First Phase Development of a Patient-reported Outcome Measure for Midface Oncology.

Background: Facial cancer surgery involving the midface (comprising the lower eyelids, nose, cheeks, and upper lip) can have debilitating life-changing functional, social, and psychological impacts on the patient. Midface symptoms are inadequately captured by existing patient-reported outcome measures (PROMs). PROMs are increasingly used for individual patient care, quality improvement, and standardized reporting of treatment outcomes. This study aimed to present our findings from the first phase of the development of a midface, specifically periocular and nasal, PROM. Methods: After international guidance for PROM development, the first phase comprised identification of salient issues and item generation. Fifteen patients who had midface surgery and 10 clinicians from various specialties with more than 5 years' experience treating these patients were recruited. Semi-structured interviews explored aesthetic, functional, social, and psychological outcomes, with specific attention to deficiencies in current PROMs. Thematic analysis was used to develop an item pool, and group interviews with clinicians were carried out to create and refine PROM scales. Results: Qualitative data from patient interviews were grouped into aesthetic, functional, and psychosocial domains for the eyelids and nose. Ninety-nine draft items were generated across these domains. Following focus group discussions, the final version of the midface-specific PROM contained 31 items (13 eye-specific, 10-nose-specific, eight general midface items). Conclusions: This midface-specific PROM is valuable in assessing and comparing patient-reported outcomes in those who have undergone complex resection and reconstruction of the midface. This PROM is currently undergoing field testing.

Improving the Safety of Computed Tomography Through Automated Quality Measurement: A Radiologist Reader Study of Radiation Dose, Image Noise, and Image Quality.

OBJECTIVES: The Centers for Medicare and Medicaid Services funded the development of a computed tomography (CT) quality measure for use in pay-for-performance programs, which balances automated assessments of radiation dose with image quality to incentivize dose reduction without compromising the diagnostic utility of the tests. However, no existing quantitative method for assessing CT image quality has been validated against radiologists' image quality assessments on a large number of CT examinations. Thus to develop an automated measure of image quality, we tested the relationship between radiologists' subjective ratings of image quality with measurements of radiation dose and image noise. MATERIALS AND METHODS: Board-certified, posttraining, clinically active radiologists rated the image quality of 200 diagnostic CT examinations from a set of 734, representing 14 CT categories. Examinations with significant distractions, motion, or artifact were excluded. Radiologists rated diagnostic image quality as excellent, adequate, marginally acceptable, or poor; the latter 2 were considered unacceptable for rendering diagnoses. We quantified the relationship between ratings and image noise and radiation dose, by category, by analyzing the odds of an acceptable rating per standard deviation (SD) increase in noise or geometric SD (gSD) in dose. RESULTS: One hundred twenty-five radiologists contributed 24,800 ratings. Most (89%) were acceptable. The odds of an examination being rated acceptable statistically significantly increased per gSD increase in dose and decreased per SD increase in noise for most categories, including routine dose head, chest, and abdomen-pelvis, which together comprise 60% of examinations performed in routine practice. For routine dose abdomen-pelvis, the most common category, each gSD increase in dose raised the odds of an acceptable rating (2.33; 95% confidence interval, 1.98-3.24), whereas each SD increase in noise decreased the odds (0.90; 0.79-0.99). For only 2 CT categories, high-dose head and neck/cervical spine, neither dose nor noise was associated with ratings. CONCLUSIONS: Radiation dose and image noise correlate with radiologists' image quality assessments for most CT categories, making them suitable as automated metrics in quality programs incentivizing reduction of excessive radiation doses.

Spiced RCT: Success and Pain Associated with Intravenous Cannulation in the Emergency Department Randomized Controlled Trial.

