Postoperative Adjuvant Hepatic Arterial Infusion Chemotherapy With FOLFOX in Hepatocellular Carcinoma With Microvascular Invasion: A Multicenter, Phase III, Randomized Study

PURPOSE

To report the efficacy and safety of postoperative adjuvant hepatic arterial infusion chemotherapy (HAIC) with 5-fluorouracil and oxaliplatin (FOLFOX) in hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI).

PATIENTS AND METHODS

In this randomized, open-label, multicenter trial, histologically confirmed HCC patients with MVI were randomly assigned (1:1) to receive adjuvant FOLFOX-HAIC (treatment group) or routine follow-up (control group). The primary end point was disease-free survival (DFS) by intention-to-treat (ITT) analysis while secondary end points were overall survival, recurrence rate, and safety.

RESULTS

Between June 2016 and August 2021, a total of 315 patients (ITT population) at five centers were randomly assigned to the treatment group (n = 157) or the control group (n = 158). In the ITT population, the median DFS was 20.3 months (95% CI, 10.4 to 30.3) in the treatment group versus 10.0 months (95% CI, 6.8 to 13.2) in the control group (hazard ratio, 0.59; 95% CI, 0.43 to 0.81; P = .001). The overall survival rates at 1 year, 2 years, and 3 years were 93.8% (95% CI, 89.8 to 98.1), 86.4% (95% CI, 80.0 to 93.2), and 80.4% (95% CI, 71.9 to 89.9) for the treatment group and 92.0% (95% CI, 87.6 to 96.7), 86.0% (95% CI, 79.9 to 92.6), and 74.9% (95% CI, 65.5 to 85.7) for the control group (hazard ratio, 0.64; 95% CI, 0.36 to 1.14; P = .130), respectively. The recurrence rates were 40.1% (63/157) in the treatment group and 55.7% (88/158) in the control group. Majority of the adverse events were grade 0-1 (83.8%), with no treatment-related death in both groups.

CONCLUSION

Postoperative adjuvant HAIC with FOLFOX significantly improved the DFS benefits with acceptable toxicities in HCC patients with MVI.

Lycorine inhibits tumor growth of human osteosarcoma cells by blocking Wnt/β-catenin, ERK1/2/MAPK and PI3K/AKT signaling pathway

Osteosarcoma (OS) is the most common type of primary bone cancer. Even with advances in early diagnosis and aggressive treatment, the overall prognosis for OS remains to be further elevated. Lycorine was an isoquinoline alkaloid mainly existed in the bulb of lyco salvia miltiorrhiza and was shown to inhibit several types of cancer. In the present study, we investigated the anti-OS activity of lycorine and the possible underlying mechanism. We found that lycorine inhibited cell proliferation of human OS cells while had lower cytotoxcity against normal cells, and triggered cell cycle arrest at the G1/S transition. Moreover, we validated that lycorine promoted apoptosis via death receptor pathway and mitochondrial pathway, suppressed migration and invasion by reversing epithelial mesenchymal transition (EMT) and suppressing the degradation of extracellular matrix (ECM) in vitro. In addition, orthotopic implantation model of 143B OS cells further confirmed that lycorine suppressed OS growth and lung metastasis in vivo. Mechanically, lycorine reduced the protein level of β-catenin and its' downstream molecule c-Myc. Furthermore, lycorine also decreased the phosphorylation of ERK1/2 and AKT. Together, our results reveal that lycorine may inhibit tumor growth of OS cells possibly through suppressing Wnt/β-catenin, ERK1/2 and PI3K/AKT signaling pathway.

Preparation of Nanofibrous Silver/Poly(vinylidene fluoride) Composite Membrane with Enhanced Infrared Extinction and Controllable Wetting Property

Nanofibrous silver (Ag)/poly(vinylidene fluoride) (PVDF) composite membranes were obtained from a two-step preparation method. In the first step, the electrospun silver nitrate (AgNO3)/PVDF membranes were prepared and the influence of the AgNO3 content on the electrospinning process was studied. According to scanning electron microscopy (SEM) results, when the electrospinning solution contained AgNO3 in the range between 3 to 7 wt.%, the nanofiber morphologies can be obtained. In the second step, the electrospun AgNO3/PVDF membranes were reduced by sodium borohydride to form the nanofibrous Ag/PVDF composite membranes. The resultant composite membranes were characterized by SEM, X-ray diffraction (XRD), energy-dispersive spectroscopy (EDS), differential scanning calorimetry, X-ray photoelectron spectroscopy (XPS), and Fourier-transform infrared. The XRD, XPS, and EDS characterizations proved the existence of Ag in the nanofibrous Ag/PVDF composite membranes. The crystallinity degree of PVDF for composite membranes declined with the increase in Ag content. More importantly, the nanofibrous Ag/PVDF composite membranes had obviously higher Rosseland extinction coefficients and lower thermal radiative conductivities in comparison with electrospun PVDF membrane, which demonstrates that such composite membranes with high porosity, low density, and good water vapor permeability are promising thermal insulating materials to block the heat transfer resulting from thermal radiation. In addition, three different methods for surface modification have been used to successfully improve the hydrophobicity of nanofibrous Ag/PVDF composite membranes.

