Standardizing imaging findings representation: harnessing Common Data Elements semantics and Fast Healthcare Interoperability Resources structures.

OBJECTIVES: Designing a framework representing radiology results in a standards-based data structure using joint Radiological Society of North America/American College of Radiology Common Data Elements (CDEs) as the semantic labels on standard structures. This allows radiologist-created report data to integrate with artificial intelligence-generated results for use throughout downstream systems. MATERIALS AND METHODS: We developed a framework modeling radiology findings as Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) observations using CDE set/element identifiers as standardized semantic labels. This framework deploys CDE identifiers to specify radiology findings and attributes, providing consistent labels for radiology report concepts-diagnoses, recommendations, tabular/quantitative data-with built-in integration with RadLex, SNOMED CT, LOINC, and other ontologies. Observation structures fit within larger HL7 FHIR DiagnosticReport resources, providing output including both nuanced text and structured data. RESULTS: Labeling radiology findings as discrete data for interchange between systems requires two components: structure and semantics. CDE definitions provide semantic identifiers for findings and their component values. The FHIR observation resource specifies a structure for associating identifiers with radiology findings in the context of reports, with CDE-encoded observations referring to definitions for CDE identifiers in a central repository. The discussion includes an example of encoding pulmonary nodules on a chest CT as CDE-labeled observations, demonstrating the application of this framework to exchange findings throughout the imaging workflow, making imaging data available to downstream clinical systems. DISCUSSION: CDE-labeled observations establish a lingua franca for encoding, exchanging, and consuming radiology data at the level of individual findings, facilitating use throughout healthcare systems. IMPORTANCE: CDE-labeled FHIR observation objects can increase the value of radiology results by facilitating their use throughout patient care.

A Case Study in Application of the Risk Knowledge Infinity Cycle.

The Risk Knowledge Infinity (RKI) Cycle Framework was featured as part of the ICH-sanctioned training materials supporting the recent issuance of ICH Q9(R1) Quality Risk Management To support ICH Q9(R1) understanding and adoption, this paper presents a case study on the application of the RKI Cycle, based on an underlying out-of-specification investigation. This case study provides a stepwise walk-through of the cycle to illustrate how key concepts within the ICH Q9(R1) revision can be achieved through better connecting quality risk management and knowledge management with a framework such as the RKI Cycle.

Integrating and Adopting AI in the Radiology Workflow: A Primer for Standards and Integrating the Healthcare Enterprise (IHE) Profiles.

The deployment of artificial intelligence (AI) solutions in radiology practice creates new demands on existing imaging workflow. Accommodating custom integrations creates a substantial operational and maintenance burden. These custom integrations also increase the likelihood of unanticipated problems. Standards-based interoperability facilitates AI integration with systems from different vendors into a single environment by enabling seamless exchange between information systems in the radiology workflow. Integrating the Healthcare Enterprise (IHE) is an initiative to improve how computer systems share information across health care domains, including radiology. IHE integrates existing standards-such as Digital Imaging and Communications in Medicine, Health Level Seven, and health care lexicons and ontologies (ie, LOINC, RadLex, SNOMED Clinical Terms)-by mapping data elements from one standard to another. IHE Radiology manages profiles (standards-based implementation guides) for departmental workflow and information sharing across care sites, including profiles for scaling AI processing traffic and integrating AI results. This review focuses on the need for standards-based interoperability to scale AI integration in radiology, including a brief review of recent IHE profiles that provide a framework for AI integration. This review also discusses challenges and additional considerations for AI integration, including technical, clinical, and policy perspectives.

AAPM task group report 305: Guidance for standardization of vendor-neutral reject analysis in radiography.

Reject rate analysis is considered an integral part of a diagnostic radiography quality control (QC) program. A rejected image is a patient radiograph that was not presented to a radiologist for diagnosis and that contributes unnecessary radiation dose to the patient. Reject rates that are either too high or too low may suggest systemic department shortcomings in QC mechanisms. Due to the lack of standardization, reject data often cannot be easily compared between radiography systems from different vendors. The purpose of this report is to provide guidance to help standardize data elements that are required for comprehensive reject analysis and to propose data reporting and workflows to enable an effective and comprehensive reject rate monitoring program. Essential data elements, a proposed schema for classifying reject reasons, and workflow implementation options are recommended in this task group report.

Generation of structured light using pyramidal prisms.