BACKGROUND: Peripheral venous cannulation is one of the most common procedures in medicine. A larger cannula allows higher rates of fluid to be provided if needed in a deteriorating patient; however, it is also perceived that larger-gauge cannula placement is associated with increased pain and procedural difficulty. OBJECTIVE: This study aimed to compare the pain and procedural difficulty experienced during insertion between 18-gauge (18G) and 20-gauge (20G) cannulas. METHODS: We conducted a single-blinded, randomized controlled trial on adult patients who required peripheral IV cannulation within a tertiary hospital emergency department between April and October 2018. Patients were randomized to either the 18G or 20G cannula group. The primary outcomes of the study-pain experienced by patients and procedural difficulties experienced by clinical staff-were recorded on two separate 10-cm visual analog scales. Other outcomes include first-attempt success rate, operator designation, complications, and the intent and actual use of the IV cannula were documented on preformatted questionnaires. RESULTS: Data from 178 patients were included in the analysis. Eighty-nine patients were allocated to each cannula group. There were no statistically or clinically significant differences between mean pain score (0.23; 95% CI 0.56-1.02; p = 0.5662) and mean procedural difficulty score (0.12; 95% CI 0.66-0.93; p = 0.7396). between the two groups. There was no difference in first-attempt success rate (73 of 89 vs. 75 of 89; p = 0.1288), complications (2 of 89 vs. 1 of 89) between the 20G group and 18G group, respectively. CONCLUSIONS: There was no significant difference between the 18G or 20G cannula for either pain experienced by patients or procedural difficulty experienced by clinicians.

Nanoscale Iron Redistribution during Thermochemical Decomposition of CaTi1-x Fe x O3-δ Alters the Electrical Transport Pathway: Implications for Oxygen-Transport Membranes, Electrocatalysis, and Photocatalysis.

Potential applications of the earth-abundant, low-cost, and non-critical perovskite CaTi1-x Fe x O3-δ in electrocatalysis, photocatalysis, and oxygen-transport membranes have motivated research to tune its chemical composition and morphology. However, investigations on the decomposition mechanism(s) of CaTi1-x Fe x O3-δ under thermochemically reducing conditions are limited, and direct evidence of the nano- and atomic-level decomposition process is not available in the literature. In this work, the phase evolution of CaTi1-x Fe x O3-δ (x = 0-0.4) was investigated in a H2-containing atmosphere after heat treatments up to 600 °C. The results show that CaTi1-x Fe x O3-δ maintained a stable perovskite phase at low Fe contents while exhibiting a phase decomposition to Fe/Fe oxide nanoparticles as the Fe content increases. In CaTi0.7Fe0.3O3-δ and CaTi0.6Fe0.4O3-δ, the phase evolution to Fe/Fe oxide was greatly influenced by the temperature: Only temperatures of 300 °C and greater facilitated phase evolution. Fully coherent Fe-rich and Fe-depleted perovskite nanodomains were observed directly by atomic-resolution scanning transmission electron microscopy. Prior evidence for such nanodomain formation was not found, and it is thought to result from a near-surface Kirkendall-like phenomenon caused by Fe migration in the absence of Ca and Ti co-migration. Density functional theory simulations of Fe-doped bulk models reveal that Fe in an octahedral interstitial site is energetically more favorable than in a tetrahedral site. In addition to coherent nanodomains, agglomerated Fe/Fe oxide nanoparticles formed on the ceramic surface during decomposition, which altered the electrical transport mechanism. From temperature-dependent electrical conductivity measurements, it was found that heat treatment and phase decomposition change the transport mechanism from thermally activated p-type electronic conductivity through the perovskite to electronic conduction through the iron oxide formed by thermochemical decomposition. This understanding will be useful to those who are developing or employing this and similar earth-abundant functional perovskites for use under reducing conditions, at elevated temperatures, and when designing materials syntheses and processes.

An Image Quality-informed Framework for CT Characterization.

Background Lack of standardization in CT protocol choice contributes to radiation dose variation. Purpose To create a framework to assess radiation doses within broad CT categories defined according to body region and clinical imaging indication and to cluster indications according to the dose required for sufficient image quality. Materials and Methods This was a retrospective study using Digital Imaging and Communications in Medicine metadata. CT examinations in adults from January 1, 2016 to December 31, 2019 from the University of California San Francisco International CT Dose Registry were grouped into 19 categories according to body region and required radiation dose levels. Five body regions had a single dose range (ie, extremities, neck, thoracolumbar spine, combined chest and abdomen, and combined thoracolumbar spine). Five additional regions were subdivided according to dose. Head, chest, cardiac, and abdomen each had low, routine, and high dose categories; combined head and neck had routine and high dose categories. For each category, the median and 75th percentile (ie, diagnostic reference level [DRL]) were determined for dose-length product, and the variation in dose within categories versus across categories was calculated and compared using an analysis of variance. Relative median and DRL (95% CI) doses comparing high dose versus low dose categories were calculated. Results Among 4.5 million examinations, the median and DRL doses varied approximately 10 times between categories compared with between indications within categories. For head, chest, abdomen, and cardiac (3 266 546 examinations [72%]), the relative median doses were higher in examinations assigned to the high dose categories than in examinations assigned to the low dose categories, suggesting the assignment of indications to the broad categories is valid (head, 3.4-fold higher [95% CI: 3.4, 3.5]; chest, 9.6 [95% CI: 9.3, 10.0]; abdomen, 2.4 [95% CI: 2.4, 2.5]; and cardiac, 18.1 [95% CI: 17.7, 18.6]). Results were similar for DRL doses (all P < .001). Conclusion Broad categories based on image quality requirements are a suitable framework for simplifying radiation dose assessment, according to expected variation between and within categories. © RSNA, 2021 See also the editorial by Mahesh in this issue.

