I.
Cardiology Fellows Nuclear Rotation
GOAL:
To provide an opportunity to develop an understanding of the physics, diagnostic aspects
and interpretive skills of Cardiac Nuclear testing in order to apply appropriate
recommendations for diagnostic testing of patients with known or suspected cardiac
conditions. Specific responsibilities are detected in the next section. (Section II
Cardiology Fellows Responsibilities).
EDUCATION OBJECTIVES:
1.
2.
3.
4.
Learn the basics of he physics surrounding nuclear testing
Learn how to safely handle and administer to patients unsealed Radio material.
Learn how to prepare, handle and assess the quality of radiopharmaceuticals.
Learn the positive and negatives, diagnostic sensitivity and specificity for each
test and how to apply to various cardiac conditions
5. Learn the safe guards for patients and personnel involved in such testing.
6. Continue to develop and demonstrate competence in interpretative skills.
7. Learn how to function effectively as a member of a multi-disciplinary, Nuclear
Cardiology team.
8. Learn appropriate and cost effective utilization of diagnostic test in the evaluation
and management of cardiac patients.
9. Develop appropriate communication skills for interaction with laboratory
personnel and co-workers as well as the requesting medical personnel.
10. Develop stress testing skills.
TRAINING PATHWAYS:
Three levels for Training in Nuclear Cardiology are available at MUSC:
General – Level 1: 2 months
Specialized – Level 2: 4-6 months
Advanced – Level 3: 12 months
Pathways are based on the most recent ACCF COCATS 3 Training Statement: Task
Force 5 – Training in Nuclear Cardiology:
Cerqueira, M.D., Berman, D.S., Di Carli, M.F., Schelbert, H.R., Wackers, F.J.,
Williams, K.A. & American Society of Nuclear Cardiology, 2008, Task force 5:
training in nuclear cardiology endorsed by the American Society of Nuclear
Cardiology, Journal of the American College of Cardiology, 51(3), pp. 368-74.
Table 1. Classification of Nuclear Cardiology Procedures
1. Standard nuclear cardiology procedures
a. Myocardial perfusion imaging
i. SPECT with technetium-99m agents and/or thallium-201, with or
without attenuation correction
ii. PET with rubidium-82 and/or nitrogen-13 ammonia
iii. Planar with technetium-99m agents and/or thallium-201
iv. ECG gating of perfusion images for assessment of global and regional
ventricular function
v. Imaging protocols
vi. Stress protocols
1. Exercise stress
2. Pharmacologic stress
vii. Viability assessment including reinjection and delayed imaging of
thallium-201 and/or metabolic imaging where available
b. Equilibrium radionuclide angiocardiography and/or “first-pass” radionuclide
angiography at rest
c. Qualitative and quantitative methods of image display and analysis
2. Less commonly used nuclear cardiology procedures
a. Combined myocardial perfusion imaging with cardiac CT for attenuation
correction or anatomic localization
b. Equilibrium radionuclide angiocardiography and/or “first-pass” radionuclide
angiography during exercise or pharmacologic stress
c. Metabolic imaging using single-photon and/or positron-emitting radionuclides
d. Myocardial infarct imaging
e. Cardiac shunt studies
Table 2. Nuclear Cardiology Training Components
1. Didactic program
a. Lectures and self-study
b. Radiation safety
2. Interpretation of clinical cases
3. Hands-on experience
a. Clinical cases
b. Radiation safety
Table 3. Summary of Training Requirements for Nuclear Cardiology
Level
Minimum Months
Total Examinations
1
2
100*
2
4-6
300*
3
12
600*
*A minimum of 35 cases with hands-on experience must be performed and interpreted
under supervision.
General Training—Level 1 (Minimum of 2 Months)
The trainee is exposed to the fundamentals of nuclear cardiology for a minimum period
of 2 months during training. This 2-month experience provides familiarity with nuclear
cardiology technology and its clinical applications in the general clinical practice of adult
cardiology, but it is not sufficient for the specific practice of nuclear cardiology. The 3
components of training include a didactic program that includes lectures, self-study,
radiation safety and regulations, interpretation of nuclear cardiology studies, and handson experience.
