Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021.

Little is known about the extent of prior authorization requirements in otolaryngology. We performed a secondary analysis of data comparing prior authorization (PA) policies across 5 major Medicare Advantage insurers to estimate the counterfactual proportion of 2021 Medicare Part B fee-for-service spending and utilization for commonly performed otolaryngologic procedures that would have required PA. The counterfactual proportion of spending (range: 20.4%-27.6%) and utilization (range: 1.8%-4.5%) requiring PA was relatively consistent across insurers and largely attributable to rhinologic procedures. However, PA requirements for specific services varied widely among insurers. Among the 70 (of 196; 35.7%) services subject to PA by any insurer, nearly half were subject to PA by a single insurer (n = 34; 48.6%). Only 10 (14.3%) services were subject to PA by 4 (n = 6; 8.6%) or 5 (n = 4; 5.7%) insurers. These discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists and raise concerns about the validity of certain PA requirements.

Salient semantics.

Semantic features are components of concepts. In philosophy, there is a predominant focus on those features that are necessary (and jointly sufficient) for the application of a concept. Consequently, the method of cases has been the paradigm tool among philosophers, including experimental philosophers. However, whether a feature is salient is often far more important for cognitive processes like memory, categorization, recognition and even decision-making than whether it is necessary. The primary objective of this paper is to emphasize the significance of researching salient features of concepts. I thereby advocate the use of semantic feature production tasks, which not only enable researchers to determine whether a feature is salient, but also provide a complementary method for studying ordinary language use. I will discuss empirical data on three concepts, conspiracy theory, female/male professor, and life, to illustrate that semantic feature production tasks can help philosophers (a) identify those salient features that play a central role in our reasoning about and with concepts, (b) examine socially relevant stereotypes, and (c) investigate the structure of concepts.

Understanding patient demand for and use of antibiotics for upper respiratory tract infection: A qualitative application of the Necessity-Concerns Framework in Saudi Arabia.

Background: Reducing antimicrobial resistance (AMR) is a priority for public health. Inappropriate patient demand is an important driver of unnecessary antibiotic use. To develop an effective intervention to reduce inappropriate demand for antibiotics in upper respiratory tract infections (URTIs), it is important to identify patient perceptions that influence demand for, and appropriate use of antibiotics. Aim: To identify and describe the beliefs about antibiotics necessity and concerns that patients with URTIs have, in Riyadh, Saudi Arabia. Method: An exploratory qualitative approach was used. One-to-one, face-to-face or telephone semi-structured interviews were conducted with participants recruited using purposive sampling (based on age and gender) from primary healthcare centre in Riyadh, Saudi Arabia were conducted. Only adult patients who currently experience URTIs symptoms and agreed to participate were recruited. Recruitment for interviews continued until data saturation point was reached. The interview guide explored patients' necessity beliefs and concerns about antibiotics, AMR perceptions, and expectations from URTIs consultation. Interview transcripts were coded using QSR NVivo 12 using framework analysis informed by the Necessity-Concerns Framework to identify key motivations driving antibiotic requests and consultations. Results: the study interviewed 32 participants (44% were male, average age was 36.84). Results identified that the patients often relate their personal need for antibiotics when encountering an URTIs symptoms to the type, severity and duration of symptoms. Patients also linked antibiotics with quicker recovery, generally expressing few concerns about antibiotics mainly because of its short duration of use. However, some conveyed their concern about frequent administration of antibiotics and effect on the body's immune system function, which may make them more prone to infections in the future. Participants varied widely in their awareness of AMR; this was associated with many misconceptions, such as confusing AMR with antibiotics efficacy and tolerance. Interestingly, the interplay between necessity beliefs and concerns was observed to influence the decision to start and stop antibiotic, potentially impacting inappropriate antibiotic demand and unnecessary use. Conclusion: This study highlighted important beliefs and misconceptions about antibiotics and AMR in Saudi population which can be targeted in future interventions to reduce inappropriate demand for antibiotics and optimise appropriate usage.

Development and Preliminary Validation of the Patient Outcome Planning Calculator (POP-C): A Tool for Determining Treatment Dosage in Applied Behavior Analysis.