Diagnostic reference levels and median doses for common clinical indications of CT: findings from an international registry.

OB JECTIVES: The European Society of Radiology identified 10 common indications for computed tomography (CT) as part of the European Study on Clinical Diagnostic Reference Levels (DRLs, EUCLID), to help standardize radiation doses. The objective of this study is to generate DRLs and median doses for these indications using data from the UCSF CT International Dose Registry. METHODS: Standardized data on 3.7 million CTs in adults were collected between 2016 and 2019 from 161 institutions across seven countries (United States of America (US), Switzerland, Netherlands, Germany, UK, Israel, Japan). DRLs (75th percentile) and median doses for volumetric CT-dose index (CTDIvol) and dose-length product (DLP) were assessed for each EUCLID category (chronic sinusitis, stroke, cervical spine trauma, coronary calcium scoring, lung cancer, pulmonary embolism, coronary CT angiography, hepatocellular carcinoma (HCC), colic/abdominal pain, appendicitis), and US radiation doses were compared with European. RESULTS: The number of CT scans within EUCLID categories ranged from 8,933 (HCC) to over 1.2 million (stroke). There was greater variation in dose between categories than within categories (p < .001), and doses were significantly different between categories within anatomic areas. DRLs and median doses were assessed for all categories. DRLs were higher in the US for 9 of the 10 indications (except chronic sinusitis) than in Europe but with a significantly higher sample size in the US. CONCLUSIONS: DRLs for CTDIvol and DLP for EUCLID clinical indications from diverse organizations were established and can contribute to dose optimization. These values were usually significantly higher in the US than in Europe. KEY POINTS: • Registry data were used to create benchmarks for 10 common indications for CT identified by the European Society of Radiology. • Observed US radiation doses were higher than European for 9 of 10 indications (except chronic sinusitis). • The presented diagnostic reference levels and median doses highlight potentially unnecessary variation in radiation dose.

IL-2 Shapes the Survival and Plasticity of IL-17-Producing γδ T Cells.

IL-17-producing γδ T (γδT-17) cells have proved to be an important early source of IL-17 in many inflammatory settings and are emerging as an important participant in protumor immune responses. Considering that their peripheral activation depends largely on innate signals rather than TCR ligation, it is important to understand what mechanisms exist to curb unwanted activation. Expression of the high-affinity IL-2R on γδT-17 cells prompted us to investigate a role for this cytokine. We found γδT-17 cells to be enriched, not depleted, in IL-2-deficient mice. The absence of IL-2 also resulted in higher IL-17 production and the emergence of IL-17+IFN-γ+ double producers. Furthermore, the addition of IL-2 to in vitro cultures of sorted γδT-17 cells was able to moderate IL-17 and affect differentiation into polyfunctional cytokine-producing cells. Interestingly, the Vγ6+ subset was more susceptible to the effects of IL-2 than Vγ4+ γδT-17 cells. We also found that unlike other γδ T cells, γδT-17 cells do not produce IL-2, but express Blimp-1, a known transcriptional repressor of IL-2. Although IL-2 was able to induce robust proliferation of γδT-17 cells, it did not sustain viability, negatively impacting their survival via downregulation of the IL-7R. Taken together, these data indicate that IL-2 can augment the γδT-17 response in favor of short-lived effectors with limited plasticity, particularly in the presence of IL-1ß and IL-23. In this way, IL-2 may act to curtail the innate-like response of γδT-17 cells upon arrival of IL-2-producing adaptive immune cells at the site of inflammation.