Clinical Implementation Process Research Articles

Clinical implementation of a commercial synthetic computed tomography solution for radiotherapy treatment of glioblastoma

Background and PurposeMagnetic resonance (MR)-only radiotherapy (RT) workflow eliminates uncertainties due to computed tomography (CT)-MR image registration, by using synthetic CT (sCT) images generated from MR. This study describes the clinical implementation process, from retrospective commissioning to prospective validation stage of a commercial artificial intelligence (AI)-based sCT product. Evaluation of the dosimetric performance of the sCT is presented, with emphasis on the impact of voxel size differences between image modalities. Materials and methodssCT performance was assessed in glioblastoma RT planning. Dose differences for 30 patients in both commissioning and validation cohorts were calculated at various dose-volume-histogram (DVH) points for target and organs-at-risk (OAR). A gamma analysis was conducted on regridded image plans. Quality assurance (QA) guidelines were established based on commissioning phase results. ResultsMean dose difference to target structures was found to be within ± 0.7 % regardless of image resolution and cohort. OARs’ mean dose differences were within ± 1.3 % for plans calculated on regridded images for both cohorts, while differences were higher for plans with original voxel size, reaching up to −4.2 % for chiasma D2% in the commissioning cohort. Gamma passing rates for the brain structure using the criteria 1 %/1mm, 2 %/2mm and 3 %/3mm were 93.6 %/99.8 %/100 % and 96.6 %/99.9 %/100 % for commissioning and validation cohorts, respectively. ConclusionsDosimetric outcomes in both commissioning and validation stages confirmed sCT’s equivalence to CT. The large patient cohort in this study aided in establishing a robust QA program for the MR-only workflow, now applied in glioblastoma RT at our center.

Precision Medicine Approaches to Diabetic Kidney Disease: Personalized Interventions on the Horizon.

Diabetic kidney disease (DKD) is a significant complication of diabetes that requires innovative interventions to address its increasing impact. Precision medicine is a rapidly emerging paradigm that shows excellent promise in tailoring therapeutic strategies to the unique profiles of individual patients. This abstract examines the potential of precision medicine in managing DKD. It explores the genetic and molecular foundations, identifies biomarkers for risk assessment, provides insights into pharmacogenomics, and discusses targeted therapies. Integrating omics data and data analytics provides a comprehensive landscape for making informed decisions. The abstract highlights the difficulties encountered during the clinical implementation process, the ethical factors to be considered, and the importance of involving patients. In addition, it showcases case studies that demonstrate the effectiveness of precision-based interventions. As the field progresses, the abstract anticipates a future characterized by the integration of artificial intelligence in diagnostics and treatment. It highlights the significant impact that precision medicine can have in revolutionizing the provision of care for DKD.

Integration of Artificial Intelligence Into Sociotechnical Work Systems-Effects of Artificial Intelligence Solutions in Medical Imaging on Clinical Efficiency: Protocol for a Systematic Literature Review.

When introducing artificial intelligence (AI) into clinical care, one of the main objectives is to improve workflow efficiency because AI-based solutions are expected to take over or support routine tasks. This study sought to synthesize the current knowledge base on how the use of AI technologies for medical imaging affects efficiency and what facilitators or barriers moderating the impact of AI implementation have been reported. In this systematic literature review, comprehensive literature searches will be performed in relevant electronic databases, including PubMed/MEDLINE, Embase, PsycINFO, Web of Science, IEEE Xplore, and CENTRAL. Studies in English and German published from 2000 onwards will be included. The following inclusion criteria will be applied: empirical studies targeting the workflow integration or adoption of AI-based software in medical imaging used for diagnostic purposes in a health care setting. The efficiency outcomes of interest include workflow adaptation, time to complete tasks, and workload. Two reviewers will independently screen all retrieved records, full-text articles, and extract data. The study's methodological quality will be appraised using suitable tools. The findings will be described qualitatively, and a meta-analysis will be performed, if possible. Furthermore, a narrative synthesis approach that focuses on work system factors affecting the integration of AI technologies reported in eligible studies will be adopted. This review is anticipated to begin in September 2022 and will be completed in April 2023. This systematic review and synthesis aims to summarize the existing knowledge on efficiency improvements in medical imaging through the integration of AI into clinical workflows. Moreover, it will extract the facilitators and barriers of the AI implementation process in clinical care settings. Therefore, our findings have implications for future clinical implementation processes of AI-based solutions, with a particular focus on diagnostic procedures. This review is additionally expected to identify research gaps regarding the focus on seamless workflow integration of novel technologies in clinical settings. PROSPERO CRD42022303439; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=303439. PRR1-10.2196/40485.