Board certified behavior analysts (BCBA) are responsible for determining the medically necessary treatment dosage for patients (i.e., the number of hours of therapy a patient should receive per week to optimize progress) during applied behavior analysis (ABA) therapy. However, because there is currently no standard method for making these determinations, BCBAs must rely on their own clinical judgment. Given that clinical judgment may be underdeveloped in some BCBAs, particularly those who are newly certified, more formal strategies are needed to guide decision making as it relates to medical necessity and treatment dosage. In this article we describe the development of the Patient Outcome Planning Calculator (POP-C), a standardized decision-making tool designed to assist novice practitioners in determining the medically necessary ABA treatment intensity and appropriate treatment setting for individuals with autism spectrum disorder (ASD). We present preliminary reliability data as well as construct validity data indicating statistically significant correlations between the POP-C and several norm-referenced and criterion-referenced assessments commonly used to estimate skill level and the corresponding degree of support needed within the ASD population to inform the ABA treatment model and goals. Supplementary Information: The online version contains supplementary material available at 10.1007/s40617-023-00861-6.

Reasoning about possibilities: Modal logics, possible worlds, and mental models.

Everyone reasons about possibilities. This article explains how they could do so using mental models. The theory makes four major claims: 1. Correct inferences are necessary, referring only to facts or possibilities to which the premises refer and not ruling any of them out, for example: She left or hid; Therefore, it's possible that she left and possible that she hid. 2. A possibility such as that she hid, which is represented in an intuitive model, presupposes the possibility that it did not occur, she did not hide, which, if reasoners deliberate, is represented in the resulting model. 3. Reasoners condense consistent possibilities, such as the earlier pair, into one possibility: it is possible that she left and she hid. 4. Inconsistencies, such as she left or hid, and she neither left nor hid, refer to no possibilities whatsoever - they have an empty model - and so their only effects are local. Hence, any inference can be withdrawn with impunity if there is knowledge to the contrary. Experiments have corroborated each of these principles. They are incompatible with four essentials of standard modal logics, which concern deductions based on "possible" or "necessary". Their formal deductions correspond to valid inferences, which have no counterexamples in which the premises are true but the conclusion is false. And so the article examines the differences between the two approaches, and explores the adaptation of a modal logic to account for correct human reasoning. Its feasibility is an open question.

A oferta do café de rua nas capitais São Paulo e Vitória / The offer of coffee on the streets of the state capitals São Paulo and Vitória / La oferta de café en las calles de las capitales estatales São Paulo y Vitória

A pandemia gerou impactos sociais e econômicos, como o trabalho informal dos que se ocupam do serviço de café de rua, ampliado na retomada pós-isolamento. O artigo analisa as significações construídas pelas instalações do serviço nas ruas de São Paulo (SP) e Vitória (ES), enquanto manifestações do empreendedo-rismo por necessidade. O corpus foi coletado em dias úteis, no início das manhãs, em diversos pontos das capitais. A semiótica discursiva sustentou a análise, e o seu método permitiu traçar isotopias conectoras de figuras e temas. Os resultados apontam para comunicação dos sentidos da informalidade, casualidade e familiaridade, marcados pela presença feminina, pela autonomia imposta aos sujeitos produtor/vendedor e consumidor e pela conexão entre a energia proporcionada pela bebida e o trabalho. Esses significadosvêm embebidos no risco vivido por esses sujeitos, aconchegados entre si e alijados da proteção de políticas públicas de trabalho, condições sanitárias, serviços de transporte e saúde.

The pandemic has generated social and economic impacts, such as the informal work of those who sell coffee on the streets, expanded in the post-isolation resumption. The article analyzes the meanings constructed by the service facilities in São Paulo (SP) and Vitória (ES), as demonstrations of the entrepreneurship by necessity. The corpus was collected on weekdays, in places of the state capitals. Discursive semiotics underpins the analysis, suggesting connective isotopies of figures and themes. The results point to the communication of the senses of informality, casualness and familiarity, marked by the female presence, by the autonomy imposed on the subjects producer/seller and consumer and by the connection between the energy given by the drink and the work. These meanings are embedded in the risk experienced by these subjects, snuggled among themselves and excluded from the protection of public policies of work, sanitary conditions, transportation and health services.

