Prospective Estimation of Radiation Dose and Image Quality for Optimized CT Performance

X-ray computed tomography (CT) is a non-invasive medical imaging technique that generates cross-sectional images by acquiring attenuation-based projection measurements at multiple angles. Since its first introduction in the 1970s, substantial technical improvements have led to the expanding use of CT in clinical examinations. CT has become an indispensable imaging modality for the diagnosis of a wide array of diseases in both pediatric and adult populations [1, 2]. Currently, approximately 272 million CT examinations are performed annually worldwide, with nearly 85 million of these in the United States alone [3]. Although this trend has decelerated in recent years, CT usage is still expected to increase mainly due to advanced technologies such as multi-energy [4], photon counting [5], and cone-beam CT [6].

Despite the significant clinical benefits, concerns have been raised regarding the population-based radiation dose associated with CT examinations [7]. From 1980 to 2006, the effective dose from medical diagnostic procedures rose six-fold, with CT contributing to almost half of the total dose from medical exposure [8]. For each patient, the risk associated with a single CT examination is likely to be minimal. However, the relatively large population-based radiation level has led to enormous efforts among the community to manage and optimize the CT dose.

As promoted by the international campaigns Image Gently and Image Wisely, exposure to CT radiation should be appropriate and safe [9, 10]. It is thus a responsibility to optimize the amount of radiation dose for CT examinations. The key for dose optimization is to determine the minimum amount of radiation dose that achieves the targeted image quality [11]. Based on such principle, dose optimization would significantly benefit from effective metrics to characterize radiation dose and image quality for a CT exam. Moreover, if accurate predictions of the radiation dose and image quality were possible before the initiation of the exam, it would be feasible to personalize it by adjusting the scanning parameters to achieve a desired level of image quality. The purpose of this thesis is to design and validate models to quantify patient-specific radiation dose prospectively and task-based image quality. The dual aim of the study is to implement the theoretical models into clinical practice by developing an organ-based dose monitoring system and an image-based noise addition software for protocol optimization.

More specifically, Chapter 3 aims to develop an organ dose-prediction method for CT examinations of the body under constant tube current condition. The study effectively modeled the anatomical diversity and complexity using a large number of patient models with representative age, size, and gender distribution. The dependence of organ dose coefficients on patient size and scanner models was further evaluated. Distinct from prior work, these studies use the largest number of patient models to date with representative age, weight percentile, and body mass index (BMI) range.

With effective quantification of organ dose under constant tube current condition, Chapter 4 aims to extend the organ dose prediction system to tube current modulated (TCM) CT examinations. The prediction, applied to chest and abdominopelvic exams, was achieved by combining a convolution-based estimation technique that quantifies the radiation field, a TCM scheme that emulates modulation profiles from major CT vendors, and a library of computational phantoms with representative sizes, ages, and genders. The prospective quantification model is validated by comparing the predicted organ dose with the dose estimated based on Monte Carlo simulations with TCM function explicitly modeled.

Chapter 5 aims to implement the organ dose-estimation framework in clinical practice to develop an organ dose-monitoring program based on a commercial software (Dose Watch, GE Healthcare, Waukesha, WI). In the first phase of the study we focused on body CT examinations, and so the patient’s major body landmark information was extracted from the patient scout image in order to match clinical patients against a computational phantom in the library. The organ dose coefficients were estimated based on CT protocol and patient size as reported in Chapter 3. The exam CTDIvol, DLP, and TCM profiles were extracted and used to quantify the radiation field using the convolution technique proposed in Chapter 4.

With effective methods to predict and monitor organ dose, Chapters 6 aims to develop and validate improved measurement techniques for image quality assessment. Chapter 6 outlines the method that was developed to assess and predict quantum noise in clinical body CT images. Compared with previous phantom-based studies, this study accurately assessed the quantum noise in clinical images and further validated the correspondence between phantom-based measurements and the expected clinical image quality as a function of patient size and scanner attributes.

