Merlina Trevino

Work list management tools are finding their way into PACS offerings, but that hasn't stopped many radiology departments from launching efforts to develop their own solutions, according to studies presented at the RSNA meeting.

More and more institutions are moving their work lists away from a first-in, first-out model to a system that red-flags high-priority studies. This way, busy departments can zero in on the most urgent cases.

Radiologists at Cincinnati Children's Hospital Medical Center, for example, launched RadStream last summer. This Web-based, homegrown automated triage system ensures priority for the most acute cases and immediate communication of urgent results to referring physicians. Its use has improved reading times for inpatient and outpatient exams and reduced final sign-off times for emergency department exams, according to Dr. Mark Halsted, Cincinnati Children's chief of radiology informatics.

RadStream also provides documentation and keeps a permanent log of all communications regarding cases, including the time, date, and staff involved in each communication event. An in-house survey revealed that the hospital's radiologists like the new tool. After implementation, radiologists reported a 22% decrease in daily interruptions, which translates into nearly 1500 radiologist-hours saved per year, Halsted said.

"We need to help busy radiologists prioritize their tasks," said Dr. Matthew Morgan, a radiology resident at the University of Pittsburgh Medical Center.

Morgan and colleagues developed an in-house software algorithm that highlights time-critical exams and automatically prioritizes a radiologist's work list. When developing the system, researchers defined two types of urgent exams: those from the ER, and those read by radiology residents or by clinicians providing preliminary reads.

Morgan's system is different from traditional filtering methods, which look first at division and study time as parameters. The logic built into the software prioritizes exams by patient location as well as STAT and urgent notifications by physicians. Use of the system in the neuroradiology division has decreased the time from exam completion to final interpretation from 9.6 hours to 7.8 hours for urgent studies.

Addressing the need to streamline communication with referring physicians, Morgan's group developed four urgency levels:

Category 1. Findings are life-threatening, need high levels of attention, and require immediate synchronous communication. Minutes count in patient management.

Category 2. Findings need high levels of attention but can be managed in minutes to hours. They require reliable asynchronous communication such as e-mail.

Category 3. Findings can be treated before the sun sets. They can be communicated via synchronous/interrupted modes of communication.

Category 4. Findings do not warrant high levels of attention. Communication could be conducted through a radiology Web portal for physicians.

The software provides context-specific messaging for each different type of communication.

"One-size communication does not fit all," Morgan said.

Dr. Dan Cohen, a radiology resident at Massachusetts General Hospital, and colleagues developed a system to notify their requesting physicians of urgent findings. The alert is triggered by the radiologist and sent via e-mail to the referring physician. It does not contain the actual exam results but instead provides a link to them. To avoid desensitizing physicians to the alerts, they are not used for minor findings, Cohen said.

During an eight-month period, radiologists at MGH completed more than 390,000 exams and sent 8210 alerts. About 70% of these were viewed by physicians, but more than 20% of the alerts did not generate return receipts, indicating that physicians may not have opened or received them.

A survey revealed several reasons why physicians missed the alerts:

They had already seen the important finding in the HIS.

They had never ordered a particular study.

Their systems were outside the hospital's firewall.

These missed alerts could be reduced by hiring dedicated staff to follow up and make sure that physicians receive and respond to them, Cohen said.

Dr. Kevin McEnery, an associate professor of radiology at the University of Texas M.D. Anderson Cancer Center, continued the theme of what he called smart radiology.

"The radiology workflow needs to be aligned with clinical workflow," McEnery said.

He outlined how his institution moved away from the typical first-in, first-out mode of interpretation by developing a work list engine that gathers data from the PACS, the RIS, the EMR, and the HIS. The engine allows researchers to manage the workflow of close to 1500 cases. Radiologists in the department have expressed satisfaction with the workflow, McEnery said.

That satisfaction is due in part to eliminating repeated interruptions caused by ad hoc prioritization, according to McEnery. Inpatient studies and STAT cases receive higher priority.

These homegrown approaches reflect a dearth of work list solutions from the commercial community, said Dr. Paul Chang, chief of radiology informatics at the University of Pittsburgh, during a panel discussion. But expecting vendors to have a product that pleases everyone may be unrealistic, given the various idiosyncrasies of users.