The use and future perspective of Artificial Intelligence-A survey among German surgeons.

PurposeClinical abundance of artificial intelligence has increased significantly in the last decade. This survey aims to provide an overview of the current state of knowledge and acceptance of AI applications among surgeons in Germany.MethodsA total of 357 surgeons from German university hospitals, academic teaching hospitals and private practices were contacted by e-mail and asked to participate in the anonymous survey.ResultsA total of 147 physicians completed the survey. The majority of respondents (n = 85, 52.8%) stated that they were familiar with AI applications in medicine. Personal knowledge was self-rated as average (n = 67, 41.6%) or rudimentary (n = 60, 37.3%) by the majority of participants. On the basis of various application scenarios, it became apparent that the respondents have different demands on AI applications in the area of “diagnosis confirmation” as compared to the area of “therapy decision.” For the latter category, the requirements in terms of the error level are significantly higher and more respondents view their application in medical practice rather critically. Accordingly, most of the participants hope that AI systems will primarily improve diagnosis confirmation, while they see their ethical and legal problems with regard to liability as the main obstacle to extensive clinical application.ConclusionGerman surgeons are in principle positively disposed toward AI applications. However, many surgeons see a deficit in their own knowledge and in the implementation of AI applications in their own professional environment. Accordingly, medical education programs targeting both medical students and healthcare professionals should convey basic knowledge about the development and clinical implementation process of AI applications in different medical fields, including surgery.

How to manage polypharmacia?

Pharmacogenomics (PGx) is a key component of personalized medicine to improve clinical outcome of drug therapy and/or to avoid adverse drug reactions. Major efforts are currently spent internationally to implement PGx diagnostics into clinical practice. Evidence-based recommendations for dose-adjusted treatment which are established by international expert groups covering clinical and pharmacological expertise are publicly available. Clinical relevant examples for PGx diagnostics such as genetic testing for dihydropyrimidin-dehydrogenase and thiopurin-S-methyltransferase, as well as for various cytochrome P450 enzymes are summarized to promote the clinical implementation process of PGx in Germany.

Research progress of targeted temperature management in severe traumatic brain injury patients

Targeted temperature management is regarded as a promising treatment which can be used in multiple diseases. This paper aimed at summarizing the concept, mechanism of action, history of application development in severe traumatic brain injury patients, specific clinical implementation process and attention of targeted temperature management. Key words: Review; Craniocerebral trauma; Hypothermia, induced; Targeted temperature management

Creating Virtual Integration and Improved Oncology Care Quality Through a Co-Management Services Agreement

Implementation of a co-management services agreement (Co-MSA) creates agreed-upon cancer care delivery quality metrics, a forum for discussion of service line oversight, and virtually integrated care without institutional employment of oncologists. The goal of this project was to demonstrate that a Co-MSA improved predefined quality metrics and provided enhanced communications between a health system's oncology service line and a group of independent oncologists. Iterative planning discussions were scheduled biweekly over an 18-month period. Contractual, quality, and clinical data with benchmarking were considered in the creation of the Co-MSA. Review of the first year's implementation occurred through examination of the metric achievements and qualitative themes that arose through committee meetings, clinical implementation processes, and cross-organizational discussions. Metrics designed for the Co-MSA included improved adherence to the breast cancer, colon cancer, and non-small-cell lung cancer level I pathways; improvement of the medical oncology physician communication component of the hospital system's Hospital Consumer Assessment of Healthcare Providers and Systems survey scores; and increased delivery of survivorship care plans to appropriate patients. Nonquantifiable themes from the first year of implementation included the need for technology to collect data, both organizations needing a wider understanding of quality improvement techniques, and a need for greater executive leadership involvement. In its first year, the Co-MSA resulted in improvement of the delivery of survivorship care plans and adherence to value pathways powered by the National Comprehensive Cancer Network. Improvement of Hospital Consumer Assessment of Healthcare Providers and Systems scores did not occur.

