Bitewing radiography dosimetry of the PORTRAY stationary-intraoral tomosynthesis imaging system.

OBJECTIVE: This study measured effective (E) and equivalent doses from adult and child 3-dimensional (3D) and 2D posterior bitewing (PBW) examinations using the PORTRAY stationary-intraoral tomosynthesis radiography system. STUDY DESIGN: Adult and child phantoms and optically stimulated luminescent dosimeters were used to measure doses for adult-4 and child-2 projection PBW examinations acquired without (W/O) and with (W) a direct digital sensor in the beam path. Child doses without and with thyroid shielding were measured. RESULTS: Three-dimensional examination E values (µSv) W/O and W were 16.7 and 7.3 for adult, 9.2 and 3.5 for child, and 8.7 and 3.0 with thyroid shielding, respectively. Two-dimensional examination E values W/O and W were 4.3 and 1.5 for adult, 2.1 and 0.6 for child, and 2.0 and 0.5 with shielding, respectively. Sensor presence reduced E for all adult and child examinations (P = .0001). Child E was reduced compared with adult E for both sensor conditions in 3D (P < .0001) and 2D (P ≤ .0043) imaging. Adult and child 3D W/O and W equivalent thyroid doses did not differ (P ≥ .9996). However, child 2D W/O and W doses were lower (P ≤ .0002). Shielding produced no reduction (P ≥ .1128) for either 3D condition or 2D with the sensor (P = .6615) but reduced child 2D dose without the sensor. CONCLUSIONS: Inclusion of a sensor yielded significant reductions in adult and child E. Sensor presence impacted thyroid dose reduction more than shielding.

International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.

We identified a knowledge gap in the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. MAIN RESULTS: This international consensus process established multidisciplinary biopsychosocial recommendations on pain, nutrition, safe movement, and exercise for individuals with acute and chronic vertebral fractures. SIGNIFICANCE: These recommendations will guide clinical practice and inform interventions for future research. PURPOSE: To establish international consensus on recommendations for the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. METHODS: We adopted a five-step modified Delphi consensus process: (1) literature search and content analysis, (2) creation of the survey, (3) selection of the expert panel, (4) first round of the rating process, and (5) second round of the rating process. The first round included 49 statements and eight open-ended questions; the second round included 30 statements. Panelists were asked to rate their agreement with each of the statements using a 9-point scale, with the option to provide further comments. Consensus for each statement was determined by counting the number of panelists whose rating was outside the 3-point region containing the median. RESULTS: We invited 76 people with degree in medicine, physiotherapy, kinesiology, and experience in the management of osteoporotic vertebral; 31 (41%) and 27 (36%) experts agreed to participate to the first and the second round, respectively. The mean percentage agreement after the first and second rounds was 76.6% ± 16.0% and 90.7% ± 6.5%, respectively. We established consensus on recommendations on pain, early satiety, weight loss, bracing, safe movement, and exercise for individuals with acute and chronic vertebral fractures. CONCLUSION: Our international consensus provides multidisciplinary biopsychosocial recommendations to guide the management of osteoporotic vertebral fractures and inform interventions for future research.

Bitewing radiography dosimetry of a stationary intraoral tomosynthesis imaging system.

OBJECTIVES: This study assessed effective doses (E) from conventional and stationary intraoral tomosynthesis (s-IOT) radiography for posterior bitewing (PBW) examinations and evaluated the effect of sensor attenuation. STUDY DESIGN: An adult human tissue-equivalent phantom and optically stimulated luminescent dosimeters were used. Series of 4 PBW radiographs were acquired with circular and rectangular collimation. s-IOT PBW radiographs were acquired with built-in rectangular collimation. Radiographs were acquired without and with a sensor in the beam path. RESULTS: E (in µSv) was 15.7 and 8.2 for conventional-circular, 4.6 and 1.1 for conventional-rectangular, and 11.9 and 5.9 for s-IOT in sensor-absent and sensor-present scenarios, respectively. For sensor-absent exposures, E for conventional-rectangular was 29.3% and E for s-IOT was 75.8% of the conventional-circular dose. With the sensor present, these values were 13.4% and 72.0%, respectively (P < .001). Sensor-present E was lower than sensor-absent E for all modalities (P < .001). Reductions in equivalent doses were similar to effective dose reductions. CONCLUSIONS: For PBW examinations, E for s-IOT was smaller than for conventional radiography with circular collimation, but larger than for conventional radiography with rectangular collimation. The presence of a sensor maintained these differences but reduced E for all modalities.