One solution would be for vendors to provide service-oriented architectures, which would allow departments to customize products to fit individual needs, said Dr. Keith Dreyer, vice chair of radiology computing and information sciences at MGH.

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Homegrown work list tools provide custom solutions

Security event monitors, an emerging technology in security software, can help protect radiology departments from the increasing onslaught of network attacks, according to researchers at the University of Pittsburgh Medical Center.

The monitors correlate data from various network system defenses and provide users with one unified source of security information, said Dr. Barton F. Branstetter IV, associate director of radiology informatics at Pittsburgh. Branstetter spoke at a SCAR University session on security.

The Health Insurance Portability and Accountability Act has made security one of the hottest topics in healthcare.

"It's one thing to lose a paper chart, but it's another to expose your medical records to the outside world," Dr. Paul Chang, director of radiology informatics at Pittsburgh, said during the session.

An emerging problem in network security is the growing frequency and complexity of attacks, according to Branstetter. New event monitoring tools can help hospitals gain a better understanding of the various ways their networks may be infiltrated.

Branstetter used a pyramid analogy to describe a hospital's network security. At the base of the pyramid are static defenses such as firewalls. These are essentially "dumb" defenses that do not analyze attack types or even recognize that they have been breached. They simply block certain transactions and log those results.

The second line of defense relies on analytical software tools, including intruder detection systems that "sniff" data and look for suspicious conversations such as broadcast messages and increased traffic. Other tools at this level of the pyramid are probes that mimic hackers and can alert administrators to weak points in the system, system integrity verifiers that identify changes in system files, and log file monitors that detect rejection event patterns.

But even these more intelligent security software systems can't deal with security data overload, he said. Some larger entities can be attacked by up to 10 MB of security data threats per minute. With so many assaults, often originating at a variety of sources, managing the amount of incoming data can be nearly impossible.

This is where security event monitors, which sit at the top of the security pyramid, come in. They gather data from all the systems below them and correlate the information by time and type of event.

These tools essentially provide a meta-analysis of all collected security data, helping administrators to determine the timing and sources of attacks. Thus armed, they can prepare for impending attacks, find system loopholes, and develop containment strategies, Branstetter said.

The technology is still maturing, and only a few products are on the market. The University of Pittsburgh uses many elements from the middle tier of the security pyramid but is waiting for security event monitoring technology to fully mature.

"In medicine, we tend to be way behind the curve in adoption of this sort of technology, compared with business and others in academia. It is important that we keep abreast of such developments," he said.

New software crystallizes network security big picture

Security event monitors, the latest advance in security software, can help defend radiology departments against the growing onslaught of network attacks, according to researchers at the University of Pittsburgh Medical Center.

The monitors correlate data from various network system defenses and provide users with one unified source of security information, said Dr. Barton F. Branstetter IV, associate director of radiology informatics at the center.

"An emerging problem in network security is not the type of attacks, but the growing frequency and complexity of those attacks. What makes it even worse is the growing complexity of the systems that need defending," Branstetter said at a SCAR University session Friday. 

New event monitoring tools can help hospitals gain a better understanding of the various ways their networks may be attacked. Branstetter used a pyramid scheme to describe a hospital's network security. At the base of the pyramid are static defenses, such as firewalls. These are essentially "dumb" defenses that do not analyze attack types or even know that they have been breached. They simply block certain transactions and log those results.

Moving up the pyramid, the second line of defense consists of more analytical software tools, including:

Intruder detection systems that "sniff" data and look for suspicious conversations such as broadcast messages and increased traffic 

Probes that mimic hackers and can alert administrators to weak points in the system 

System integrity verifiers that look for changes in system files 

Log file monitors that detect rejection event patterns. 

But even these more intelligent security software systems can't deal with security data overload, Branstetter said. Some larger entities can be attacked by up to 10 megabytes of security data a minute. With so many attacks, often coming from a variety of sources, managing the amount of incoming data can be nearly impossible.

This is where security event monitors, which sit at the top of the security pyramid, step in. They gather data from all the systems that sit below them in the security pyramid and correlate the information by time and type of event.

In essence, these tools provide a meta-analysis of all the collected security data. This analysis arms administrators with one information source that allows them to determine the timing and recurring sources of attacks. They can then prepare for impending attacks, find system loopholes, and develop containment strategies, Branstetter said.