Chapter 7 aims to develop a practical strategy to generate hybrid CT images and assess the impact of dose reduction on diagnostic confidence for the diagnosis of acute pancreatitis. The general strategy is (1) to simulate synthetic CT images at multiple reduced-dose levels from clinical datasets using an image-based noise addition technique; (2) to develop quantitative and observer-based methods to validate the realism of simulated low-dose images; (3) to perform multi-reader observer studies on the low-dose image series to assess the impact of dose reduction on the diagnostic confidence for multiple diagnostic tasks; and (4) to determine the dose operating point for clinical CT examinations based on the minimum diagnostic performance to achieve protocol optimization.

Chapter 8 concludes the thesis with a summary of accomplished work and a discussion about future research.

Extracurricular Activities and Academic Achievement in Fourth Grade Students

This action research project will investigate the relationship between participation in extracurricular activities and academic achievement of students in the fourth grade. Students’ achievement scores on the FAIR exams will be the measure of academic success. Analysis will consist of a correlation between extracurricular activities and academic success.

UPTAKE OF THE PERIODIC HEALTH EXAM AMONG ADULTS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES FROM 2003 TO 2015

Background: Over the past decade, annual heath exams have been de-emphasized for the general population but emphasized for adults with intellectual and developmental disabilities (IDD). The purpose of this project was to determine if there has been an increase in the uptake of the health exam among adults with IDD in Ontario, to what extent, and the effect on the quality of preventive care provided. Methods: Using administrative health data, the proportion of adults (18-64 years old) with IDD who received a health exam (long appointment, general assessment, and “true” health exam), a high value on the primary care quality composite score (PCQS), and a health exam or high PCQS each year was compared to the proportion in a propensity score matched sample of the general population. Negative binomial and segmented negative binomial regression controlling for age and sex were used to determine the relative risk of having a health exam/high PCQS/health exam or PCQS over time. Results: Pre joinpoint, the long appointment and general assessment health exam definitions saw a decrease and the “true” health exam saw an increase in the likelihood of adults having a health exam. Post joinpoint, all health exam definitions saw a decrease in the likelihood of adults having a health exam. Pre joinpoint, all PCQS measures (high PCQS, long appointment or high PCQS, “true” health exam or high PCQS) saw an increase in the likelihood for adults to achieve a high PCQS or high PCQS/have a health exam. Post joinpoint, all PCQS measures saw a decrease in the likelihood for adults to achieve a high PCQS or high PCQS/have a health exam. Achieving a high PCQS was strongly associated with having a health exam regardless of health exam definition or IDD status. Conclusions: Despite the publication of guidelines, only a small proportion of adults with IDD are receiving health exams. This indicates that the publication of guidelines alone was not sufficient to change practice. More targeted measures, such as the implementation of an IDD-specific health exam fee code, should be considered to increase the uptake of the health exam among adults with IDD.

Legal Writing (4th edition)

Legal Writing guides students comprehensively through this vital legal skill and addresses a range of assessment methods from exam questions to final essays and problem answers. It considers how to deconstruct essay and problem questions and how to conduct and apply legal research to answer set questions. Lisa Webley explains how to reference others' work clearly and correctly, making this book a useful tool for students concerned about issues of plagiarism. It also focuses on how to develop critical thinking and communicate legal arguments, with both good and bad examples of written work considered and discussed in the text. Legal Writing is particularly useful for undergraduate students, especially at the beginning of degree studies, and for GDL and CPE students too. This fully revised fourth edition includes: Guidance on the avoidance of plagiarism including examples of poor practice and best practice. Worked examples throughout the text, including guidance on deciphering essay questions in exams and coursework, along with additional examples from across the legal curriculum on the companion website. An improved companion website with increased guidance for revision to allow students to test their progress and further engage with the topics in the book. Clearly written and easy to use, Legal Writing enables students to fully engage with essay and exam writing as a vital foundation to their undergraduate degree.

