Synthesis of the European ALARA network 18th workshop 'ALARA for decommissioning and site remediation'.

The European ALARA Network regularly organises workshops on topical issues in radiation protection. The topic of the 18th workshop was 'ALARA for Decommissioning and Site Remediation'. The workshop was jointly organised with the ISOE Working Group on Decommissioning (ISOE WG-DECOM) and the French Atomic Alternatives Energy and Atomic Energy Commission (CEA). The main objective was to examine the conceptual and practical aspects of the implementation of the optimisation principle (or ALARA principle) in the 'nuclear' and 'non-nuclear' sectors and also for legacy sites. This memorandum presents a synthesis of the presentations and working groups discussion that took place. It also summaries the conclusions from former EAN workshops on the same topic (1997, 2006) to highlight the commonalities and the new topics. The theoretical scheme for applying the ALARA principle is illustrated by the various presentations of decommissioning and remediation (D&R) projects given at the workshop. The theoretical scheme includes, a starting point, the planning and implementation of the D&R strategy (including ALARA analysis) and the definition of an end-state. To lay down the foundations of ALARA, the initial characterisation should be comprehensive; considering not only radiation protection but other risks and circumstances both on site and off site. Decision-making is not trivial because many factors influence the D&R strategy and they can be addressed together using an holistic approach. A general methodology for such an approach in D&R was drafted by the participants. Techniques are apparently industrially mature and dosimetric data suggest that good control has been achieved, however experience shows that the D&R strategy will go through multiple adaptations along the way. The management of wastes remains a challenge in many cases as well as the decision on the end-state leading to question of what is a 'sustainable ALARA end-state?'.

Evaluation of State-Mandated Reporting of Neonatal Abstinence Syndrome - Six States, 2013-2017.

From 2004 to 2014, the incidence of neonatal abstinence syndrome (NAS) in the United States increased 433%, from 1.5 to 8.0 per 1,000 hospital births. The latest national data from 2014 indicate that one baby was born with signs of NAS every 15 minutes in the United States (1). NAS is a drug withdrawal syndrome that most commonly occurs among infants after in utero exposure to opioids, although other substances have also been associated with NAS. Prenatal opioid exposure has also been associated with poor fetal growth, preterm birth, stillbirth, and possible specific birth defects (2-5). NAS surveillance has often depended on hospital discharge data, which historically underestimate the incidence of NAS and are not available in real time, thus limiting states' ability to quickly direct public health resources (6,7). This evaluation focused on six states with state laws implementing required NAS case reporting for public health surveillance during 2013-2017 and reviews implementation of the laws, state officials' reports of data quality before and after laws were passed, and advantages and challenges of legally mandating NAS reporting for public health surveillance in the absence of a national case definition. Using standardized search terms in an online legal research database, laws in six states mandating reporting of NAS from medical facilities to state health departments (SHDs) or from SHDs to a state legislative body were identified. SHD officials in these six states completed a questionnaire followed by a semistructured telephone interview to clarify open-text responses from the questionnaire. Variability was found in the type and number of surveillance data elements reported and in how states used NAS surveillance data. Following implementation, five states with identified laws reported receiving NAS case reports within 30 days of diagnosis. Mandated NAS case reporting allowed SHDs to quantify the incidence of NAS in their states and to inform programs and services. This information might be useful to states considering implementing mandatory NAS surveillance.

Can you really swim? Validation of self and parental reports of swim skill with an inwater swim test among children attending community pools in Washington State.

BACKGROUND: Drowning is the second leading cause of unintentional injury death among US children. Multiple studies describe decreased drowning risk among children possessing some swim skills. Current surveillance for this protective factor is self/proxy-reported swim skill rather than observed inwater performance; however, children's self-report or parents' proxy report of swim skill has not been validated. This is the first US study to evaluate whether children or parents can validly report a child's swim skill. It also explores which swim skill survey measure(s) correlate with children's inwater swim performance. METHODS: For this cross-sectional convenience-based sample, pilot study, child/parent dyads (N=482) were recruited at three outdoor public pools in Washington State. Agreement between measures of self-reports and parental-reports of children's swim skill was assessed via paired analyses, and validated by inwater swim test results. RESULTS: Participants were representative of pool's patrons (ie, non-Hispanic White, highly educated, high income). There was agreement in child/parent dyads' reports of the following child swim skill measures: 'ever taken swim lessons', perceived 'good swim skills' and 'comfort in water over head'. Correlation analyses suggest that reported 'good swim skills' was the best survey measure to assess a child's swim skill-best if the parent was the informant (r=0.25-0.47). History of swim lessons was not significantly correlated with passing the swim test. CONCLUSIONS: Reported 'good swim skills' was most correlated with observed swim skill. Reporting 'yes' to 'ever taken swim lessons' did not correlate with swim skill. While non-generalisable, findings can help inform future studies.