We present a numerical study of the structured light produced by a laser beam transmitted by a symmetric pyramidal prism. From the Fresnel diffraction formulation, we obtain expressions for the amplitudes valid for an arbitrary number of prism faces, and for both acute and flat-topped prisms. The expressions are readily evaluated numerically and are a significant advancement over the restrictive plane wave models used in prior work. We consider applications in optical trapping and give examples in which the intensity distributions contain a number of bright spots having similar power, as is suitable for the simultaneous trapping of several particles. We also consider applications in lithography and, under other conditions, obtain results in which uniform periodic intensity patterns are produced. Advantages of employing pyramidal prisms in such applications are their excellent stability and their efficiency in the production of structured light.

Supercritical-CO2 Foam Extrusion of Hydroxypropyl Methyl Cellulose Acetate Succinate/Itraconazole Amorphous Solid Dispersions: Processing-Structure-Property Relations.

This study investigates the effects of supercritical CO2 as a foaming agent on structure and physical properties of hot melt extruded hydroxypropyl methylcellulose acetate succinate (HPMCAS)-itraconazole (ITZ) amorphous solid dispersions (ASDs) with the aim of improving the milling efficiency and tabletability of these ASDs. Two different grades of AFFINISOLTM HPMCAS, the standard grade (Std) and the High Productivity grade (HP) were used. The HP-grade has a lower molecular weight, melt viscosity and wider processing temperature range. Extrudates with different ITZ concentrations (0%, 20% and 40%) and CO2 injection pressure of 100 and 200 bar were prepared. The cellular microstructure of the foams showed that HP-grade HPMCAS had better affinity with the CO2 resulting in better distribution of CO2. The results of DSC and X-ray diffraction analysis revealed that the supercritical CO2 did not affect the amorphous state of the API in the extrudates. Milling efficiency of the ASDs was significantly improved up to around 90% increase in the mass recovery. The tabletability of the milled extrudates showed a considerable increase in tablet tensile strength. In addition, foaming considerably improved the supersaturation of HP-grade ASD while showing minimal improvement in dissolution behavior of the Std-grade material.

Detachment of Dunaliella tertiolecta Microalgae from a Glass Surface by a Near-Infrared Optical Trap.

We report on the observation of the detachment in situ and in vivo of Dunaliella tertiolecta microalgae cells from a glass surface using a 1064 nm wavelength trapping laser beam. The principal bends of both flagella of Dunaliella were seen self-adhered to either the top or bottom coverslip surfaces of a 50 µm thick chamber. When a selected attached Dunaliella was placed in the trapping site, it photoresponded to the laser beam by moving its body and flagellar tips, which eventually resulted in its detachment. The dependence of the time required for detachment on the trapping power was measured. No significant difference was found in the detachment time for cells detached from the top or bottom coverslip, indicating that the induced detachment was not due solely to the optical forces applied to the cells. After detachment, the cells remained within the optical trap. Dunaliella detached from the bottom were seen rotating about their long axis in a counterclockwise direction, while those detached from the top did not rotate. The rotation frequency and the minimal force required to escape from the trap were also measured. The average rotation frequency was found to be independent of the trapping power, and the swimming force of a cell escaping the laser trap ranged from 4 to 10 picoNewtons. Our observations provide insight into the photostimulus produced when a near-infrared trapping beam encounters a Dunaliella. The microalgae frequently absorb more light than they can actually use in photosynthesis, which could cause genetic and molecular changes. Our findings may open new research directions into the study of photomovement in species of Dunaliella and other swimming microorganisms that could eventually help to solve technological problems currently confronting biomass production. In future work, studies of the response to excess light may uncover unrecognized mechanisms of photoprotection and photoacclimation.

The role of patient advocacy organizations in shaping medical research: the Pompe model.

The Pompe model is the term used by the Pompe community to describe the relationship that exists between the patient community, the medical/scientific community, and industry. The development of the Pompe model represented a new paradigm for the involvement of patients in new treatments-and also for scientists and pharmaceutical companies. It saw patients developing a sense of agency, of involvement in the process of treatment development rather than powerless recipients or (if lucky) occasional spectators. At the same time, as described below, it benefited the other partners in the process with the result that the different components of the model added up to more than the sum of their parts. However, in order for this to happen, each part had to undergo a transformation in mindset. The development of enzyme replacement therapy (ERT) for Pompe disease represented a unique set of circumstances and individuals that helped to bring about this change and, in doing so, created a model that has had far wider applications.

Rheology of Cellulose Ether Excipients Designed for Hot Melt Extrusion.