"Left to my own devices, I don't know": using theory and patient-reported barriers to move from physical activity recommendations to practice.

Knowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision). INTRODUCTION: Physical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW). METHODS: Focus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified. RESULTS: Two hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision. CONCLUSIONS: Barriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

"I do not have time. Is there a handout I can use?": combining physicians' needs and behavior change theory to put physical activity evidence into practice.

Guidelines for physical activity exist and following them would improve health. Physicians can advise patients on physical activity. We found barriers related to physicians' knowledge, a lack of tools and of physician incentives, and competing demands for limited time with a patient. We discuss interventions that could reduce these barriers. INTRODUCTION: Uptake of physical activity (PA) guidelines would improve health and reduce mortality in older adults. However, physicians face barriers in guideline implementation, particularly when faced with needing to tailor recommendations in the presence of chronic disease. We performed a behavioral analysis of physician barriers to PA guideline implementation and to identify interventions. The Too Fit To Fracture physical activity recommendations were used as an example of disease-specific PA guidelines. METHODS: Focus groups and semi-structured interviews were conducted with physicians and nurse practitioners in Ontario, stratified by type of physician, geographic area, and urban/rural, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the behavior change wheel framework, themes were categorized into capability, opportunity and motivation, and interventions were identified. RESULTS: Fifty-nine family physicians, specialists, and nurse practitioners participated. Barriers were as follows: Capability-lack of exercise knowledge or where to refer; Opportunity-pragmatic tools, fit within existing workflow, available programs that meet patients' needs, physical activity literacy and cultural practices; Motivation-lack of incentives, not in their scope of practice or professional identity, competing priorities, outcome expectancies. Interventions selected: education, environmental restructuring, enablement, persuasion. Policy categories: communications/marketing, service provision, guidelines. CONCLUSIONS: Key barriers to PA guideline implementation among physicians include knowledge on where to refer or what to say, access to pragmatic programs or resources, and things that influence motivation, such as competing priorities or lack of incentives. Future work will report on the development and evaluation of knowledge translation interventions informed by the barriers.

A portable shield for a neutron howitzer used for instructional and research purposes.

Neutron howitzers are routinely used in universities to activate samples for instructional laboratory experiments on radioactivity. They are also a convenient source of neutrons and gammas for research purposes, but they must be used with caution. This paper describes the modeling, design, construction, and testing of a portable, economical shield for a 1.0 Curie neutron howitzer. The Monte Carlo N Particle Transport Code (MCNP5) has been used to model the (239)PuBe source and the howitzer and to design the external neutron and gamma shield.

Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures.

