AAPM Task Group Report 261: Comprehensive quality control methodology and management of dental and maxillofacial cone beam computed tomography (CBCT) systems.

Cone-beam computed tomography (CBCT) systems specifically designed and manufactured for dental, maxillofacial imaging (MFI) and otolaryngology (OLR) applications have been commercially available in the United States since 2001 and have been in widespread clinical use since. Until recently, there has been a lack of professional guidance available for medical physicists about how to assess and evaluate the performance of these systems and about the establishment and management of quality control (QC) programs. The owners and users of dental CBCT systems may have only a rudimentary understanding of this technology, including how it differs from conventional multidetector CT (MDCT) in terms of acceptable radiation safety practices. Dental CBCT systems differ from MDCT in several ways and these differences are described. This report provides guidance to medical physicists and serves as a basis for stakeholders to make informed decisions regarding how to manage and develop a QC program for dental CBCT systems. It is important that a medical physicist with experience in dental CBCT serves as a resource on this technology and the associated radiation protection best practices. The medical physicist should be involved at the pre-installation stage to ensure that a CBCT room configuration allows for a safe and efficient workflow and that structural shielding, if needed, is designed into the architectural plans. Acceptance testing of new installations should include assessment of mechanical alignment of patient positioning lasers and x-ray beam collimation and benchmarking of essential image quality performance parameters such as image uniformity, noise, contrast-to-noise ratio (CNR), spatial resolution, and artifacts. Several approaches for quantifying radiation output from these systems are described, including simply measuring the incident air-kerma (Kair) at the entrance surface of the image receptor. These measurements are to be repeated at least annually as part of routine QC by the medical physicist. QC programs for dental CBCT, at least in the United States, are often driven by state regulations, accreditation program requirements, or manufacturer recommendations.

Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater.

People experiencing homelessness balance competing priorities resulting in reduced capacity to meet the care demands of chronic conditions, including Type 2 Diabetes Mellitus (T2DM). Arts-based performances present an avenue to expose others to these challenges. This article describes the process of incorporating qualitative research findings in a community-based participatory theater production to expose audiences to the day-to-day realities of living with T2DM while simultaneously experiencing homelessness. We conducted five focus groups and two individual interviews with people living with T2DM who had experienced homelessness with guidance from a community-engaged research team. We then collaborated with a local theater company to present common themes from these focus groups in a co-created play about the experience of managing T2DM while being homeless. We performed a staged reading of the play and assessed audience members' perceived stigma through a pre- and post-survey to determine if audience engagement within our theatrical production could reduce stigma toward individuals living with diabetes and/or people experiencing homelessness. This theatrical production is titled "Life Heist: Stealing Hope While Surviving Diabetes and Homelessness." Our work illustrates the feasibility and effectiveness of using participatory theater to disseminate qualitative research findings.

Expanding the Parameters for Excellence in Patient Assignments: Is Leveraging an Evidence-Data-Based Acuity Methodology Realistic?

Finding the balance of equitable assignments continues to be a challenge for health care organizations seeking to leverage evidence-based leadership practices. Ratios and subjective acuity strategies for nurse-patient staffing continue to be the dominant approach in health care organizations. In addition to ratio-based assignments and acuity-based assignment models driven by financial targets, more emphasis on using evidence-based leadership strategies to manage and create science for effective staffing is needed. In particular, nurse leaders are challenged to increase the sophistication of management of patient turnover (admissions, discharges, and transfers) and integrate tools from Lean methodologies and quality management strategies to determine the effectiveness of nurse-patient staffing.

The tomato cell death suppressor Adi3 is restricted to the endosomal system in response to the Pseudomonas syringae effector protein AvrPto.

The tomato (Solanum lycopersicum) AGC protein kinase Adi3 functions as a suppressor of cell death and was first identified as an interactor with the tomato resistance protein Pto and the Pseudomonas syringae effector protein AvrPto. Models predict that loss of Adi3 cell death suppression (CDS) activity during Pto/AvrPto interaction leads to the cell death associated with the resistance response initiated from this interaction. Nuclear localization is required for Adi3 CDS. Prevention of nuclear accumulation eliminates Adi3 CDS and induces cell death by localizing Adi3 to intracellular punctate membrane structures. Here we use several markers of the endomembrane system to show that the punctate membrane structures to which non-nuclear Adi3 is localized are endosomal in nature. Wild-type Adi3 also localizes in these punctate endosomal structures. This was confirmed by the use of endosomal trafficking inhibitors, which were capable of trapping wild-type Adi3 in endosomal-like structures similar to the non-nuclear Adi3. This suggests Adi3 may traffic through the cell using the endomembrane system. Additionally, Adi3 was no longer found in the nucleus but was visualized in these punctate endosomal-like membranes during the cell death induced by the Pto/AvrPto interaction. Therefore we propose that inhibiting nuclear import and constraining Adi3 to the endosomal system in response to AvrPto is a mechanism to initiate the cell death associated with resistance.

Two Pdk1 phosphorylation sites on the plant cell death suppressor Adi3 contribute to substrate phosphorylation.

The tomato AGC kinase Adi3 is phosphorylated by Pdk1 for activation of its cell death suppression activity. The Pdk1 phosphorylation site for activation of Adi3 is at Ser539. However, there is at least one additional Pdk1 phosphorylation site on Adi3 that has an unknown function. Here we identify an Arabidopsis thaliana sequence homologue of Adi3 termed AGC1-3. Two Pdk1 phosphorylation sites were identified on AGC1-3, activation site Ser596 and Ser269, and by homology Ser212 on Adi3 was identified as a second Pdk1 phosphorylation site. While Ser212 is not required for Adi3 autophosphorylation, Ser212 was shown to be required for full phosphorylation of the Adi3 substrate Gal83.

