with emphasis of human factors lessons to be learned. The authors describe the changes in culture that are occurring within the DOE's nuclear complex as the DOE seeks to adopt the best knowledge within the world technical community. The lessons learned that are described provide a glimpse into over 40 years of experience that the DOE will share with the rest of the nuclear community.< <ETX xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">&gt;</ETX>

Measurements obtained from health physics instrumentation are basic to the radiation control process and are used by management to assure that radiation exposures are kept within limits specified by national-international authorities. Because of this inseparable relationship, health physics instrumentation must be keyed on a continuing basis to changes in radiation exposure standards. In the last five years, there have been dramatic changes to the basic radiation protection standards. These changes should be evaluated in the context of the need for corresponding changes in instrumentation technology. At the time these assessments are made, care must be exercised to assure that radiation protection standards are not dictated by inadequate state-of-the-art technology. It is imperative that the development pathway to be followed be properly structured. This is particularly true for "critical" instrumentation standards i.e., those standards directly related to the determination of the radiation status of the worker, public, and their environment.

The Nano-Tera.ch initiative is a collaborative engineering program that fosters research and crossbreeding of hardware and software technologies in the areas of implantable, wearable, and ambient systems. The scientific outcome is expected to better the quality of health, security, and environmental systems; to foster a vision of engineering with social objectives; and to promote related educational programs. The mission of this program can be summarized as the research, design, and engineering of complex (terascale) systems using micro/ nanotechnologies to monitor and connect humans and/or the environment through distributed and networked systems and services.

Pacific Northwest Laboratory performed a two-step process to characterize the current beta measurement practices at DOE facilities. PNL issued a survey questionnaire on beta measurement practices to DOE facilities and reported the results. PNL measured beta doses and spectra at seven selected DOE facilities and compared selected measurement techniques in the facility environment. This report documents the results of the radiation field measurements and the comparison of measurement techniques at the seven facilities. Data collected included beta dose and spectral measurements at seven DOE facilities that had high beta-to-gamma ratios (using a silicon surface barrier spectrometer, a plastic scintillator spectrometer, and a multielement beta dosimeter). Other dosimeters and survey meters representative of those used at DOE facilities or under development were also used for comparison. Field spectra were obtained under two distinct conditions. Silicon- and scintillation-based spectrometer systems were used under laboratory conditions where high beta-to-gamma dose ratios made the beta spectra easier to observe and analyze. In the second case, beta spectrometers were taken into actual production and maintenance areas of DOE facilities. Analyses of beta and gamma spectra showed that /sup 234/Th- /sup 234m/Pa, /sup 231/Th, /sup 137/Cs, and /sup 90/Sr//sup 90/Y were the major nuclides contributing to beta doses at the facilities visited. Beta doses from other fission products and /sup 60/Co were also measured, but the potential for exposure was less significant. 21 refs., 64 figs., 18 tabs.