UNLABELLED: An international consensus process resulted in exercise and physical activity recommendations for individuals with osteoporosis. Emphasis was placed on strength, balance, and postural alignment. Rather than providing generic restrictions, activity should be encouraged while considering impairments, fracture risk, activity history, and preference, and guidance on spine sparing techniques should be provided. INTRODUCTION: The objectives of this study were to establish expert consensus on key questions posed by patients or health care providers regarding recommended assessment domains to inform exercise prescription, therapeutic goals of exercise, and physical activity and exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. METHODS: The Too Fit To Fracture expert panel identified researchers and clinicians with expertise in exercise and osteoporosis and stakeholder groups. We delivered a modified online Delphi survey (two rounds) to establish consensus on assessment, exercise, and physical activities for three cases with varying risk (osteoporosis based on bone mineral density; 1 spine fracture and osteoporosis; multiple spine fractures, osteoporosis, hyperkyphosis, and pain). Duplicate content analyses of free text responses were performed. RESULTS: Response rates were 52% (39/75) and 69% (48/70) for each round. Key consensus points are the following: (a) Current physical activity guidelines are appropriate for individuals with osteoporosis without spine fracture, but not for those with spine fracture; (b) after spine fracture, physical activity of moderate intensity is preferred to vigorous; (c) daily balance training and endurance training for spinal extensor muscles are recommended for all; (d) providing guidance on spine-sparing techniques (e.g., hip hinge) during activities of daily living or leisure, considering impairments, fracture risk, activity history, and preference, is recommended rather than providing generic restrictions (e.g., lifting <10 lbs, no twisting), but for those with vertebral fracture, especially in the presence of pain, multiple fractures, or hyperkyphosis, the risks of many activities may outweigh the benefits-physical therapist consultation is recommended. Examples of spine-sparing techniques and exercise prescription elements are provided. CONCLUSIONS: Our recommendations guide health care providers on assessment, exercise prescription, and safe movement for individuals with osteoporosis.

Too Fit To Fracture: a consensus on future research priorities in osteoporosis and exercise.

UNLABELLED: An international consensus process identified the following research priorities in osteoporosis and exercise: study of exercise in high-risk cohorts, evaluation of multimodal interventions, research examining translation into practice and a goal to examine fracture outcomes. INTRODUCTION: To identify future research priorities related to exercise for people with osteoporosis with and without osteoporotic spine fracture via international consensus. METHODS: An international expert panel and representatives from Osteoporosis Canada led the process and identified opinion leaders or stakeholders to contribute. A focus group of four patient advocates identified quality of life, mobility, activities of daily living, falls, bone mineral density, and harms as outcomes important for decision-making. Seventy-five individuals were invited to participate in an online survey asking respondents to define future research priorities in the area of osteoporosis and exercise; the response rate was 57%. Fifty-five individuals from seven countries were invited to a half-day consensus meeting; 60% of invitees attended. The results of the online survey, knowledge synthesis activities, and results of the focus group were presented. Nominal group technique was used to come to consensus on research priorities. RESULTS: Research priorities included the study of exercise in high-risk cohorts (e.g., ≥ 65 years, low BMD, moderate/high risk of fracture, history of osteoporotic vertebral fractures, hyperkyphotic posture, functional impairments, or sedentary), the evaluation of multimodal interventions, research examining translation into practice, and a goal to examine fracture outcomes. The standardization of outcomes or protocols that could be evolved into large multicentre trials was discussed. CONCLUSIONS: The research priorities identified as part of the Too Fit To Fracture initiative can be used to inform the development of multicentre collaborations to evaluate and implement strategies for engaging individuals with osteoporosis in a safe and effective exercise.

Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture.

SUMMARY: A consensus process was conducted to develop exercise recommendations for individuals with osteoporosis or vertebral fractures. A multicomponent exercise program that includes balance and resistance training is recommended. INTRODUCTION: The aim was to develop consensus on exercise recommendations for older adults: (1) with osteoporosis and (2) with osteoporotic vertebral fracture(s). METHODS: The Grading of Recommendations Assessment, Development, and Evaluation method was used to evaluate the quality of evidence and develop recommendations. Outcomes important for decision making were nominated by an expert panel and patient advocates. They included falls, fractures, bone mineral density (BMD), and adverse events for individuals with osteoporosis/vertebral fractures, and pain, quality of life, and function for those with vertebral fracture. Meta-analyses evaluating the effects of exercise on the outcomes were reviewed. Observational studies or clinical trials were reviewed when meta-analyses were not available. Quality ratings were generated, and informed the recommendations. RESULTS: The outcome for which evidence is strongest is falls. Point estimates of the effects of exercise on falls, fractures, and BMD vary according to exercise type. There is not enough evidence to quantify the risks of exercise in those with osteoporosis or vertebral fracture. Few trials of exercise exist in those with vertebral fracture. The exercise recommendations for exercise in individuals with osteoporosis or osteoporotic vertebral fracture are conditional. The panel strongly recommends a multicomponent exercise program including resistance and balance training for individuals with osteoporosis or osteoporotic vertebral fracture. The panel recommends that older adults with osteoporosis or vertebral fracture do not engage in aerobic training to the exclusion of resistance or balance training. CONCLUSIONS: The consensus of our international panel is that exercise is recommended for older adults with osteoporosis or vertebral fracture, but our recommendations are conditional.