New software class provides big picture on network security

Radiology departments need not fear irreversible compression of medical images, according to a Canadian review of the medical literature.

Two independent reviewers concluded that lossy compression is clinically acceptable for image compression, said Peter Bak, Ph.D., project director of diagnostic imaging architecture for Canada Health Infoway. The organization promotes adoption of electronic health information systems in Canada.

Some data loss does occur with lossy compression, which leads to concern that a misdiagnosis could result if relevant information was lost, he said Thursday at the SCAR meeting.

Bak and colleagues commissioned two independent researchers to systematically review the research on lossy compression. They scanned radiology and related journals, surveyed radiologists in the U.S. and Canada, and sampled professional radiology organizations in both countries for position statements on the use of irreversible image compression. The reviewers studied 120 papers, most dating from 1998.

They found that two main compression algorithm categories are currently in use: discrete cosine transform-based and wavelet-based algorithms.

The researchers also discovered that different modalities and anatomic structures have different compression tolerances; there is no one-size-fits-all compression scheme. Their consensus was that a 50:1 compression ratio is acceptable for large-matrix images, with 25:1 optimal. An acceptable ratio for small-matrix images is 20:1, with 10:1 optimal. 

Acceptable compression ratios varied between modalities, from 40:1 for MRI and up to 90:1 for nuclear medicine studies.

The adoption of electronic health records will require optimum use of networking capabilities among institutions, and compressing images can go a long way toward achieving that goal, according to Bak.

The Canadian Association of Radiologists has endorsed lossy compression for primary reads.

"We in Canada have a good motive to use lossy compression. We see lossy compression as having a positive impact on our national EHR plans if we can make it happen," he said.

Investigation of the barriers to and drivers of lossy compression adoption will require more than a research review, Bak said. In the future, more work will be done to determine legal risks, assess regulatory frameworks, determine economic impact, and provide clinical and performance evaluations.

Lossy compression provides viable option for storing medical images

Help has arrived for radiologists who want to make the best use of the Integrating the Healthcare Enterprise integration profiles when selecting and implementing informatics technology. The IHE released a radiology-specific handbook at the SCAR meeting that guides readers in the use of IHE profiles, said Kevin O'Donnell, co-chair of the IHE radiology planning committee.

The first of the handbook's two sections covers purchasing decisions and explains how to choose the appropriate integration profiles that can improve throughput and reduce errors. It also shows radiologists how to find products that implement desired integration profiles and how to incorporate those profile requirements into a request for purchase.

The second section explains how IHE integration profiles facilitate installation and operation of the various systems radiology departments employ, including the radiology information system, PACS, modalities, and workstations. Radiologists will find information on how to conduct acceptance testing, leverage electronic workflows, and interface with non-IHE systems.

The IHE initiative covers eight domains, including radiology and cardiology, and has deployed 28 profiles. The radiology IHE domain, which is sponsored by the RSNA, covers 13 deployed profiles, including the consistent presentation of images, presentation of grouped procedures, and portable data for imaging profiles.

Additionally, the IHE will publish new radiology supplements covering teaching files and clinical trial export, a radiology option for the audit trail node authentication profile, and a cross-enterprise document-sharing profile for imaging, which will cover distribution of radiology reports and images across different vendor and hospital systems. 

The cross-enterprise document-sharing profile for imaging supplement will be open to public comment between June 15 and July 15.

The handbook was designed to provide guidance to the radiologists who must purchase, install, and operate radiology informatics systems, O'Donnell said.

Help has arrived for radiologists who want to make the best use of the Integrating the Healthcare Enterprise integration profiles when selecting and implementing informatics technology. The IHE released a radiology-specific handbook at the SCAR meeting that guides readers in the use of IHE profiles, said Kevin O’Donnell, co-chair of the IHE radiology planning committee.

IHE introduces new handbook for radiologists

Data mining has the potential to revolutionize clinical information management. But while data mining is a hot topic in information technology circles, it has yet to make many forays into radiology. Only a few departments have taken the plunge. 

Data mining at its most fundamental is the monitoring of trends and the extraction of those trends from a vast repository of common data. It is a way to discover new meaning from existing data. Beyond that definition, data mining can encompass a profusion of applications. 