Didactic Program
Lectures and self-study. This component consists of lectures on the basic aspects of
nuclear cardiology and parallel self-study material consisting of reading and viewing case
files. The material presented should integrate the role of nuclear cardiology into total
patient management. Such information can be included within a weekly noninvasive or
invasive cardiology conference, with presentation and discussion of nuclear cardiology
image data as part of diagnostic and therapeutic management.
Knowledge and appreciation of radiation safety. The didactic program should
include reading and practical experience with the effects of radiation and provide the
fellow with an understanding of radiation safety as it relates to patient selection and
administration of radiopharmaceuticals and utilization of CT systems.
Interpretation of Nuclear Cardiology Studies
During the 2-month rotation, fellows should actively participate in daily nuclear
cardiology study interpretation (minimum of 100 cases). Experience in all the areas listed
in Table 1 is recommended. If some procedures are not available or are performed in low
volume, an adequate background for general fellowship training can be satisfied by
appropriate reading or review of case files. The teaching file should consist of perfusion
and ventricular function studies with angiographic/cardiac catheterization documentation
of disease.
Hands-On Experience
Fellows should perform complete nuclear cardiology studies alongside a qualified
technologist or other qualified laboratory personnel. They should, under supervision,
observe and participate in a large number of the standard procedures and as many of the
less commonly performed procedures as possible. Fellows should have experience in the
practical aspects of radiation safety associated with performing clinical patient studies.
Specialized Training—Level 2 (Minimum of 4-6 Months)
**Training which meets the Certification Board of Nuclear Cardiology (CBNC)
requirements (appended below) and NRC requirements for “Authorized User” status.
Fellows who wish to practice the specialty of nuclear cardiology are required to have at
least 4 months of training. Level 2 training includes a minimum of 700 h of radiation
safety experience in nuclear cardiology. There needs to be didactic, clinical study
interpretation, and hands-on involvement in clinical cases. In training programs with a
high volume of procedures, clinical experience may be acquired in as short a period as 4
months. In programs with a lower volume of procedures, a total of 6 months of clinical
experience will be necessary to achieve Level 2 competency. The additional training
required of Level 2 trainees is to enhance their clinical skills, knowledge, and hands-on
experience in radiation safety and qualify them to become authorized users of radioactive
materials in accordance with the regulations of the NRC and/or the Agreement States.
Didactic Program
Lectures and self-study. The didactic training should include in-depth details of all
aspects of the procedures listed in Table 1. This program may be scheduled over a 12-to
24-month period concurrent and integrated with other fellowship assignments.
Radiation safety. Classroom and laboratory training needs to include extensive
review of radiation physics and instrumentation, radiation protection, mathematics
pertaining to the use and measurement of radioactivity, chemistry of byproduct material
for medical use, radiation biology, the effects of ionizing radiation, and
radiopharmaceuticals. There should be a thorough review of regulations dealing with
radiation safety for the use of radiopharmaceuticals and ionizing radiation. This
experience should total a minimum of 80 h and be separately documented.
Interpretation of Clinical Cases
Fellows should participate in the interpretation of all nuclear cardiology imaging data
for the 4- to 6-month training period. It is imperative that the fellows have experience in
correlating catheterization or CT angiographic data with radionuclide-derived data for a
minimum of 30 patients. A teaching conference in which the fellow presents the clinical
material and nuclear cardiology results is an appropriate forum for such experience. A
total of 300 cases should be interpreted under preceptor supervision, from direct patient
studies (Table 3).
Hands-On Experience
Clinical cases. Fellows acquiring Level 2 training should have hands-on supervised
experience with a minimum of 35 patients: 25 patients with myocardial perfusion
imaging and 10 patients with radionuclide angiography. Such experience should include
pre-test patient evaluation; radiopharmaceutical preparation (including experience with
relevant radio-nuclide generators and CT systems); performance of studies with and
without attenuation correction; administration of the dosage, calibration, and setup of the
gamma camera and CT system; setup of the imaging computer; processing the data for
display; interpretation of the studies; and generating clinical reports.