A DICOM-based 2nd generation Molecular Imaging Data Grid implementing the IHE XDS-i integration profile

PURPOSE

A Molecular Imaging Data Grid (MIDG) was developed to address current informatics challenges in archival, sharing, search, and distribution of preclinical imaging studies between animal imaging facilities and investigator sites. This manuscript presents a 2nd generation MIDG replacing the Globus Toolkit with a new system architecture that implements the IHE XDS-i integration profile. Implementation and evaluation were conducted using a 3-site interdisciplinary test-bed at the University of Southern California.

METHODS

The 2nd generation MIDG design architecture replaces the initial design's Globus Toolkit with dedicated web services and XML-based messaging for dedicated management and delivery of multi-modality DICOM imaging datasets. The Cross-enterprise Document Sharing for Imaging (XDS-i) integration profile from the field of enterprise radiology informatics was adopted into the MIDG design because streamlined image registration, management, and distribution dataflow are likewise needed in preclinical imaging informatics systems as in enterprise PACS application. Implementation of the MIDG is demonstrated at the University of Southern California Molecular Imaging Center (MIC) and two other sites with specified hardware, software, and network bandwidth.

RESULTS

Evaluation of the MIDG involves data upload, download, and fault-tolerance testing scenarios using multi-modality animal imaging datasets collected at the USC Molecular Imaging Center. The upload, download, and fault-tolerance tests of the MIDG were performed multiple times using 12 collected animal study datasets. Upload and download times demonstrated reproducibility and improved real-world performance. Fault-tolerance tests showed that automated failover between Grid Node Servers has minimal impact on normal download times.

CONCLUSIONS

Building upon the 1st generation concepts and experiences, the 2nd generation MIDG system improves accessibility of disparate animal-model molecular imaging datasets to users outside a molecular imaging facility's LAN using a new architecture, dataflow, and dedicated DICOM-based management web services. Productivity and efficiency of preclinical research for translational sciences investigators has been further streamlined for multi-center study data registration, management, and distribution.

Intelligent ePR system for evidence-based research in radiotherapy: proton therapy for prostate cancer

PURPOSE

Proton therapy (PT) utilizes high energy particle proton beam to kill cancer cells at the target region for target cancer therapy. Due to the physical properties of the proton beam, PT delivers dose with higher precision and no exit dose compared to conventional radiotherapy. In PT, patient data are distributed among multiple systems, a hindrance to research on efficacy and effectiveness. A data mining method and a treatment plan navigator utilizing the infrastructure and data repository of a PT electronic patient record (ePR) was developed to minimize radiation toxicity and improve outcomes in prostate cancer treatment. MATERIALS/METHOD(S): The workflow of a proton therapy treatment in a radiation oncology department was reviewed, and a clinical data model and data flow were designed. A prototype PT ePR system with DICOM compliance was developed to manage prostate cancer patient images, treatment plans, and related clinical data. The ePR system consists of four main components: (1) Data Gateway; (2) ePR Server; (3) Decision Support Tools; and (4) Visualization and Display Tools. Decision support and visualization tools are currently developed based on DICOM images, DICOM-RT and DICOM-RT-ION objects data from prostate cancer patients treated with hypofractionation protocol proton therapy were used for evaluating ePR system effectiveness. Each patient data set includes a set of computed tomography (CT) DICOM images and four DICOM-RT and RT-ION objects. In addition, clinical outcomes data collected from PT cases were included to establish a knowledge base for outcomes analysis.

RESULTS

A data mining search engine and an intelligent treatment plan navigator (ITPN) were developed and integrated with the ePR system. Evaluation was based on a data set of 39 PT patients and a hypothetical patient.

CONCLUSIONS

The ePR system was able to facilitate the proton therapy workflow. The PT ePR system was feasible for prostate cancer patient treated with hypofractionation protocol in proton therapy. This ePR system improves efficiency in data collection and integration to facilitate outcomes analysis.