Intervención cognitivo-conductual para el control de ansiedad ante la biopsia insicional en pacientes con cáncer de mama

Oncological patients are submitted to invasive exams in order to obtain an accurate diagnosis; these procedures may cause maladaptative reactions (fear, anxiety and pain). Particularly in breast cancer, the most common diagnose technique is the incisional biopsy. Most of the patients are unaware about the procedure and for that reason they may focus their thoughts on possible events such as pain, bleeding, the anesthesia, or the later surgical wound care. Anxiety and pain may provoke physiological, behavioral and emotional complications, and because of this reason, the Behavioral Medicine trained psychologist takes an active role before and after the biopsy. The aim of this study was to evaluate the effect of a cognitive-behavioral program to reduce anxiety in women submitted to incisional biopsy for the first time. There were 10 participants from the Hospital Juárez de México, Oncology service; all of them were treated as external patients. The intervention program focused in psycho-education and passive relaxation training using videos, tape-recorded instructions and pamphlets. Anxiety measures were performed using the IDARE-State inventory, and a visual-analogue scale of anxiety (EEF-A), and the measurement of blood pressure and heart rate). Data were analyzed both intrasubject and intersubject using the Wilcoxon test (p≤0.05). The results show a reduction in anxiety (as in punctuation as in ranges) besides, a reduction in the EEF-A.

Textbook: Maternal- Neonatal Care made Incredibly Easy!

This textbook is the perfect reference book for students new to midwifery and those studying for exams. The diagrams and explanations are simple and esay to follow

Nationella läsförståelseprov – på papper eller på skärm? : En studie av elevresultat på digitala läsförståelseprov gentemot pappersbaserade prov

Due to the upcoming digitalization of the Swedish schools standardized national tests, the aim of this study is to compare the results of a reading comprehension test on paper versus on computer screen and to examine whether the results differ between boys and girls and between swedish and swedish as a second lanuague students, or not. Previous studies show inconclusive results, some show that students get higher results when taking a test on paper then on computer screen, some show that the results don’t differ between the two medias. In this study, the national test for course Svenska 1 (Swedish) and Svenska som andraspråk 1 (Swedish as a second language) from the autumn term 2011 was transformed into a digital test. 38 students in the 10th grade took the test and the results were then compared with the same students results on the following national test of the spring term 2016 which is given on paper. The results show that the scores between the digital test and the paperbased test don’t differ. The boys got equally lower scores than the girls in both the digital test and the paperbased test. The swedish as a second language students got lower scores than the swedish students. The results are discussed in relation to previous research by Ackerman and Lauterman (2012), Mangen, Walgermo and Brønnick (2013), Rasmusson (2014) , Pasquarella, Gottardo and Grant (2012) and Norman and Furnes (2016).

Prevalence and severity of dental fluorosis among students from João Pessoa, PB, Brazil

The aim of this study was to determine the prevalence and severity of dental fluorosis among 12-15-year-old students from João Pessoa, PB, Brazil before starting a program of artificial fluoridation of drinking water. The use of fluoridated dentifrice was also surveyed. A sample of 1,402 students was randomly selected. However, 31 students refused to participate and 257 were not permanent residents in João Pessoa, thus leaving a final sample of 1,114 students. Clinical exams were carried out by two calibrated dentists (Kappa = 0.78) under natural indirect light. Upper and lower front teeth were cleaned with gauze and dried, and then examined using the TF index for fluorosis. A questionnaire on dentifrice ingestion and oral hygiene habits was applied to the students. The results revealed that fluorosis prevalence in this age group was higher than expected (29.2%). Most fluorosis cases were TF = 1 (66.8%), and the most severe cases were TF = 4 (2.2%). The majority of the students reported that they had been using fluoridated dentifrices since childhood; 95% of the participants preferred brands with a 1,500 ppm F concentration, and 40% remembered that they usually ingested or still ingest dentifrice during brushing. It was concluded that dental fluorosis prevalence among students in João Pessoa is higher than expected for an area with non-fluoridated water. However, although most students use fluoridated dentifrices, and almost half ingest slurry while brushing, the majority of cases had little aesthetic relevance from the professionals' point of view, thus suggesting that fluorosis is not a public health problem in the locality.

Air Pollution and High Density Lipoprotein Structure and Function

Thesis (Ph.D.)--University of Washington, 2016-06

New statin use and left ventricular structure: estimating long-term associations in the Multi-Ethnic Study of Atherosclerosis (MESA)

Thesis (Master's)--University of Washington, 2016-08

The Views of Young People about an Intervention Programme Designed to Support Them with Exam Related Anxiety and Stress