College Sports-Related Injuries - United States, 2009-10 Through 2013-14 Academic Years.

Sports-related injuries can have a substantial impact on the long-term health of student-athletes. The National Collegiate Athletic Association (NCAA) monitors injuries among college student-athletes at member schools. In academic year 2013-14, a total of 1,113 member schools fielded 19,334 teams with 478,869 participating student-athletes in NCAA championship sports (i.e., sports with NCAA championship competition) (1). External researchers and CDC used information reported to the NCAA Injury Surveillance Program (NCAA-ISP) by a sample of championship sports programs to summarize the estimated national cumulative and annual average numbers of injuries during the 5 academic years from 2009-10 through 2013-14. Analyses were restricted to injuries reported among student-athletes in 25 NCAA championship sports. During this period, 1,053,370 injuries were estimated to have occurred during an estimated 176.7 million athlete-exposures to potential injury (i.e., one athlete's participation in one competition or one practice). Injury incidence varied widely by sport. Among all sports, men's football accounted for the largest average annual estimated number of injuries (47,199) and the highest competition injury rate (39.9 per 1,000 athlete-exposures). Men's wrestling experienced the highest overall injury rate (13.1 per 1,000) and practice injury rate (10.2 per 1,000). Among women's sports, gymnastics had the highest overall injury rate (10.4 per 1,000) and practice injury rate (10.0 per 1,000), although soccer had the highest competition injury rate (17.2 per 1,000). More injuries were estimated to have occurred from practice than from competition for all sports, with the exception of men's ice hockey and baseball. However, injuries incurred during competition were somewhat more severe (e.g., requiring ≥7 days to return to full participation) than those acquired during practice. Multiple strategies are employed by NCAA and others to reduce the number of injuries in organized sports. These strategies include committees that recommend rule and policy changes based on surveillance data and education and awareness campaigns that target both athletes and coaches. Continued analysis of surveillance data will help to understand whether these strategies result in changes in the incidence and severity of college sports injuries.

Reach and knowledge change among coaches and other participants of the online course: "concussion in sports: what you need to know".

OBJECTIVES: To describe the reach of the Heads Up "Concussion in Sports: What You Need to Know," online course and to assess knowledge change. SETTING: Online. PARTICIPANTS: Individuals who have taken the free online course since its inception in May 2010 to July 2013. DESIGN: Descriptive, uncontrolled, before and after study design. MAIN MEASURES: Reach is measured by the number of unique participants and the number of times the course was completed by state and sport coached and the rate of participation per 100,000 population by state. Knowledge change is measured by the distribution and mean of pre- and posttest scores by sex, primary role (e.g., coach, student, and parent), and sport coached. RESULTS: Between May 2010 and July 2013, the online concussion course was completed 819,223 times, reaching 666,026 unique participants, including residents from all US states and the District of Columbia. The distribution of overall scores improved from pre- to posttests, with 21% answering all questions correctly on the pretest and 60% answering all questions correctly on the posttest. CONCLUSION: Online training can be effective in reaching large audiences and improving knowledge about emerging health and safety issues such as concussion awareness.

Trends in Sports- and Recreation-Related Traumatic Brain Injuries Treated in US Emergency Departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012.

IMPORTANCE: Sports- and recreation-related traumatic brain injuries (SRR-TBIs) are a growing public health problem affecting persons of all ages in the United States. OBJECTIVE: To describe the trends of SRR-TBIs treated in US emergency departments (EDs) from 2001 to 2012 and to identify which sports and recreational activities and demographic groups are at higher risk for these injuries. DESIGN: Data on initial ED visits for an SRR-TBI from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for 2001-2012 were analyzed. SETTING: NEISS-AIP data are drawn from a nationally representative sample of hospital-based EDs. PARTICIPANTS: Cases of TBI were identified from approximately 500,000 annual initial visits for all causes and types of injuries treated in EDs captured by NEISS-AIP. MAIN OUTCOME MEASURE(S): Numbers and rates by age group, sex, and year were estimated. Aggregated numbers and percentages by discharge disposition were produced. RESULTS: Approximately 3.42 million ED visits for an SRR-TBI occurred during 2001-2012. During this period, the rates of SRR-TBIs treated in US EDs significantly increased in both males and females regardless of age (all Ps < .001). For males, significant increases ranged from a low of 45.8% (ages 5-9) to a high of 139.8% (ages 10-14), and for females, from 25.1% (ages 0-4) to 211.5% (ages 15-19) (all Ps < .001). Every year males had about twice the rates of SRR-TBIs than females. Approximately 70% of all SRR-TBIs were reported among persons aged 0 to 19 years. The largest number of SRR-TBIs among males occurred during bicycling, football, and basketball. Among females, the largest number of SRR-TBIs occurred during bicycling, playground activities, and horseback riding. Approximately 89% of males and 91% of females with an SRR-TBI were treated and released from EDs. CONCLUSION AND RELEVANCE: The rates of ED-treated SRR-TBIs increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Prevention's Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.