A new family of cellulosic ether polymeric excipients has been recently engineered for fabrication of amorphous solid dispersions of active pharmaceutical ingredients via hot-melt extrusion (HME). These hydroxypropyl methyl cellulose excipients enable plasticizer-free melt processing at much lower temperatures (135-160 °C) due to their substantially reduced glass transition temperatures ( Tg = 98-110 °C). The novel amorphous cellulose ethers were found to be rheologically solidlike well above their glass transition ( Tg + 70 °C). We demonstrate that in the pharmaceutically relevant HME processing temperature range these polymers behave similarly to yield-stress fluids and flow only when the applied stress exceeds a critical stress value. This critical stress value (0.50 ± 0.05 MPa, 150 °C) is surprisingly high but is easily achieved under typical HME conditions. The origin of their yield-stress fluidlike behavior is hypothesized to arise from hydrogen bonds of the HPMC materials that act as physical cross-links and do not relax within the measured temperature and time window unless the applied stress exceeds the critical stress value. Support for this hypothesis arises from infrared spectroscopic estimates of the free and bound hydrogen bond levels at end-use temperatures.

Hysteretic Photochromic Switching (HPS) in Doubly Doped GaN(Mg):Eu-A Summary of Recent Results.

Europium is the most-studied and least-well-understood rare earth ion (REI) dopant in GaN. While attempting to increase the efficiency of red GaN light-emitting diodes (LEDs) by implanting Eu⁺ into p-type GaN templates, the Strathclyde University group, in collaboration with IST Lisbon and Unipress Warsaw, discovered hysteretic photochromic switching (HPS) in the photoluminescence spectrum of doubly doped GaN(Mg):Eu. Our recent work, summarised in this contribution, has used time-, temperature- and light-induced changes in the Eu intra-4f shell emission spectrum to deduce the microscopic nature of the Mg-Eu defects that form in this material. As well as shedding light on the Mg acceptor in GaN, we propose a possible role for these emission centres in quantum information and computing.

DICOMweb™: Background and Application of the Web Standard for Medical Imaging.

This paper describes why and how DICOM, the standard that has been the basis for medical imaging interoperability around the world for several decades, has been extended into a full web technology-based standard, DICOMweb. At the turn of the century, healthcare embraced information technology, which created new problems and new opportunities for the medical imaging industry; at the same time, web technologies matured and began serving other domains well. This paper describes DICOMweb, how it extended the DICOM standard, and how DICOMweb can be applied to problems facing healthcare applications to address workflow and the changing healthcare climate.

Demonstrating Pharmaceutical Quality System Effectiveness and Driving Continual Improvement: Evidence-Based Risk Reduction.

Product knowledge grows and evolves during the life of a product. In order to maintain a state of control and deliver product with consistent quality throughout its commercial life, continuous improvement and product lifecycle management become essential. The practical link between product and process knowledge, risk-based control strategies, and continual improvement and innovation can be made stronger through evidence-based risk reduction. This paper introduces the concept of evidence-based risk reduction within the continual improvement framework. It presents how regulatory relief and flexibility in post-approval change management and overall product lifecycle management can likely only be achieved via (1) effective application of science and risk-based concepts and (2) demonstrated effectiveness of the pharmaceutical quality system in assuring a state of control.

Review of the Campaign to Prevent Falls in Construction.

Roofing is one of the most dangerous activities in the construction industry according to the US Bureau of Labor Statistics. Although injuries are manifold in this industry element, the vast majority of them occur as a result of falls from elevation (1, 2). These events lead to physical injury, fatalities, and financial burdens to the individual injured, their families, the employer, and the construction market as a whole (3, 4). In order to reduce construction worker falls, Occupational Health and Safety Administration launched the nationwide Campaign to Prevent Falls in Construction on April 26, 2012 (5). The campaign applied several learning theories that are utilized and proven effective in public health interventions. However, the initiative fails to address a key subpopulation. Further critical assessment of this campaign is now needed to evaluate overall effectiveness.

The efficacy of inhaled nanoparticle tacrolimus in preventing rejection in an orthotopic rat lung transplant model.

OBJECTIVE: The immunosuppressive efficacy of inhaled nanoparticle tacrolimus was compared with systemic tacrolimus in a rodent allogeneic lung transplant model. METHODS: Sixteen rats underwent allogeneic left orthotopic lung transplantation and were divided into 3 treatment groups: (1) inhaled nanoparticle tacrolimus: 6.4 mg tacrolimus/6.4 mg lactose twice per day; (2) intramuscular tacrolimus: 1 mg/kg tacrolimus once per day; and (3) inhaled lactose: 6.4 mg of lactose twice per day. Five days after transplant, the rats were necropsied and underwent histologic rejection grading and cytokine analysis. Trough levels of tacrolimus were measured in allograft, blood, and kidney. RESULTS: Both intramuscular (n = 6) and nanoparticle tacrolimus (n = 6) rats displayed lower histologic grades of rejection (mean scores 3.4 ± 0.6 and 4.6 ± 0.9, respectively) when compared with lactose rats (n = 4) (mean score 11.38 ± 0.5, P = .07). Systemic tacrolimus trough levels (median) were lower in nanoparticle tacrolimus-treated rats versus intramuscular-treated rats (29.2 vs 118.6 ng/g; P < .001 in kidney, and 1.5 vs 4.8 ng/mL; P = .01 in blood). CONCLUSIONS: Inhaled nanoparticle tacrolimus provided similar efficacy in preventing acute rejection when compared with systemic tacrolimus while maintaining lower systemic levels.