Both preparing for and sitting exams can be extremely stressful for children and young people. Whilst the research within the area of exam anxiety acknowledges the detrimental impact that it can have on individuals, much of the research has been completed with university students. Limited research has been carried out with children and young people. In addition to this, there is also little research that has been completed in order to understand which interventions are helpful in reducing exam anxiety in young people. The systematic literature review highlighted that much of the research employed quantitative techniques. This means young people’s views and experiences of exam anxiety has largely been unexplored. The EPS service in which the TEP currently works is a partially traded service. Some of the schools that had bought a service level agreement requested support for certain pupils that were experiencing exam anxiety. The EPS service therefore delivered an intervention called ‘beating exam anxiety together’ (further details of this intervention can be found within chapter 1). Seven semi-structured interviews were carried out with GCSE students who took part in the ‘beating exam anxiety together’ intervention. The purpose of the interviews was to understand more about young people’s views on exam anxiety, and also their experiences of the intervention in which they took part. The research highlighted the possible detrimental impact of exam anxiety on young people in terms of their mental health, and also how able they feel to prepare for their exams. The results of the research interestingly showed that young people experience high levels of pressure from school teachers and also their parents. Furthermore, students reported that they didn't know how to revise. The results revealed that young people feel that the way in which exams are spoken about in schools is largely negative. As a result of this, the researcher suggested that it may be helpful to shift the narrative around the way in which exams are currently spoken about. In addition to this, the results indicate that the intervention was largely helpful in improving young people’s well being and their ability to be able to manage exam anxiety.

Exploring Forensic Nursing Ethics and Practice: Roles, Loyalties and Photodocumentation Practices

Thesis (Ph.D.)--University of Washington, 2016-08

Eleição nas escolas: uma análise do impacto do diretor eleito sobre o desempenho educacional no Estado da Bahia

In Brazil, the selection of school principals is set in a decentralized manner by each state and city, such that processes may vary with time for a specific locality. In the state of Bahia, school principals were appointed by a higher political hierarchy until 2008, when schools under state administration started selecting principals by elections. The main goal of this work is to evaluate whether changing this specific rule affected students proficiency levels. This is achieved by using a panel data and difference-in-differences approachs that compares state schools (treatment group) to city schools (control group) that did not face a selection rule change and thus kept having their principals politically appointed. The databases used are Prova Brasil 2007, 2009 and 2011, the first one prior and the other two former to the policy change. Our results suggest that students attending schools with principals that are selected and elected have slightly lower mean proficiency levels both in mathematics and in portuguese exams than those attending schools with appointed principals. This result, according to the literature, could be related to perverse effects of selecting school administrators by vote, such as corporatism, clientelism and politicization of the school environment

Emergency emicolectomy for intestinal primary Aspergillosis in acute myeloid leukemia

ntestinal aspergillosis is an infection with a very high death rate especially in leukemic patients. Here we describe a case of a 46 years old woman with acute myeloid leukemia (LAM M5) who developed intestinal primary aspergillosis. This patient was diagnosed with LAM M5 through bone marrow aspiration and bone biopsy in March 2004. Symptoms of the disease were slight persistent fever, weight loss, asthenia, anemia, thrombocytopenia,and leukocytosis with high number of blasts in peripheral blood. After induction chemotherapy with ICE (Ifosfamide, Carboplatin, Etoposide), she developed neutropenia and high fever without apparent infective foci. She was treated with empiric antibiotic therapy, nevertheless she developed an intense diarrhea and ileo-cecal distention. Diagnostic exams didn’t show signs of a focal lesion. Despite the change in antibiotic treatment and the transfusions of granulocytes and blood cells, the patient developed extremely critical conditions with persistence of neutropenia and abdominal distention. A surgical treatment was decided at the time. We treated the patient with a two steps surgical procedure. The first step was a right abdominal ileostomy followed by improvement of general conditions and then the second step a right colectomy. The histological morphology confirmed necrotizing colitis with Aspergillus ife. At that time , treatment with voriconazole was started. The general conditions of the patient improved rapidly and we were able to treat the patient with other medical anti-leukemic therapies. The patient is now cured and in healthy state. We obtained a good clinical result as only in other few cases described in literature.

O reconhecimento dado ao manual escolar nas aprendizagens: perspetivas de alunos, encarregados de educação e docentes

Relatório de Estágio apresentado à Escola Superior de Educação de Lisboa para obtenção de grau de mestre em Ensino do 1.º e 2.º Ciclos do Ensino Básico