La pandemia generó impactos sociales y económicos, como el trabajo informal de quienes se ocupan del servicio de café en las calles, ampliado en la reanudación post-aislamiento. El artículo analiza los signifi-cados construidos por las instalaciones de servicios en las calles de São Paulo (SP) y Vitória (ES), como manifestaciones de emprendimiento por necesidad. El corpus fue recolectado entresemana, en puntos de las capitales. La semiótica discursiva sustenta el análisis y permitió trazar isotopías conectoras de figuras y temas. Los resultados apuntan para la comunicación de los significados de informalidad, marcados por la presencia femenina, por la autonomía impuesta a los sujetos productor/vendedor y consumidor, y por la conexión entre la energía dada por la bebida y el trabajo. Estos significados están incrustados en el riesgo vivido por estos sujetos, y excluidos de la protección de las políticas públicas laborales, las condiciones sanitarias, los servicios de transporte y salud.

Demographic determinants of happiness in Andalusia: insights from the 2022 social survey data.

The Social Survey of Andalusia is an instrument for monitoring the Andalusian reality developed by the regional government of Andalusia, whose dataset is open access to the citizens. The 2022 edition included questions related to happiness, social relations as well as socio-demographic factors. Based on this dataset, the present study aimed to analyse the relationship between socio-demographic factors and people's experiences of happiness. It also set out to explore which factors might be indispensable for experiencing moments of happiness as measured in the survey. A sample of 4,968 cases was gotten, conducting a descriptive analysis, a logit regression in complex samples, and a Necessary Conditions Analysis. The results found two very different social profiles in terms of the experience of happiness, determined by age, sex, educational level and economic status. However, neither factor proved to be a necessary condition for happiness. Both conclusions should be taken into consideration in any socio-community intervention.

Ground by Status.

What is the explanatory role of 'status-truths' such as essence-truths, necessity-truths and law-truths? A plausible principle, suggested by various authors, is Ground by Status, according to which status truths ground their prejacents. For instance, if it is essential to a that p, then this grounds the fact that p. But Ground by Status faces a forceful objection: it is inconsistent with widely accepted principles regarding the logic of grounding (Glazier in Philos Stud 174(11):2871-2889, 2017a, Synthese 174(198):1409-1424, 2017b; Kappes in Synthese 199(1-2):2575-2595, 2020, Philos Stud 178(4):1267-1284, 2021). I defend Ground by Status against this objection.

Cause for coercion: cause for concern?

In his 2000 book, From Chaos to Coercion: Detention and the Control of Tuberculosis, Richard Coker makes a number of important observations and arguments regarding the use of coercive public health measures in response to infectious disease threats. In particular, Coker argues that we have a tendency to neglect public health threats and then demand immediate action, which can leave policymakers with fewer effective options and may require (or may be perceived as requiring) more aggressive, coercive measures to achieve public health goals. While Coker makes a convincing case as to why we should find it ethically problematic when governments find themselves in this position and resort to coercion, left outstanding is the question of whether this should preclude governments and health authorities from using coercion if and when they do find themselves in this position. In this paper, I argue that, while we should consider it ethically objectionable when governments resort to coercion because they have neglected a public health threat, its causes, and other possible responses to that threat, this should not then necessarily rule out the use of coercion in such circumstances; that there are ethically objectionable antecedents for why coercion is being considered should not necessarily or automatically cause us to think coercion in such cases cannot be justified. I address an objection to this argument and draw several conclusions about how governments' use of coercion in public health should be evaluated.

The Necessity to Investigate In Vivo Fate of Nanoparticle-Loaded Dissolving Microneedles.

Transdermal drug delivery systems are rapidly gaining prominence and have found widespread application in the treatment of numerous diseases. However, they encounter the challenge of a low transdermal absorption rate. Microneedles can overcome the stratum corneum barrier to enhance the transdermal absorption rate. Among various types of microneedles, nanoparticle-loaded dissolving microneedles (DMNs) present a unique combination of advantages, leveraging the strengths of DMNs (high payload, good mechanical properties, and easy fabrication) and nanocarriers (satisfactory solubilization capacity and a controlled release profile). Consequently, they hold considerable clinical application potential in the precision medicine era. Despite this promise, no nanoparticle-loaded DMN products have been approved thus far. The lack of understanding regarding their in vivo fate represents a critical bottleneck impeding the clinical translation of relevant products. This review aims to elucidate the current research status of the in vivo fate of nanoparticle-loaded DMNs and elaborate the necessity to investigate the in vivo fate of nanoparticle-loaded DMNs from diverse aspects. Furthermore, it offers insights into potential entry points for research into the in vivo fate of nanoparticle-loaded DMNs, aiming to foster further advancements in this field.