Hospitals are branching out in the ways they use data repositories to improve their business operations and to help with clinical research, according to the second survey of data warehouse use in healthcare organizations performed by the Healthcare Information and Management Systems Society Data Warehouse and Data Mining Special Interest Group. The group reports that data warehouses are no longer the exclusive province of either the clinical or financial components of a healthcare organization. They are now more generally used in all areas of the hospital, said Larry Wolf, senior consulting architect at Kindred Healthcare in Louisville, KY. 

Wolf presented the 2004 survey results during an electronic session at the February 2005 HIMSS meeting in Dallas. 

In addition to financial analysis, budgeting, and clinical research-the areas that had been addressed in the group's first study, released in 2001-respondents reported using data warehouse technology to address several new areas, including managed-care analysis, clinical benchmarking, performance management, clinical effectiveness, and labor/productivity analysis. 

Radiology departments are turning to data mining technologies to help them with everything from searching for specific teaching cases to determining exam ordering appropriateness. 

Dr. Daniel L. Rubin, an informatics research scientist, and colleagues at Stanford University School of Medicine developed Radbank, a data warehouse using open source tools that has amassed more than 1.8 million radiological reports and 270,000 pathology reports. Physicians have mined the data in Radbank to identify patient cohorts for research studies, teaching cases, and summary statistics such as utilization rates of particular radiological procedures. 

"Implementing Radbank has allowed us to access the vast clinical repository that has previously been trapped in disparate proprietary commercial medical information systems," Rubin said. 

Radbank's data warehouse is implemented as a relational database. The system's developers identified and separated the core functions of Radbank into individual components to reduce the complexity of code management and evolution. Some of the components include separate modules to import historical data from each of the different source departmental databases, a module to capture and parse concurrent clinical data in HL7, a module to convert text reports to XML, and backup/recovery modules. 

A review of Radbank's effectiveness revealed that physicians located 13 times as many teaching cases than were found manually, Rubin said at the 2004 RSNA meeting. In one instance, a radiologist searching for pathologically confirmed viral esophagitis found no cases, while Radbank discovered 55. 

Additional work is under way to make Radbank more user-friendly by moving toward a Web-based interface and away from an SQL-query format, Rubin said. The staff required to develop and deploy Radbank was a small one: one programmer and one physician. The system took about one year to develop and cost less than $2000 to build. 

A system called LEXIMER, for lexicon-mediated entropy reduction, developed at Massachusetts General Hospital, can isolate reports with positive findings and recommendations for additional action from those with no findings or recommendations. It can also identify patterns associated with those findings and recommendations. 

"LEXIMER brings structure to unstructured radiology reports so we can perform highly sophisticated data mining," said Dr. Keith Dreyer, vice chair of radiology computing and information sciences at MGH. 

Creating LEXIMER wasn't easy. It took about 18 months to design and train the system's natural language engine, according to Dreyer, the chief developer. After the system was created, it required seven people to validate it and four more to implement it. Once validated, the system was fully integrated with the departmental RIS and operational for data mining in about three months. 

A review of LEXIMER by Dr. Mannudeep K. Kalra, a research fellow in radiology, and colleagues at MGH found that in a seven-year period CT chest scans generated recommendations at rates ranging from 5% to 31%. In the same period, recommendation rates for MR were 5% to 13%, for mammography 5% to 12%, for nuclear medicine 4% to 5%, and for PET 3% to 28% (Table 1). 

More than three million unstructured radiology reports were included in the database. A more detailed analysis of patterns over those seven years revealed that recommendation rates for all CT scans grew from 11% in 1995 to 20% in 2002, Kalra said at the 2004 RSNA meeting. 

Data mining techniques developed at MGH can also be used to analyze physician ordering patterns and can deliver vital pieces of information: 

the number of specific examinations ordered by a physician, the number and type of indications given by the ordering physician, the positive exam outcome for each indication, and the average exam appropriateness rating by physician. 

Dreyer gave an example using brain CT ordered by two different theoretical physicians: Dr. A ordered 1200 brain CT scans over a 12-month period. Of those exams, Dr. A reported visual disturbances as the exam indication for 60% of the cases and tinnitus for 40% of the cases. Dr. B, on the other hand, ordered 2000 brain CTs during the same time period, citing headache as the indication for 70% of the orders and dizziness for the other 30%. 