SU‐FF‐T‐50: Clinical Implementation of New Endometrial Cylinder Applicator for Electronic Brachytherapy

Introduction: Cylindrical applicators for vaginal cuff irradiation are now commercially available for use with a 50 kV electronic brachytherapy (EB) source and are similar in size and shape to cylinders that have been long employed with iridium‐192 brachytherapy (IB). Although the insertion of the new applicator is relatively the same, the implementation from simulation to treatment can be quite different than conventional IB. This study describes the clinical implementation process of the first ever treatment of a patient using this applicator. Methods: The EB endometrial cylinder applicator (Axxent Vaginal Applicator) was supplied and manufactured by Xoft Inc., Sunnyvale, CA. Prior to treatment, a detailed analysis was performed to verify the position of dwell positions, dose distribution verification using gafchromic film and applicator geometry measurements to verify length and diameter. Finally, treatment plans were generated using PLATO software (Nucletron Corp., Columbia, MD) on CT scan data and verified using TLD data. Results: The results of the dwell position verification show that the dummy seed insert agree with the gafchromic film measurements. The distance from dwell position 1 and the surface of the apex of the applicator vary with cylinder size. The dose distribution can be verified at the point of prescription. Discussion: The results of this study show that the EB endometrial cylinder applicator can and has been implemented safely. It should be noted that this applicator has some differences from the traditional IB applicators and need to be accounted for.

Quality Assurance of Radiation Therapy Planning Systems: Current Status and Remaining Challenges

Computerized radiation therapy planning systems (RTPSs) are pivotal for treatment planning. The acceptance, commissioning, and quality control of RTPSs are uniquely complex and are described in the American Association of Physicists in Medicine Task Group Report 53 (1998) and International Atomic Energy Agency Technical Report Series No. 430 (2004). The International Atomic Energy Agency also developed a document and data package for use by vendors and purchasers to aid with acceptance testing of RTPSs. This document is based on International Electrotechnical Commission standard 62083 (2000) and describes both "type" tests to be performed in the factory and "site" tests to be performed in the clinic. The American Association of Physicists Task Group Report 67 described benchmark tests for the validation of dose calculation algorithms. Test data are being produced with the backing of the U.S. National Cancer Institute. However, significant challenges remain. Technology keeps evolving rapidly, thus requiring new quality assurance (QA) procedures. Intensity-modulated radiation therapy with its use of inverse optimization has added a new dimension to QA, because the results are not intuitively obvious. New technologies such as real-time ultrasound guidance for brachytherapy, TomoTherapy, and Cyberknife, require their own specialized RTPSs with unique QA requirements. On-line imaging allows for the generation of dose reconstructions using image warping techniques to determine the daily dose delivered to the patient. With increasing computer speeds, real-time reoptimization of treatment plans will become a reality. Gating technologies will require four-dimensional dose calculations to determine the actual dose delivered to tissue voxels. With these rapidly changing technologies, it is essential that a strong QA culture is invoked in every institution implementing these procedures and that new protocols are developed as a part of the clinical implementation process.

Clinical Use of Electronic Portal Imaging

Accurate and routine target localization is necessary for successful outcome in radiation therapy treatments. Electronic portal imaging devices (EPIDs) provide an advanced tool with digital technology to improve target localization and maintain clinical efficiency. EPIDs are ubiquitous in the radiation therapy clinic, and they provide a powerful and flexible tool to collect and process data in a quantitative manner to improve treatment accuracy for virtually any treatment site. This manuscript provides an overview of the clinical implementation process for effective use of EPIDs. It continues with a review of correction strategies and finally highlights numerous examples of effective clinical application of EPID.

The Experience and Management of Temporality in Five Cases of Dementia

How persons with dementia may experience time, temporal problems and temporal adaptations in their everyday lives is explored. The clinical implementation process and outcome of time aid interventions in five cases are also described. Data were collected through initial interviews with five participants, diagnosed with dementia, and with three spouses. Thereafter, time aids were chosen for intervention in each case. During the intervention, data were collected through fieldnotes and interviews, including evaluative interviews closing the interventions. The participants described experiences of temporal rhythms and extensions. Their temporal problems mainly concerned temporal relationships and coherence, and "knowing when" and "how long". They individually met the problems with strategies that aimed to overall decrease the effects of the temporal problems in general, as well as with direct and conscious attempts to address problems mainly concerning temporal orientation. When time aids were used, difficulty "knowing when" seemed to be most responsive to aids. However, the success of the time aid interventions was limited, as was the success of the spontaneously used strategies. Motivation and insight seemed to be important, as well as the participants' present and former attitudes to temporality. Possible implications for occupational therapy interventions are discussed, considering the clinical and piloting nature of the study.