Radiation safety work experience. This experience should total 620 h and be
acquired during training in the clinical environment where radioactive materials are being
used and under the supervision of an authorized user who meets the NRC requirements of
Part 35.290 or Part 35.290(c)(ii)(G) and Part 35.390 or the equivalent Agreement State
requirements, and must include:
a. Ordering, receiving, and unpacking radioactive materials safely and performing the
related radiation surveys;
b. Performing quality control procedures on instruments used to determine the
activity of dosages and per-forming checks for proper operation of survey meters;
c. Calculating, measuring, and safely preparing patient or human research subject
dosages;
d. Using administrative controls to prevent a medical event involving the use of
unsealed byproduct material;
e. Using procedures to safely contain spilled radioactive material and using proper
decontamination procedures;
f. Administering dosages of radioactive material to patients or human research
subjects; and
g. Eluting generator systems appropriate for preparation of radioactive drugs for
imaging and localization studies, measuring and testing the eluate for radionuclide
purity, and processing the eluate with reagent kits to prepare labeled radioactive
drugs.
Additional Experience
The training program for Level 2 must also provide experience in computer methods
for analysis. This should include perfusion and functional data derived from thallium or
technetium agents and ejection fraction and regional wall motion measurements from
radionuclide angiographic studies.
This pathway will require completion of all physics/radiation safety/radiation biology
training modules available on the MUSC Moodle site, 4-6 months Nuclear Cardiology
clinical rotations (MUSC plus VAMC), and completion of a clinical Nuclear Cardiology
research project. Please review “II. Cardiology Fellows Responsibilities” while on
Nuclear Cardiology.
Advanced Training—Level 3 (Minimum of 12 Months)
For fellows planning an academic career in nuclear cardiology or a career directing a
clinical nuclear cardiology laboratory, an extended program is required. This may be part
of the standard 3-year cardiology fellowship. In addition to the recommended program
for Level 2, the Level 3 program should include advanced quality control of nuclear
cardiology studies and active participation and responsibility in ongoing laboratory or
clinical research. In parallel with participation in a research program, the trainee should
participate in clinical imaging activities for the total training period of 12 months, to
include supervised interpretative experience in a minimum of 600 cases. Hands-on
experience should be similar to, or greater than, that required for Level 2 training. The
fellow should be trained in most of the following areas:
 Qualitative interpretation of standard nuclear cardiology studies, including
SPECT and/or PET myocardial perfusion imaging, ECG-gated perfusion studies,
attenuation-corrected studies, gated-equilibrium studies, “first-pass,” and any of
the less commonly performed procedures available at the institution
 Quantitative analysis of SPECT and/or PET myocardial perfusion and/or
metabolic studies
 Quantitative radionuclide angiographic and gated-myocardial perfusion analyses,
including measurement of global and regional ventricular function
 SPECT and/or PET perfusion acquisition, reconstruction, and display
 ECG-gated SPECT and/or perfusion acquisition, analysis, and display of
functional data
 Imaging of positron-emitting tracers using dedicated PET systems or hybrid
PET/CT systems
The requirements for Level 1 to 3 training in nuclear cardiology are summarized in Table
3.
Specific Training in Cardiac Imaging of Positron-Emitting Radionuclides
Cardiac PET and PET/CT imaging of positron-emitting radionuclides are part of nuclear
cardiology. An increasing number of nuclear laboratories have access to both
conventional SPECT and PET imaging. For institutions that have positron-imaging
devices, training guidelines are appropriate. Training in this particular imaging
technology should go hand-in-hand and may be concurrent with training in conventional
nuclear cardiology. Such training should include those aspects that are unique or specific
to the imaging of positron-emitting radionuclides. Depending on the desired level of
expertise, training in cardiac PET and imaging with positron-emitting radionuclides
should include knowledge of substrate metabolism in the normal and diseased heart;
knowledge of positron-emitting tracers for blood flow, metabolism and neuronal activity,
medical cyclotrons, radioisotope production, and radiotracer synthesis; and principles of
tracer kinetics and their in vivo application for the noninvasive measurements of regional,
metabolic, and functional processes. The training should also include the physics of
positron decay, aspects of imaging instrumentation specific to the imaging of positron
emitters and the use of CT, production of radiopharmaceutical agents, quality control,
handling of ultra-short life radioisotopes, appropriate radiation protection and safety, and
regulatory aspects. Consistent with the training guidelines for general nuclear cardiology,
training should be divided into 3 classes.