Having these data available and matching them to a modified ACR appropriateness criterion, Dr. A, in this case, might show an overall appropriateness criteria of 8.7 for CT of the brain compared with 4.2 for Dr. B, Dreyer said. Further analysis could reveal a 75% positive exam outcome for brain CT for Dr. A compared with 35% for Dr. B. 

Some radiology departments that have not yet developed specific data mining technology investigate data by manually extracting it from a number of systems. At Northwestern University, physicians aggregate the extracted data and analyze them on their own, according to Dr. David Channin, chief of imaging informatics. 

The radiology department uses the extracted information in a number of ways, including tracking down all studies to ensure that they were promptly performed and interpreted. 

"The primary goal of the data mining here is continuous quality improvement-knowing exactly what is being done, when, and where, and then continuously examining how we do things in order to improve," he said. 

Implementing infrastructure to mine electronic data can be difficult because many information systems have proprietary database schemas with poor mechanisms for extracting reports. Channin found this to be a problem even with the large clinical information systems at his facility, where only a fraction of the desired information is available. A common theme among radiology departments attempting to tackle data mining is that homegrown systems must be developed. 

One possible answer to the problem, Channin said, is to monitor the HL7 traffic between systems. The messages flowing between systems contain a large amount of information that can be used to perform data mining for clinical, research, and administrative purposes. Additionally, the Integrating the Healthcare Enterprise initiative specifies an audit trail and node authentication integration profile that defines how different information systems can all log messages to a central server. 

The radiology department at the University of California, Los Angeles, like Northwestern, uses data mining for a variety of applications, including examining workflow and productivity, according to Dr. Osman Ratib, vice chair of information systems in the radiology department. 

"The data that we have from the RIS can be mined to track workloads, efficiency, and turnaround time," he said. 

While the answers to all of these operational queries reside in the RIS, vendors currently provide very little to extract those answers, Ratib said. The department developed its own software layers to place over the RIS for data mining purposes. 

Using the software, managers can better monitor daily and even hourly workload changes on particular scanners. They can then make appropriate plans for renewal and extension of scanners in areas where they reach capacity. Workload trends extracted through data mining can also be used to plan for extended hours in certain areas to provide better coverage and to accommodate more studies per day. 

"Data mining allows us to make capital investment decisions in areas that show rapid growth, like the unpredicted growth in CT due to multislice CT capabilities, which has led to investments in more high-end CTs, and the similar growth in hybrid PET/CT scanners with the rapid increase in demand from oncology for these types of studies," he said. 

Aside from tracking financial and workflow information, the department is also involved in InfoShare, a hospital-wide project to share and produce mineable data. InfoShare was developed using funding received from the National Library of Medicine's Integrated Advanced Information Management Systems program. The InfoShare program, now in its operations phase, is based on policies at UCLA to share technology investments in information systems from one area of patient care, education, or research to enhance activities in other areas, according to the project's Web site (http://infoshare.mednet.ucla.edu). 

InfoShare aims to tailor presentation of the medical record to the specific context in which the data are being requested, such as clinical, research, or educational requirements. It will also link investment in an institutional review board electronic administration system to the electronic medical record for authentication. 

With so few data mining tools specific to radiology applications commercially available, most departments have been required to develop their own systems. These homegrown solutions vary widely depending on the specific information they are tracking. Many respondents to the HIMSS data warehouse survey said they have more than one type of data warehouse architecture in use at their facility (Table 2), according to Wolf. 

Most data warehouse theories argue for a tightly integrated data-sharing model, in contradiction to the variety of architectures actually used, often at the same institution, Wolf said. 

The question remains whether organizations will reduce architectural complexity to meet the integrated warehouse gold standard, or the architectures will stay fragmented to cope with the increasing complexity and wide array of tasks being addressed, he said. 

As each department within a hospital facility develops its own data mining infrastructure, the task of using information from one part of the hospital to improve research or operations in another becomes more difficult. 

Another challenge to data mining includes the wide variety of medical terminologies in use in many hospitals, Rubin said. A disease like diabetes may be recorded in the medical record using the term "diabetes mellitus" or "diabetes" or "DM" or an ICD-9 code. 

Physicians need to develop effective strategies to map existing medical data to controlled terminologies or to collect medical information directly using these terminologies to make data mining activities more effective, Rubin said. 