Processing thermally labile drugs by hot-melt extrusion: The lesson with gliclazide.

The formation of molecularly dispersed amorphous solid dispersions by the hot-melt extrusion technique relies on the thermal and mechanical energy inputs, which can cause chemical degradation of drugs and polymeric carriers. Additionally, drug degradation may be exacerbated as drugs convert from a more stable crystalline form to a higher energy amorphous form. Therefore, it is imperative to study how drug degrades and evaluate methods to minimize drug degradation during the extrusion process. In this work, gliclazide was used as a model thermally labile drug for the degradation kinetics and process optimization studies. Preformulation studies were conducted using thermal analyses, and liquid chromatography-mass spectroscopy to identify drug degradation pathways and to determine initial extrusion conditions. Formulations containing 10% drug and 90% AFFINISOL™ HPMC HME 100LV were then extruded using a twin screw extruder, and the extrudates were characterized using X-ray powder diffraction, modulated dynamic scanning calorimetry, and potency testing to evaluate physicochemical properties. The energies of activation for both amorphous gliclazide, crystalline gliclazide, and gliclazide solution were calculated using the Arrhenius equation to further guide the extrusion optimization process. Preformulation studies identify two hydrolysis degradation pathways of gliclazide at elevated temperatures. The activation energy study indicates a significantly higher degradation rate for the amorphous gliclazide compared to the crystalline form. After optimization of the hot-melt extrusion process, including improved screw designs, machine setup, and processing conditions, gliclazide amorphous solid dispersion with ∼95% drug recovery was achieved. The ability to process thermally labile drugs and polymers using hot-melt extrusion will significantly expand the possible applications of this manufacturing process.

Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review.

BACKGROUND: Current postoperative rehabilitation protocols after isolated meniscal repair vary widely. No consensus exists with regard to the optimal amount of weightbearing, range of motion, or speed at which the patient progresses through the rehabilitation phases. Confounding factors including concomitant ligamentous or cartilaginous injuries have made studying isolated meniscal tears problematic. PURPOSE: To systematically review and evaluate the influence of range of motion and weightbearing status during the postoperative rehabilitation period after isolated meniscal repair on clinical efficacy and outcome scores. STUDY DESIGN: Systematic review. METHODS: A search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials was conducted. The selection criteria for inclusion were English-language in vivo clinical studies reporting on isolated meniscal repairs utilizing an arthroscopically assisted technique that outlined the postoperative rehabilitation protocol and included at least a 2-year follow-up. Titles, abstracts, and articles were reviewed, and data concerning patient demographics, tear type, repair technique, postoperative protocol details, clinical failures, and outcome scores were extracted from the eligible studies. Rehabilitation protocols were divided into "accelerated," "motion restricted," "weight restricted," and "dual restricted" according to the limitations placed on the treatment groups. RESULTS: Fifteen studies, containing 17 different treatment groups, met the inclusion criteria. The 2 accelerated groups, 2 motion-restricted groups, 4 weight-restricted groups, and 9 dual-restricted groups showed similar efficacy in terms of clinical success and postoperative outcome scores. Early range of motion and weightbearing status showed no influence over clinical outcomes. Of the 17 groups, 13 reported a greater than 70% clinical success rate with significant variation in the tear type, fixation technique, and postoperative restrictions. CONCLUSION: Early range of motion and immediate postoperative weightbearing appear to have no detrimental effect on the chances for clinical success after isolated meniscal repair. Significant variation exists between postoperative protocols, with no current consensus on the ideal parameters for weightbearing and range of motion. Studies reporting outcomes regarding isolated meniscal repair are limited. Future research should include determining the ideal combination of weightbearing and range of motion for specific tear types.

A New Extrudable Form of Hypromellose: AFFINISOL™ HPMC HME.