Treating the innocent victims of trolleys and war.

Both trolleys and war leave innocent victims to suffer death and injury. Trolley problems accounting for the injured, and not only the dead, tease out intuitions about liability that enhance our understanding of the obligation to provide compensation and medical care to civilian victims of war. Like many trolley victims, civilians in war may suffer justifiable, excusable, or negligent harms that demand compensation. Chief among these is collateral harm befalling civilians. Collateral harm is endemic to war and comprises permissible but unavoidable death or injury following necessary and proportionate military operations. Although state armies sometimes offer condolence payments for civilian death, injury, and property loss, they deny liability. Instead, they use compensation to enhance counterinsurgency efforts and assuage feelings of agent regret. As part of the medical rules of eligibility, Coalition forces in Iraq and Afghanistan also provided medical care to victims of collateral harm. However, they denied care to similarly sick or injured civilians. While compensation is often justified to cure the harm civilians suffer, the differential use of medical resources is not. Rather, medical care remains subject to the principle of beneficence and medical need. The duty to provide civilian healthcare in war, particularly in wars of humanitarian intervention, is far-reaching and imposes significant costs that military and medical ethics are yet to recognize.

Microdiscectomy Insurance Medical Necessity Criteria Are Inconsistent and Unnecessarily Restrictive.

BACKGROUND: Microdiscectomy for patients with chronic lumbar radiculopathy refractory to conservative therapy has significantly better outcomes than continued nonoperative management. The North American Spine Society (NASS) outlined specific criteria to establish medical necessity for elective lumbar microdiscectomy. We hypothesized that insurance providers have substantial variability among one another and from the NASS guidelines. METHODS: A cross-sectional analysis of US national and local insurance companies was conducted to assess policies on coverage recommendations for lumbar microdiscectomy. Insurers were selected based on their enrollment data and market share of direct written premiums. The top 4 national insurance providers and the top 3 state-specific providers in New Jersey, New York, and Pennsylvania were selected. Insurance coverage guidelines were accessed through a web-based search, provider account, or telephone call to the specific provider. If no policy was provided, it was documented as such. Preapproval criteria were entered as categorical variables and consolidated into 4 main categories: symptom criteria, examination criteria, imaging criteria, and conservative treatment. RESULTS: The 13 selected insurers composed roughly 31% of the market share in the United States and approximately 82%, 62%, and 76% of the market share for New Jersey, New York, and Pennsylvania, respectively. Insurance descriptions of symptom criteria, imaging criteria, and the definition of conservative treatment had substantial differences as compared with those defined by NASS. CONCLUSION: Although a guideline to establish medical necessity was developed by NASS, many insurance companies have created their own guidelines, which have resulted in inconsistent management based on geographic location and selected provider. CLINICAL RELEVANCE: Providers must be cognizant of the differing preapproval criteria needed for each in-network insurance company in order to provide effective and efficient care for patients with lumbar radiculopathy.

Surrogacy and the Fiction of Medical Necessity.

A number of countries and states prohibit surrogacy except in cases of "medical necessity" or for those with specific medical conditions. Healthcare providers in some countries have similar policies restricting the provision of clinical assistance in surrogacy. This paper argues that surrogacy is never medically necessary in any ordinary understanding of this term. The author aims to show first that surrogacy per se is a socio-legal intervention and not a medical one and, second, that the intervention in question does not treat, prevent, or mitigate any actual or potential harm to health. Legal regulations and healthcare-provider policies of this kind therefore codify a fiction-one which both obscures the socio-legal motivations for surrogacy and inhibits critical examination of those motivations while mobilizing normative connotations of appeals to medical need. The persisting distinction, in law and in moral discourse, between "social" and "medical" surrogacy, is unjustified.