"The technology exists for us to start tapping into the rich electronic data resources available in hospital information systems. The challenge is that data warehouse technology thus far has only been sparsely implemented in hospitals, likely because of cost and technical issues," he said. "A goal of our work is to delineate methods to make such implementation tractable and to encourage the healthcare community to pursue similar projects." 

Data mining has the potential to revolutionize clinical information management. But while data mining is a hot topic in information technology circles, it has yet to make many forays into radiology. Only a few departments have taken the plunge.

Radiology tackles broad range of applications with data mining

The Society for Computer Applications in Radiology will celebrate its silver anniversary at this year's annual meeting in Orlando with a new look. In a move designed to reposition itself in the changing world of electronic imaging, the society will unveil a new tagline at the conference next month: Innovating Imaging Informatics. 

The tagline change acknowledges the fact that while its roots are deep in radiology, the society also seeks to advance education and research in all of medical imaging, said executive director Anna Marie Mason. 

SCAR grew out of a need for an organization that would oversee issues of implementation involving radiology information systems, patient scheduling and demographics, radiology reporting, reporting repositories, and radiology work list functions, all within an analog imaging environment, said society chair Dr. Anthony Seibert. 

"Most imaging was performed in radiology as a radiology-centric activity," Seibert said. 

As imaging moved to digital technology, SCAR was there for the earliest implementations of PACS, he said. The newest PACS have made Web-based technology commonplace and have pushed the distribution of electronic images throughout the hospital enterprise. 

"Being at the right place at the right time with the right membership-radiologists, physicists, technologists, information specialists, and administrators-has allowed the SCAR annual meeting to grow tremendously," Seibert said. 

That membership may soon grow further to include other medical specialties. SCAR is not solely a society for radiology but is changing along with the rest of the medical field, according to Seibert. 

Other specialties are embracing imaging and informatics technologies, spurring members of the SCAR board of directors to contemplate a possible name change to reflect the new imaging landscape. 

"Our membership is not exclusive. We welcome all medical imaging specialists, technologists, information technology personnel, administrators, and others who might gain from membership and the opportunities and value-added benefits that are available through our society," Seibert said. 

The theme "Past, Present, and Future" will be reflected in a variety of ways throughout the meeting, including a talk by Seibert that will present a retrospective history of the society, Mason said. Corporate vendors are being invited to develop historical displays to be presented in the registration area. 

The society has already addressed some of the changes brought about by technological advances. Its Transforming the Radiological Interpretation Process (TRIP) initiative has targeted the problem of information overload. 

The meeting's closing session will feature a panel of experts, Dr. Paul J. Chang, Dr. Richard L. Morin, and Dr. Eliot L. Siegel, providing their own glimpses into the future of electronic radiology. 

"Certainly, the rate of change is going to continue to increase. What will be the agenda at the annual meeting at the 50th anniversary of SCAR-or whatever its name might be at the time-makes for some interesting conversation and future thought," Seibert said.

The Society for Computer Applications in Radiology will celebrate its silver anniversary at this year's annual meeting in Orlando with a new look. In a move designed to reposition itself in the changing world of electronic imaging, the society will unveil a new tagline at the conference next month: Innovating Imaging Informatics.

SCAR ponders broader direction for future efforts

Beginning next month, medical scientists funded by the National Institutes of Health will be asked to voluntarily submit final manuscripts describing their research to the PubMed Central online medical archive.

The NIH Public Access Policy will apply to all manuscripts accepted for publication resulting from research supported entirely or in part by the NIH, according to a press release issued by the institutes. 

The move could have far-reaching effects on medical research and the evolution of medical literature accessible on the Internet. Medical societies that sponsor peer-reviewed publications have increasingly turned to for-profit publishers such as Springer, Wiley, and Elsevier Science to manage their online publication services. Subscriptions costs for these journals are often several hundred dollars per year. The cost to download an article can be as high as $30.

"This represents a philosophy of information dissemination for the public good which is in contrast with protecting one's results for the purpose of being singularly credited with the findings of that particular research," said Dr. Douglas Beall, an associate professor of radiology at the University of Oklahoma Health Sciences Center.

The public access policy will cover such funding as: 

research grant and career development award mechanisms 

institutional and individual Ruth L. Kirschstein national research service awards 

In the release, the government strongly urged authors to submit accepted papers early in the publication process; preferably, within 12 months of the official final publication date. 