Hypromellose is a hydrophilic polymer widely used in immediate- and modified-release oral pharmaceutical dosage forms. However, currently available grades of hypromellose are difficult, if not impossible, to process by hot melt extrusion (HME) because of their high glass transition temperature, high melt viscosity, and low degradation temperature. To overcome these challenges, a modified grade of hypromellose, AFFINISOL™ HPMC HME, was recently introduced. It has a significantly lower glass transition temperature and melt viscosity as compared to other available grades of hypromellose. The objective of this paper is to assess the extrudability and performance of AFFINISOL™ HPMC HME (100LV and 4M) as compared to other widely used polymers in HME, including HPMC 2910 100cP (the currently available hypromellose), Soluplus®, Kollidon® VA 64, and EUDRAGIT® E PO. Formulations containing polymer and carbamazepine (CBZ) were extruded on a co-rotating 16-mm twin-screw extruder, and the effect of temperature, screw speed, and feed rate was investigated. The performance of the solid dispersions was evaluated based on Flory-Huggins modeling and characterized by differential scanning calorimetry (DSC), X-ray powder diffraction (XRD), Raman spectroscopy, Fourier-transform infrared (FTIR) spectroscopy, and dissolution. All formulations extruded well except for HPMC 2910 100cP, which resulted in over-torqueing the extruder (machine overloading because the motor cannot provide efficient energy to rotate the shaft). Among the HME extrudates, only the EUDRAGIT® E PO formulation was crystalline as confirmed by DSC, XRD, and Raman, which agreed with predictions from Flory-Huggins modeling. Dissolution testing was conducted under both sink and non-sink conditions. Sink dissolution testing in neutral media revealed that amorphous CBZ in the HME extrudates completely dissolved within 15 min, which was much more rapid than the time for complete dissolution of bulk CBZ (60 min) and EUDRAGIT® E PO solid dispersion (more than 6 h). Non-sink dissolution in acidic media testing revealed that only CBZ contained in the AFFINISOL™ HPMC HME, and EUDRAGIT® E PO solid dispersions rapidly supersaturated after 15 min, reaching a twofold drug concentration compared to the CBZ equilibrium solubility. In summary, AFFINISOL™ HPMC HME 100LV and AFFINISOL™ HPMC HME 4M are useful in the pharmaceutical HME process to increase wetting and dissolution properties of poorly water-soluble drugs like CBZ.

Anatomic and Reverse Total Shoulder Arthroplasty in Patients Older Than 80 Years.

Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) are routinely performed in patients older than 80 years. Often unaware of the differences between the 2 procedures, patients may expect similar outcomes from these procedures. This article reports the outcomes of primary TSA and RSA in patients older than 80 years, with attention directed toward differences in outcomes between the procedures. The authors evaluated a consecutive series of patients who were at least 80 years old and were treated with primary shoulder arthroplasty and had a minimum follow-up of 2 years. Of these patients, 18 underwent primary TSA for osteoarthritis and 33 underwent primary RSA for rotator cuff tear arthropathy. Pain scores, function scores, and range of motion were evaluated preoperatively and at final follow-up. Perioperative and postoperative complications, transfusion rates, length of stay, and subjective satisfaction with the outcome were reported. In these patients, TSA and RSA were similarly effective in improving pain scores, functional scores, and range of motion measurements. Patients who had TSA reported significantly greater satisfaction with surgery and had superior American Shoulder and Elbow Society total and function scores, forward elevation, and external rotation, but similar net improvement from preoperative levels. Although no significant differences were shown in complications, length of stay, or requirement for transfusion, patients treated with RSA had higher rates of transfusion and postoperative complications. Both procedures were similarly effective treatments for patients older than 80 years and showed similar improvements in pain, function, and motion. Patients undergoing RSA were less likely to have good to excellent results, with higher complication and transfusion rates.

Quantitative Chemical Mapping of InGaN Quantum Wells from Calibrated High-Angle Annular Dark Field Micrographs.

We present a simple and robust method to acquire quantitative maps of compositional fluctuations in nanostructures from low magnification high-angle annular dark field (HAADF) micrographs calibrated by energy-dispersive X-ray (EDX) spectroscopy in scanning transmission electron microscopy (STEM) mode. We show that a nonuniform background in HAADF-STEM micrographs can be eliminated, to a first approximation, by use of a suitable analytic function. The uncertainty in probe position when collecting an EDX spectrum renders the calibration of HAADF-STEM micrographs indirect, and a statistical approach has been developed to determine the position with confidence. Our analysis procedure, presented in a flowchart to facilitate the successful implementation of the method by users, was applied to discontinuous InGaN/GaN quantum wells in order to obtain quantitative determinations of compositional fluctuations on the nanoscale.