MIDG-Emerging grid technologies for multi-site preclinical molecular imaging research communities

PURPOSE

Molecular imaging is the visualization and identification of specific molecules in anatomy for insight into metabolic pathways, tissue consistency, and tracing of solute transport mechanisms. This paper presents the Molecular Imaging Data Grid (MIDG) which utilizes emerging grid technologies in preclinical molecular imaging to facilitate data sharing and discovery between preclinical molecular imaging facilities and their collaborating investigator institutions to expedite translational sciences research. Grid-enabled archiving, management, and distribution of animal-model imaging datasets help preclinical investigators to monitor, access and share their imaging data remotely, and promote preclinical imaging facilities to share published imaging datasets as resources for new investigators.

METHODS

The system architecture of the Molecular Imaging Data Grid is described in a four layer diagram. A data model for preclinical molecular imaging datasets is also presented based on imaging modalities currently used in a molecular imaging center. The MIDG system components and connectivity are presented. And finally, the workflow steps for grid-based archiving, management, and retrieval of preclincial molecular imaging data are described.

RESULTS

Initial performance tests of the Molecular Imaging Data Grid system have been conducted at the USC IPILab using dedicated VMware servers. System connectivity, evaluated datasets, and preliminary results are presented. The results show the system's feasibility, limitations, direction of future research.

CONCLUSIONS

Translational and interdisciplinary research in medicine is increasingly interested in cellular and molecular biology activity at the preclinical levels, utilizing molecular imaging methods on animal models. The task of integrated archiving, management, and distribution of these preclinical molecular imaging datasets at preclinical molecular imaging facilities is challenging due to disparate imaging systems and multiple off-site investigators. A Molecular Imaging Data Grid design, implementation, and initial evaluation is presented to demonstrate the secure and novel data grid solution for sharing preclinical molecular imaging data across the wide-area-network (WAN).

A multimedia electronic patient record (ePR) system for image-assisted minimally invasive spinal surgery

PURPOSE

This paper presents the concept of bridging the gap between diagnostic images and image-assisted surgical treatment through the development of a one-stop multimedia electronic patient record (ePR) system that manages and distributes the real-time multimodality imaging and informatics data that assists the surgeon during all clinical phases of the operation from planning Intra-Op to post-care follow-up. We present the concept of this multimedia ePR for surgery by first focusing on image-assisted minimally invasive spinal surgery as a clinical application.

METHODS

Three clinical phases of minimally invasive spinal surgery workflow in Pre-Op, Intra-Op, and Post-Op are discussed. The ePR architecture was developed based on the three-phased workflow, which includes the Pre-Op, Intra-Op, and Post-Op modules and four components comprising of the input integration unit, fault-tolerant gateway server, fault-tolerant ePR server, and the visualization and display. A prototype was built and deployed to a minimally invasive spinal surgery clinical site with user training and support for daily use.

SUMMARY

A step-by-step approach was introduced to develop a multimedia ePR system for imaging-assisted minimally invasive spinal surgery that includes images, clinical forms, waveforms, and textual data for planning the surgery, two real-time imaging techniques (digital fluoroscopic, DF) and endoscope video images (Endo), and more than half a dozen live vital signs of the patient during surgery. Clinical implementation experiences and challenges were also discussed.

Racial differences in growth patterns of children assessed on the basis of bone age

PURPOSE

To collect up-to-date data in healthy children to create a digital hand atlas (DHA) that can be used to evaluate, on the basis of the Greulich and Pyle atlas method, racial differences in skeletal growth patterns of Asian, African American, white, and Hispanic children in the United States.

MATERIALS AND METHODS

This retrospective study was HIPAA compliant and approved by the institutional review board. Informed consent was obtained from all subjects or their guardians. From May 1997 to March 2008, a DHA containing 1390 hand and wrist radiographs obtained in male and female Asian, African American, white, and Hispanic children with normal skeletal development was developed. The age of subjects ranged from 1 day to 18 years. Each image was read by two pediatric radiologists working independently and without knowledge of the subject's chronologic age, and evaluation was based on their experience with the Greulich and Pyle atlas. Statistical analyses were performed with the paired-samples t test and analysis of variance to study racial differences in growth patterns. P <or= .05 indicated a significant difference.

RESULTS

Bone age (P </= .05) was significantly overestimated in Asian and Hispanic children. These children appear to mature sooner than their African American and white peers. This was seen in both male and female subjects, especially in girls aged 10-13 years and boys aged 11-15 years.

CONCLUSION

Ethnic and racial differences in growth patterns exist at certain ages; however, the Greulich and Pyle atlas does not recognize this fact. Assessment of bone age in children with use of the Greulich and Pyle atlas can be improved by considering the subject's ethnicity.