Injury Prevention Practices as Depicted in G- and PG-Rated Movies, 2008-2012.

Unintentional injuries are the leading cause of death among children in the United States. The use of recommended safety practices can reduce injuries. Children often learn behaviors from media exposure. Children's movies released in 1995-2007 infrequently depicted appropriate injury prevention practices. The aim of this study was to determine if injury prevention practices in children's movies have improved. The top grossing 25 G- and PG-rated movies in the United States per year for 2008-2012 were eligible for inclusion in the study. Movies or scenes were excluded if they were animated, not set in the present day, fantasy, documentary, or not in English. Injury prevention practices involving riding in a motor vehicle, walking, boating, bicycling, and four other activities were recorded for characters with speaking roles. Fifty-six (45%) of the 125 movies met the inclusion criteria. A total of 603 person-scenes were examined involving 175 (29%) children and 428 (71%) adults. Thirty-eight person-scenes involved crashes or falls, resulting in four injuries and no deaths. Overall, 59% (353/603) of person-scenes showed appropriate injury prevention practices. This included 313 (70%) of 445 motor-vehicle passengers who were belted; 15 (30%) of 50 pedestrians who used a crosswalk, 2 (7%) of 30 boaters who wore personal flotation devices, and 8 (29%) of 28 bicyclists who wore helmets. In comparison with previous studies, there were significant increases in usage of seat belts, crosswalks, personal flotation devices, and bicycle helmets. However, 41% of person-scenes still showed unsafe practices and the consequences of those behaviors were infrequently depicted.

Racial/ethnic disparities in fatal unintentional drowning among persons aged ≤ 29 years - United States, 1999-2010.

In the United States, almost 4,000 persons die from drowning each year. Drowning is responsible for more deaths among children aged 1-4 years than any other cause except congenital anomalies. For persons aged ≤29 years, drowning is one of the top three causes of unintentional injury death (2). Previous research has identified racial/ethnic disparities in drowning rates. To describe these differences by age of decedent and drowning setting, CDC analyzed 12 years of combined mortality data from 1999-2010 for those aged ≤29 years. Among non-Hispanics, the overall drowning rate for American Indians/Alaska Natives (AI/AN) was twice the rate for whites, and the rate for blacks was 1.4 times the rate for whites. Disparities were greatest in swimming pools, with swimming pool drowning rates among blacks aged 5-19 years 5.5 times higher than those among whites in the same age group. This disparity was greatest at ages 11-12 years; at these ages, blacks drown in swimming pools at 10 times the rate of whites. Drowning prevention strategies include using barriers (e.g., fencing) and life jackets, actively supervising or lifeguarding, teaching basic swimming skills and performing bystander cardiopulmonary resuscitation (CPR). The practicality and effectiveness of these strategies varies by setting; however, basic swimming skills can be beneficial across all settings.

Fatalities in swimming pools with lifeguards: USA, 2000-2008.

BACKGROUND: Pools with lifeguards are often perceived to represent a safe environment for swimming. OBJECTIVES: To examine how often fatalities occurred in pools with lifeguards and what factors were common in these incidents. DESIGN: Case series. SETTING: USA. SUBJECTS: A case was defined as a death in a swimming pool with at least one lifeguard that occurred in the USA from 2000 to 2008. Potential cases were identified from media accounts using Lexis-Nexis and ProQuest databases. Supplemental information was obtained through internet based searches and review of death certificates. RESULTS: A total of 140 deaths from 37 states were identified. Of decedents, 109 (78%) were children and 93 (66%) were males. African Americans accounted for 44% of deaths among those of known race. 104 (74%) fatalities occurred during May through August; 85 (61%) deaths occurred in outdoor pools. Sites for fatal incidents included 53 (38%) municipal pools, 21 (15%) community organisations, and 20 (14%) schools. The median swimmer to lifeguard ratio was 13:1. Decedents were initially identified in the pool twice as often by non-lifeguards (eg, other swimmers or bystanders) as by lifeguards. CONCLUSIONS: Deaths in pools with lifeguards are uncommon, but do occur. Groups most affected include children, males, and African Americans. While lifeguards provide an important layer of protection at swimming pools, they alone cannot prevent all drownings. Additional safety measures are needed.

Prevention of Drowning.

Drowning is a leading cause of injury-related death in children. In 2018, almost 900 US children younger than 20 years died of drowning. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in prevention of drowning.