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial.

UNLABELLED: We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management. INTRODUCTION: To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control). METHODS: A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications. RESULTS: Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0). CONCLUSIONS: A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.

A self-administered pain severity scale for patellofemoral pain syndrome.

OBJECTIVE: To develop a scale for estimating the severity of patellofemoral pain syndrome (PFPS) and to determine its reliability and validity. DESIGN: The PFPS Severity Scale (PSS) was developed following a literature search, input from clinicians, and pilot testing in people with PFPS. The final version of the instrument encompasses 10 statements regarding PFPS pain in a visual analogue format. Reliability and validity of the new scale were determined in a PFPS population. SETTING: All testing was performed at the Canadian Forces Base Kingston, Physiotherapy Department. SUBJECTS: Twenty-nine military subjects (7 female) between the ages of 20 and 48 (32 years +/- 8.9) with subjective and objective findings consistent with PFPS were recruited. Twenty-four of the participants (6 female, 31.8 years +/- 9.4) participated in the reliability phase of the study. METHODS: Reliability of the PSS was determined by comparing the scores obtained on two test days (24 hours apart). Convergent validity of the PSS was determined by comparing data from the PSS with two established knee scales: the WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index and the Hughston Foundation subjective knee scale. RESULTS: Test-retest reliability was excellent (Spearman's rho = 0.95, p < 0.0001). The correlations between the PSS and the WOMAC and Hughston scales were strong (rho = 0.72 and 0.83, p < 0.001 respectively). CONCLUSIONS: The PSS is reliable and has demonstrated convergent validity making it a useful tool for monitoring rehabilitative or surgical outcomes in clients with PFPS.

Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome.

Strengthening of the vastus medialis oblique (VMO) has been advocated as a treatment for patellofemoral pain syndrome (PFPS), as weakness of this component of the quadriceps is postulated to contribute to malalignment of the patella. This study investigated the surface electromyographic activity (EMG) of the VMO relative to the vastus lateralis (VL) during five isometric exercises in eight PFPS female subjects and 19 controls. The area under the EMG curve of each muscle was normalized to the EMG area acquired while subjects performed a submaximal isometric contraction (50% of maximum voluntary contraction), and the "normalized" outcome measure was expressed as a proportion (VMO:VL). A two-factor repeated measures analysis of variance indicated no differences in the VMO:VL proportion between the control group and PFPS participants across the five exercises (p > .05). The VMO:VL proportions for medial tibial rotation and knee extension combined and knee extension alone were significantly greater than for the other three exercises (p < 0.005). Hip adduction or the combination of hip adduction and knee extension did not result in greater recruitment of the VMO compared with the VL.

Substance abuse treatment and HIV services: Massachusetts' policies and programs.

States and communities use many strategies and policies to facilitate the integration of HIV and AIDS services with alcoholism and drug abuse treatment and prevention programs. Massachusetts' policy initiatives that promoted collaboration between substance abuse programs and AIDS services are outlined. The review begins with an overview of the HIV epidemic in Massachusetts and reflects on the initial challenges of building system capacity so that HIV and substance abuse services could become more closely integrated. The discussion summarizes specific policy strategies implemented to encourage system development and to develop program and staff skills for working with men and women with HIV/AIDS and at risk of infection. The initiatives included integration of alcoholism and drug abuse treatment programs, expansion of Medicaid reimbursement for substance abuse treatment, training and skills development for counselors, and coordinated service development and advocacy for substance abuse and development for counselors, and coordinated service development and advocacy for substance abuse and AIDS/HIV services.