General Training (2 Months)
This level is for cardiology fellows who are associated with an institution where PET
and/or PET/CT devices are available and who wish to become conversant with cardiac
positron imaging. Training should therefore be the same as for Level 1 training in nuclear
cardiology but should include aspects specific to cardiac positron imaging. The additional
proficiency to be acquired by physician trainees includes background in substrate
metabolism, patient standardization and problems related to diabetes mellitus and lipid
disorders, positron-emitting tracers of flow and metabolism, and technical aspects of
positron and CT imaging. A didactic program should include the interpretation of cardiac
PET studies of myocardial blood flow and substrate metabolism, the interpretation of
studies combining SPECT for evaluation of blood flow with PET for evaluation of
metabolism, the evaluation of diagnostic accuracy and cost-effectiveness of viability
assessment of coronary artery disease detection, and the understanding of radiation safety
as specifically related to positron emitters. Hands-on experience should include
supervised observation and interpretation of cardiac studies performed with positronemitting radionuclides and PET and PET/CT imaging devices.
Specialized Training (Minimum of 4 Months)
This level of training is for fellows who wish to perform and interpret cardiac PET or
positron imaging studies in addition to nuclear cardiology. This training should include
all Level 1 and Level 2 training in nuclear cardiology (4 to 6 months) as well as general
training for cardiac PET and PET/CT. Specific aspects of training for PET and for using
positron-emitting radionuclides should include radiation dosimetry, radiation protection
and safety, dose calibration, physical decay rates of radioisotopes, handling of large doses
of high-energy radioactive materials of short physical half-lives, quality assurance
procedures, and NRC safety and record-keeping requirements. This level of training
requires direct patient experience with a minimum of 40 patient studies of myocardial
perfusion, metabolism, or both.
Advanced Training (Minimum 1 Year)
This level of training is intended for fellows planning an academic career in cardiac PET
or who wish to direct a clinical cardiac PET laboratory. Similar to Level 3 training in
nuclear cardiology, this training should include active participation in laboratory and
clinical research in parallel with clinical activities. In addition to the requirements for
general and specialized cardiac PET training (including standard nuclear cardiology
training, as previously described), advanced training should include the following:
1. Basic principles of cyclotrons, isotope production, radiosynthesis, tracer kinetic
principles and models, cardiac innervation and receptors, and methods for
quantifying regional myocardial blood flow and substrate metabolism.
2. Imaging instrumentation including dedicated PET systems, hybrid PET/CT
systems and SPECT-like positron imaging devices with high-energy photon
collimators or coincidence detection. Image acquisition and processing to include
review of sinograms, errors in image reconstruction, correction routines for
photon attenuation, and patient misalignment.
3. Tissue kinetics of positron-emitting tracers; in vivo application of tracer kinetic
principles; tracer kinetic models, generation of tissue time-activity curves, and
computer-assisted calculation of region of functional processes of the
myocardium.
4. Computer-assisted data manipulation, quantitative image analysis, and image
display.
PROCEDURES:
Fellows will be appropriately supervised for all interpretations by a Cardiology Attending
and a Nuclear Medicine attending.
METHODOLOGY:
Duration:
Start Time:
End Time
Attendings:
8 weeks
7:00 am
6:00 pm
Cardiology Division and Nuclear Medicine faculty.
PRINCIPAL TEACHING METHODS:
Teaching Rounds:
These are held daily with discussions of interpretation between 2
pm and 5:30 pm
Reading List:
A collection of important nuclear cardiology references has been
attached
Articles:
Supplied by faculty and other personnel assigned to the specific
procedure. Outlined in WIKI – Obtain Cardiology Attending
recommendations.
Conferences:
Daily Cardiology Division conferences are mandatory. Monthly
Heart and Vascular Center Mortality and Morbidity conference is
mandatory, Fellows are encouraged to attend Department of
Medicine Grand Rounds.
Supervision:
Fellows are directly supervised by the Cardiology Attending and
Nuclear Medicine Attending.
FELLOW EVALUATION:
Fellows are evaluated by the Nuclear Medicine staff and Attendings each rotation using
the eValue, which incorporates the standard Division criteria for each competency.
PatientCare is assessed based on direct observation, application of evidence based
medicine and chart review.
Knoweledge is assessed through direct questioning during interpretation sessions.
Fellows must demonstrate competent EKG interpretation and successful stress
testing capabilities.
Professionalism is assessed based on observation of the resident’s demeanor and behavior
on the rotation.