Development and validation of a scoring system to predict esophagogastroduodenoscopy necessity.

OBJECTIVE: This study aimed to develop and validate a scoring system for predicting the need for esophagogastroduodenoscopy (EGD) in clinical practice to enhance accuracy and reduce misapplications. METHODS: From February 2021 to April 2022, outpatients scheduled for EGD at the Department of Gastroenterology in our hospital were recruited. Patients completed the system evaluation by providing clinical symptoms, relevant medical history, and endoscopic findings. Patients were randomly divided into the training and validation cohorts (at 2:1 ratio). The optimal algorithm was selected from five alternatives including a parallel test. Six physicians participated in a human-computer comparative validation. Sensitivity and negative likelihood ratio (-LR) were used as the primary indicators. RESULTS: Altogether 865 patients were enrolled, with 578 in the training cohort and 287 in the validation cohort. The scoring system comprised 21 variables, including age, 13 typical clinical symptoms, and seven medical history variables. The parallel test was selected as the final algorithm. Positive EGD findings were reported in 54.5% of the training cohort and 62.7% of the validation cohort. The scoring system demonstrated a sensitivity of 79.0% in the training cohort and 83.9% in the validation cohort, with -LR being 0.627 and 0.615, respectively. Compared to physicians, the scoring system exhibited higher sensitivity (84.0% vs 68.7%, P = 0.02) and a lower -LR (1.11 vs 2.41, P = 0.439). CONCLUSIONS: We developed a scoring system to predict the necessity of EGD using a parallel test algorithm, which was user-friendly and effective, as evidenced by single-center validation.

Qualitatively exploring the application of the necessity concerns framework to antenatal physical activity.

BACKGROUND: Adherence to physical activity (PA) recommendations during pregnancy is low. A common reason for low adherence is concern of harm to mother and/or baby. The Necessity-Concerns Framework (NCF), is a well-established framework in medicine adherence, however it has not been used to explore adherence to antenatal PA. This study aims to explore (1) what influences pregnant women's PA in the context of the NCF; and (2) if the NCF is an appropriate framework to understand antenatal PA engagement. METHODS: Semi-structured interviews were conducted with 18 pregnant women in the UK and Ireland (mean gestation 27 weeks). Interviews explored beliefs, experiences, perceived necessities and concerns about PA. Interviews were transcribed verbatim and analysed using thematic framework analysis. RESULTS: Five themes were identified as influential to antenatal PA: (1) Perceived benefits and necessity of PA, (2) Concerns regarding antenatal PA, (3) Balancing the necessity and concern, (4) Barriers to antenatal PA, (5) Facilitators of antenatal PA. Women described a number of perceived necessities and concerns regarding antenatal PA. These necessities and concerns were described as being consciously balanced, supporting the NCF. However, a number of additional influences (for example, feelings of nausea and lack of advice and knowledge) seemed to impact antenatal PA engagement before women could consider their perceived necessities and concerns around antenatal PA. CONCLUSIONS: The Necessity Concerns Framework is a useful framework to help explain how and why women engage with antenatal PA, more specifically why women do and do not engage in antenatal PA at different times during their pregnancy. However, there are a number of other interpersonal and intrapersonal influences on antenatal PA (e.g. physical symptoms, motivation and time), suggesting the NCF alone may be too simplistic to understand and influence complex behaviour such as antenatal PA.

Medical need and health need.

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I also argue against an overly strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort.

What is 'medical necessity'?

Imagine that we are considering whether our healthcare system (or insurer) should fund treatment or procedure X. One factor that may be cited is that of so-called 'medical necessity'. The claim would be that treatment X should be eligible for funding if it is medically necessary, but ineligible if this does not apply. Similarly, (and relevant to the debates in this special issue), if considering whether a particular treatment should be ethically and/or legally permitted, we may wish to distinguish between cases where the treatment is medically necessary, and those were it is not. But what do we mean by this concept? Here I will propose and briefly defend one plausible and practical definition.

Are humans still necessary?