Dental staff doses with handheld dental intraoral x-ray units.

A handheld portable dental intraoral x-ray system is available in the United States and elsewhere. The system is designed to minimize the user's radiation dose. It includes specially designed shielding of the x-ray tube housing and an integral radiation shield to minimize backscatter. Personnel radiation dose records were obtained from 18 dental facilities using both the handheld system and a wall mounted dental x-ray system, providing 661 individual dose measurements. Dental staff doses were also compared for the handheld and conventional systems using both film and digital imaging for the same facilities and staff members. The results indicate that the doses for the handheld systems are significantly less than for wall-mounted systems. The average monthly dose for the handheld systems was 0.28 µSv vs. 7.86 µSv (deep dose equivalent) for the wall-mounted systems, a difference that is statistically significant at the p = 0.01 level. Consequently, there should be no concern about the use of this handheld dental intraoral x-ray system. Additional shielding efforts, (e.g., wearing a lead apron) will not provide significant benefit nor reduce staff radiation dose.

Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007.

The U.S. National Council on Radiation Protection and Measurements and United Nations Scientific Committee on Effects of Atomic Radiation each conducted respective assessments of all radiation sources in the United States and worldwide. The goal of this article is to summarize and combine the results of these two publicly available surveys and to compare the results with historical information. In the United States in 2006, about 377 million diagnostic and interventional radiologic examinations and 18 million nuclear medicine examinations were performed. The United States accounts for about 12% of radiologic procedures and about one-half of nuclear medicine procedures performed worldwide. In the United States, the frequency of diagnostic radiologic examinations has increased almost 10-fold (1950-2006). The U.S. per-capita annual effective dose from medical procedures has increased about sixfold (0.5 mSv [1980] to 3.0 mSv [2006]). Worldwide estimates for 2000-2007 indicate that 3.6 billion medical procedures with ionizing radiation (3.1 billion diagnostic radiologic, 0.5 billion dental, and 37 million nuclear medicine examinations) are performed annually. Worldwide, the average annual per-capita effective dose from medicine (about 0.6 mSv of the total 3.0 mSv received from all sources) has approximately doubled in the past 10-15 years.

Medical radiation exposure in the U.S. in 2006: preliminary results.

Medical radiation exposure of the U.S. population has not been systematically evaluated for almost 25 y. In 1982, the per capita dose was estimated to be 0.54 mSv and the collective dose 124,000 person-Sv. The preliminary estimates of the NCRP Scientific Committee 6-2 medical subgroup are that, in 2006, the per capita dose from medical exposure (not including dental or radiotherapy) had increased almost 600% to about 3.0 mSv and the collective dose had increased over 700% to about 900,000 person-Sv. The largest contributions and increases have come primarily from CT scanning and nuclear medicine. The 62 million CT procedures accounted for 15% of the total number procedures (excluding dental) and over half of the collective dose. Nuclear medicine accounted for about 4% of all procedures but 26% of the total collective dose. Medical radiation exposure is now approximately equal to natural background radiation.

Radiation protection standards: their evolution from science to philosophy.

The concept of applying constraints on individual sources to a small fraction of the public dose limit has been deemed inappropriate when shielding the medical X-ray sources. This represents a broad-based consensus of medical physics and radiological societies in the United States, and the report series on the shielding design for medical X-ray sources (including dental, X-ray imaging and therapeutic X ray) from the National Council on Radiation Protection and Measurements (NCRP) utilises 1 mSv y(-1) as a source control limit. In the present study, the rationale for such a conclusion is discussed, and a somewhat critical look at the current model of radiation protection of the public is made.

Reference values for diagnostic radiology: application and impact.

Reference values (RVs) are recommended by the American Association of Physicists in Medicine for four radiographic projections, computed tomography, fluoroscopy, and dental radiography. RVs are used to compare radiation doses from individual pieces of radiographic equipment with doses from similar equipment assessed in national surveys. RVs recommended by the American Association of Physicists in Medicine have been developed from the Nationwide Evaluation of X-ray Trends survey performed by the state radiation protection agencies with the cooperation and support of the U.S. Food and Drug Administration, the Conference of Radiation Control Program Directors, and the American College of Radiology. The RVs selected by the American Association of Physicists in Medicine represent, approximately, the 80th percentile of the survey distributions. Consequently, equipment exceeding the RVs is using higher radiation doses than is 80% of the equipment in the surveys. Radiation doses for specific projections, with standard phantoms, should be measured annually, as recommended by the American College of Radiology. When the RVs are exceeded, the medical physicist should investigate the cause and determine, in cooperation with the responsible radiologist, whether these doses are justified or the imaging system should be optimized to reduce patient radiation doses. RVs are a useful tool for comparing patient radiation doses at institutions throughout the United States and for providing information about radiographic equipment performance.

Important changes in medical x-ray imaging facility shielding design methodology. A brief summary of recommendations in NCRP Report No. 147.

The recently published Report No. 147 of The National Council on Radiation Protection and Measurements entitled "Structural shielding design for medical x-ray imaging facilities" provides an update of shielding recommendations for x rays used for medical imaging. The goal of this report is to ensure that the shielding in these facilities limits radiation exposures to employees and members of the public to acceptable levels. Board certified medical and health physicists, as defined in this report, are the "qualified experts" who are competent to design radiation shielding for these facilities. As such, physicists must be aware of the new technical information and the changes from previous reports that Report No. 147 supersedes. In this article we summarize the new data, models and recommendations for the design of radiation barriers in medical imaging facilities that are presented in Report No. 147.