Interpersonal and Communication Skills are assess by observing the residents interactions
with the patients, families, staff and colleagues.
System Based Practice is evaluated based on the residents ability to perform in
the team setting, including interactions with the Nuclear Medicine Technologist, Nurses,
Practice Based Learning is evaluated based on the residents ability to learn and improve
his or her skills based on feedback, study, literature review and appropriate application of
evidence based medicine.
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2011 CERTIFICATION ELIGIBILITY REQUIREMENTS FOR
CANDIDATES TRAINED IN THE UNITED STATES
(all criteria must be met to receive a U.S. certificate)
Requirement 1: Training/Experience in the provision of Nuclear Cardiology Services (Level
2 nuclear cardiology training, including 80 hours of Classroom and Laboratory Training (CLT)
must be completed prior to submission of application)
Formal Training Pathway (effective as of 2009)
• Candidates must document Level 2 training in nuclear cardiology in accordance with the
ACCF/ASNC COCATS Guidelines in Nuclear Cardiology, Revised 2008 by providing a
preceptor attestation letter. Training in nuclear cardiology must occur at a center that has
an ACGME or AOA accredited training program in Cardiovascular Disease, Nuclear
Medicine, or Radiology.
• All applicants must document Authorized User status or a minimum of 80 hours of Classroom
and Laboratory Training (CLT) in radiation safety that meets the NRC topic
requirements. Documentation may be a copy of the facility RAM license listing the
applicant's name or a copy of a certificate of completion of an 80 hour CLT course that
meet NRC topic requirements.
◦
The CLT hours must have been taken no more than seven (7) years prior to the date of
the exam for which an individual is applying. CLT must be repeated if more than
7 years have elapsed since initial CLT and the applicant is not an Authorized
user. Classroom and Laboratory Training (CLT) may be taken externally from
the fellowship program.
◦
If CLT hours were taken directly within the fellowship program, the preceptor must
state this in the preceptor attestation letter by including the sentence
"Dr.__________ completed a minimum of 80 hours of Radioisotope Handling
Classroom and Laboratory Training which meets the requirements of the Nuclear
Regulatory Commission within his/her fellowship program". If using the online
preceptor letter template the box that states that this part of training was
completed as an "integral" part of the fellowship should be checked.
• A preceptor attestation letter must be provided from an individual who can verify the
candidate's total training in nuclear cardiology. All components of Level 2 training in
nuclear cardiology, including the 80 hours of Classroom and Laboratory Training (CLT),
must be completed prior to applying to sit for the exam. The preceptor letter must
document the dates of the applicant's training, be written on organizational letterhead and
dated no earlier than 36 months prior to application.
Important Notice: Beginning in 2011 all preceptors must have a Program Verification on file
with CBNC before a preceptor attestation letter can be accepted. Check with your preceptor prior
to sending your documents as your application cannot be approved without this document on file.
Preceptor Information and Guidance
A preceptor for this pathway must be one of the following:
• Program Director of an accredited residency or fellowship in Cardiovascular Disease, Nuclear
Medicine, or Radiology
• Director of Nuclear Cardiology laboratory at an institution with an accredited residency or
fellowship in Cardiovascular Disease, Nuclear Medicine, or Radiology.
• If the preceptor is not an authorized user, an authorized user at the training institution must cosign the letter to verify that the candidate has had appropriate training in radiation safety.
Recentness of Training
If nuclear cardiology training was completed seven (7) or more years prior to the date of the
CBNC exam for which you are applying, you must provide:
• documentation of at least 300 cases within the last 24 months at time of application.
• 25 CME Category I hours in nuclear cardiology taken within the last 36 months at time of
application. See Guidance on CME Credit
"Experience" Pathway Candidates [no new candidates accepted]
Candidates who did not receive nuclear cardiology training within the context of an accredited
fellowship or residency program and who have sat previously for the CBNC exam must provide:
• Documentation of Authorized User status (e.g., by copy of current facility radioactive materials
license listing the applicant's name) or Authorized User eligibility (e.g., by certificate of
completion of a course with a minimum of 80 hours which included all topic areas
required by the Nuclear Regulatory Commission, taken no more than 7 years prior to the
date of the exam for which you are applying).