The electronic age has increased the availability of information and the speed with which it can be accessed. Online publication of government-funded research should benefit physicians, researchers, and the public and may shape future research efforts by allowing the most current information to be included in manuscripts as they are written, Beall said.

The need for speed fostered by electronic availability of information may have its own set of problems, however. 

"Pressure to make manuscripts available to conduct prompt peer reviews has the potential to cause evaluation speed to be placed at a higher priority than evaluation accuracy. The thoughtfulness and meticulous evaluation of manuscripts must be emphasized equally as much as the speed by which the manuscripts are evaluated," Beall said.

For more information from the online Diagnostic Imaging archives:

 Publication lags presentation at RSNA meeting

 Webcasts provide immediate access to current research

Public gains access to federally funded research

The amygdala, a brain structure critical in making judgments, is markedly smaller in cocaine addicts, according to a study conducted at Harvard Medical School. While the results are preliminary, they may indicate that reduced amygdala volumes predispose people to cocaine addiction.

The amygdala is an almond-shaped structure in the anterior section of the brain's temporal lobe. It allows people to evaluate environmental cues for evidence of danger. The amygdala orchestrates other brain regions to produce appropriate responses in dangerous situations, said Dr. Nickos Makris, an assistant professor of neurology and the study's lead author.

"Subjects who have reduced amygdala volumes, like the cocaine-dependent population in our study, show significant difficulty identifying and judging the potential negative outcomes of their behavior," he said.

Makris and colleagues examined structural MR imaging data from the brains of 27 cocaine addicts and a control group of nonaddicts (Neuron 2004 Nov. 18;44[4]:729-740).

The amygdalas of cocaine-addicted subjects were an average of 13% smaller on the left side of the brain and 23% smaller on the right side, compared with control subjects. Additionally, the amygdalas in the cocaine-dependent subjects showed unequal volumes on the two sides of the brain as opposed to the laterality seen in the amygdalas of the healthy subjects.

Amygdala size did not correlate to measures of anxiety, depression, cocaine use, or age at which cocaine use began. The researchers did not have sufficient evidence to determine whether reduced size resulted from cocaine abuse or predated the abuse.

Family-based or longitudinal studies of illness progression are being developed at the Massachusetts General Hospital NMR Center. They could settle the question of whether the observed decrease in amygdala volume in these subjects represents an early neural marker of cocaine use or a developmental trait that increases the risk of drug dependence, Makris said.

"The results of our study have clear policy implications. If it is proven that genes are to blame, then MRI-based strategies for prediction and prevention measures should be applied," he said.

 Imaging untangles mystery of drug-addicted brain

 MR brain scan documents substance abuse damage

MRI documents potential precursor to cocaine addiction

 Dr. Deborah J. Rhodes and colleagues at the Mayo Clinic in Rochester, MN, have developed a new molecular breast imaging technique that combines a cadmium-zinc-telluride semiconductor detector with light breast compression to improve image resolution. The detector can be placed very close to the breast, eliminating dead space associated with conventional scintimammography. Earlier trials indicated that when equipped with a long-bore collimator, it was superior to conventional gamma cameras.

 The gamma camera, equipped with an array of 2.5 x 2.5-mm solid-state detector elements producing a 20 x 20-cm field-of-view, was mounted on a modified mammography gantry. Forty women scheduled for breast biopsy were imaged after the injection of 20 millicuries of technetium-99m sestamibi. The scanner identified 33 of 36 cancerous lesions for an overall sensitivity rate of 92%. It found 19 of 22 surgery-confirmed lesions smaller than 1 cm for a sensitivity of 86%. The study was published in the January issue of Mayo Clinic Proceedings.

 Molecular breast imaging using a modified mammography gantry detects invasive cancer in a patient's right breast. Dimensions of the lesion at surgery were 17 x 13 x 19 mm.

 Breast imaging performed with this new technology will cost less than MRI and is not affected by breast density, as is the case with conventional mammography. The technology potentially fills a gap in the current array of breast imaging options, according to Rhodes.

"It will not replace mammograms, ultrasound, or MRI but will offer an important additional option to subgroups of women who are not served well by traditional imaging techniques," she said.