Our long accepted and historically-persistent human narrative almost exclusively places us at the motivational centre of events. The wellspring of this anthropocentric fable arises from the unitary and bounded nature of personal consciousness. Such immediate conscious experience frames the heroic vision we have told to, and subsequently sold to ourselves. But need this centrality necessarily be a given? The following work challenges this, oft unquestioned, foundational assumption, especially in light of developments in automated, autonomous, and artificially-intelligent systems. For, in these latter technologies, human contributions are becoming ever more peripheral and arguably unnecessary. The removal of the human operator from the inner loops of momentary control has progressed to now an ever more remote function as some form of supervisory monitor. The natural progression of that line of evolution is the eventual excision of humans from access to any form of control loop at all. This may even include system maintenance and then, prospectively, even initial design. The present argument features a 'unit of analysis' provocation which explores the proposition that socially, and even ergonomically, the human individual no longer occupies priority or any degree of pre-eminent centrality. Rather, we are witnessing a transitional phase of development in which socio-technical collectives are evolving as the principle sources of what, may well be profoundly unhuman motivation. These developing proclivities occupy our landscape of technological innovations that daily act to magnify, rather than diminish, such progressive inhumanities. Where this leaves a science focused on work as a human-centred enterprise serves to occupy the culminating consideration of the present discourse.

Understanding the changes in discretionary, as compared to obligatory, roles of human users and operators in systems is central to Ergonomic practice. Envisioning this path of potential progress, and then witnessing and impacting its actual realisation, permits practitioners to optimise their professional and personal strategies as they deal with this next critical step in the relationship between humans and technology.

[Early Prediction of Support Necessity for Pharmacy Clinical Internship Using Deep Learning].

The duration of undergraduate study was extended in 2006 to six years for pharmaceutical education aimed at training highly qualified pharmacists. Clinical internship in current pharmaceutical education is positioned as being important for fostering the qualities required of a pharmacist, and the support of faculty members is essential. Based on the above, we thought that support from faculty members should be provided easily and positively, which would enrich community pharmacy clinical internships. This study aimed to examine the method of predicting the need for support from weekly reports of community pharmacy practice trainees at Showa Pharmaceutical University. It became evident that the level of necessary support could not be predicted by using the support needs listed. However, application of deep learning to the contents of the weekly report for the first to fifth weeks in 2019 enabled the prediction of the level of support needed in 2020 with 97% accuracy. Although this research is currently limited to predicting the level of support required for community pharmacy practical internship at our university, it demonstrates the use of deep learning to predict the level of support needed based on five weeks' worth of weekly reports.

Radiology's Ionising Radiation Paradox: Weighing the Indispensable Against the Detrimental in Medical Imaging.

Ionising radiation stands as an indispensable protagonist in the narrative of medical imaging, underpinning diagnostic evaluations and therapeutic interventions across an array of medical conditions. However, this protagonist poses a paradox - its inestimable service to medicine coexists with an undercurrent of potential health risks, primarily DNA damage and subsequent oncogenesis. The narrative of this comprehensive review unfurls around this intricate enigma, delicately balancing the indispensable diagnostic utility against the non-negotiable commitment to patient safety. In this critical discourse, the intricacies of ionising radiation are dissected, illuminating not only its sources but also the associated biological and health hazards. The exploration delves into the labyrinth of strategies currently deployed to minimise exposure and safeguard patients. By casting light on the scientific nuances of X-rays, computed tomography (CT), and nuclear medicine, it traverses the complex terrain of radiation use in radiology, to promote safer medical imaging practices, and to facilitate an ongoing dialogue about diagnostic necessity and risk. Through a rigorous examination, the pivotal relationship between radiation dose and dose response is elucidated, unravelling the mechanisms of radiation injury and distinguishing between deterministic and stochastic effects. Moreover, protection strategies are illuminated, demystifying concepts such as justification, optimisation, the As Low As Reasonably Achievable (ALARA) principle, dose and diagnostic reference levels, along with administrative and regulatory approaches. With an eye on the horizon, promising avenues of future research are discussed. These encompass low-radiation imaging techniques, long-term risk assessment in large patient cohorts, and the transformative potential of artificial intelligence in dose optimisation. This exploration of the nuanced complexities of radiation use in radiology aims to foster a collaborative impetus towards safer medical imaging practices. It underscores the need for an ongoing dialogue around diagnostic necessity and risk, thereby advocating for a continual reassessment in the narrative of medical imaging.