• A preceptor attestation letter. The preceptor must be certified by one of the following Boards:
CBNC, ABNM, ABR, AOBNM or AOBR. ABIM certification alone does not qualify. If
the preceptor is not an Authorized User, an Authorized User must co-sign to verify that
the candidate has had appropriate training in radiation safety. The preceptor letter must be
dated no earlier than 36 months prior to application and must document the training dates
of the applicant. The preceptor verifying training/experience for this pathway must
include in the preceptor letter his or her NRC or Agreement State License Number.
• Ongoing experience as evidenced by interpretation of a minimum of 300 cases (current
Nuclear Cardiology COCATS requirement for Level 2) in the preceding 24 months of
application; See Letter Templates and
• At least 25 hours of CME specific to nuclear cardiology within the preceding 36 months of
application.
Special NOTE: All U.S. applicants must submit evidence of either Authorized User status, (e.g.,
a copy of the facility's radioactive materials license listing the candidate's name), OR of
Authorized User eligibility, (e.g., a certificate of completion of a radioisotope handling and
radiation safety course with a minimum of 80 hours which included all topic areas required by the
Nuclear Regulatory Commission and dated no more than 7 years prior to the date of the exam for
which you are applying.)
If the Classroom and Laboratory Training hours were an integral part of the fellowship program,
the candidate's preceptor should include the following text in his/her preceptor attestation:
Dr. __________ completed a minimum of 80 hours of Radioisotope Handling Classroom and
Laboratory Training which meets the requirements of the Nuclear Regulatory Commission within
his/her fellowship program.
Training and experience requirements for licensure by the Nuclear Regulatory Commission
(NRC) or Agreement States vary from state to state; therefore, candidates seeking licensure
should check with their regional NRC office or the office responsible for licensure in the
Agreement State in which they practice. Information is also available on the NRC website: nrcstp.ornl.gov/.
Requirement 2: Licensure
To be certified, applicants must hold a current, unconditional, unrestricted license to practice
medicine in the U.S. and must provide a copy of the current license.
• Individuals with limited or training medical licenses may apply to sit for the examination.
Certification will only be granted, however, when all requirements are met within 6 years
of the examination, including holding a current unrestricted medical license. Such
candidates who pass the examination will be listed as "testamurs" until all requirements
for certification are fulfilled. Individuals in this situation should call for direction on
documentation to be submitted.
Requirement 3: Board Certification
To be certified, applicants must be physicians who are Board Certified in Cardiology, Nuclear
Medicine or Radiology by a board which holds membership in either the American Board of
Medical Specialties or the Bureau of Osteopathic Specialists of the American Osteopathic
Association and must provide a copy of the current board certification.
• Individuals enrolled in an ACGME or AOA fellowship or residency program in Cardiology,
Nuclear Medicine, or Radiology may apply to sit for the examination. Certification will
only be granted, however, when all requirements are met within 6 years of the
examination, including board certification in Cardiology, Nuclear Medicine, or
Radiology. Such candidates who pass the examination will be listed as "testamurs" until
all requirements for certification are fulfilled.
Special Note Regarding Testamur Status: As noted above, individuals who pass the CBNC
exam under Testamur status have 6 years from passing the CBNC to document full licensure and
successful certification in Cardiology, Nuclear Medicine or Radiology in order to have their
Testamur status changed to Diplomate. This certification will expire 10 years from the date of
passing the CBNC examination.
Special Note:
• Beginning in 2011 all preceptors who write attestation letters for individuals who completed
Level 2 in a training program must have a Program Verification form on file with the
CBNC office before their Preceptor Attestation Letter can be accepted. Guidance and
information for preceptors can be found on this page of the CBNC website.
• CBNC is not accepting NEW applicants whose Level 2 equivalent was completed by
experience.
• Preceptor attestation letters and other supporting documentation must accompany application.
Preceptor templates may be found and completed on this link of the CBNC website.
Preceptors are STRONGLY encouraged to use these to ensure that the language in their
letters complies with CBNC requirements.
• Preceptor letters must be dated no earlier than 36 months prior to application.
• Preceptor letters must be on organizational letterhead and the author's relationship to the
applicant provided (e.g., Program Director).
• The letter must include the applicant's nuclear cardiology training dates.
• If the preceptor is not an Authorized User, an Authorized User at the training institution must
co-sign the letter to verify that the candidate has had appropriate training in radiation
safety.