Effect of a computer-aided diagnosis system on clinicians' performance in detection of small acute intracranial hemorrhage on computed tomography

RATIONALE AND OBJECTIVES

To analyze the effect of a computer-aided diagnosis (CAD) system on clinicians' performance in detection of small acute intracranial hemorrhage (AIH) on computed tomography (CT).

MATERIALS AND METHODS

The authors have developed a CAD scheme that used both image processing techniques and anatomic knowledge based classification system to improve diagnosis of small AIH on CT. A multiple-reader, multiple-case receiver operating characteristic (ROC) study was performed. Twenty clinicians, including seven emergency physicians, seven radiology residents, and six radiology specialists were recruited as readers of 60 sets of brain CT, including 30 cases that show AIH smaller than 1 cm, and 30 controls. Each reader read the same 60 cases twice, first without, then with the prompts produced by the CAD system. The clinicians ranked their confidence in diagnosing a case of showing AIH, which produced the ROC curves.

RESULTS

Significantly improved performance is observed in emergency physicians, average area under the ROC curve (Az) increased from 0.8422 to 0.9294 (P = .0107) when they make the diagnosis without and with the support of CAD. Az for radiology residents increased from 0.9371 to 0.9762 (P = .0088). Az for radiology specialists increased from 0.9742 to 0.9868, but was statistically insignificant (P = .1755).

CONCLUSIONS

CAD can improve the clinicians' performance in detecting AIH on CT. In particular, emergency physicians can benefit most from the CAD and improve their performance to a level approaching that of the average radiology residents.

Bone age assessment of children using a digital hand atlas

We have developed an automated method to assess bone age of children using a digital hand atlas. The hand atlas consists of two components. The first component is a database which is comprised of a collection of 1400 digitized left hand radiographs from evenly distributed normally developed children of Caucasian (CA), Asian (AS), African-American (AA) and Hispanic (HI) origin, male (M) and female (F), ranged from 1- to 18-year-old; and relevant patient demographic data along with pediatric radiologists' readings of each radiograph. This data is separate into eight categories: CAM, CAF, AAM, AAF, HIM, HIF, ASM, and ASF. In addition, CAM, AAM, HIM, and ASM are combined as one male category; and CAF, AAF, HIF, and ASF are combined as one female category. The male and female are further combined as the F & M category. The second component is a computer-assisted diagnosis (CAD) module to assess a child bone age based on the collected data. The CAD method is derived from features extracted from seven regions of interest (ROIs): the carpal bone ROI, and six phanlangeal PROIs. The PROIs are six areas including the distal and middle regions of three middle fingers. These features were used to train the 11 category fuzzy classifiers: one for each race and gender, one for the female, one male, and one F & M, to assess the bone age of a child. The digital hand atlas is being integrated with a PACS for validation of clinical use.

Experiences with a prototype tracking and verification system implemented within an imaging center

RATIONALE AND OBJECTIVES

Most health care facilities currently struggle with protecting medical data privacy, misidentification of patients, and long patient waiting times. This article demonstrates a novel system for a clinical environment using wireless tracking and facial biometric technologies to automatically monitor and identify staff and patients to address these problems.

MATERIALS AND METHODS

The design of the location tracking and verification system (LTVS) was based on a workflow study which was performed to observe the physical location and movement of patient and staff at the Healthcare Consultation Center II (HCC II) running hospital information systems, radiology information systems, picture archive and communication systems, and a voice recognition system. Based on the results from this workflow study, the LTVS was designed using a wireless real-time location system and a facial biometric system integrated with the radiology information system. The LTVS was tested for its functionality in a laboratory environment, then evaluated at HCC II.

RESULTS

Experimental results in the laboratory and clinical environments demonstrated that patient and staff real-time location information and identity verification can be obtained from LTVS. Warning messages can immediately be sent to alert staff when patient's waiting time is over a predefined limit, and unauthorized access to a security area can be audited. Additionally, patient misidentification can be prevented during the course of examinations.

CONCLUSIONS

The system enabled health care providers to streamline the patient workflow, protect against erroneous examinations and create a security zone to prevent, and audit unauthorized access to patient health care data required by the Health Insurance Portability and Accountability Act mandate.

A HIPAA-compliant architecture for securing clinical images

The Health Insurance Portability and Accountability Act (HIPAA, instituted April 2003) Security Standards mandate health institutions to protect health information against unauthorized use or disclosure. One approach to addressing this mandate is by utilizing user access control and generating audit trails of the various authorized as well as unauthorized user access of health data. Although most current clinical image systems [e.g., picture archiving and communication system (PACS)] have components that generate log files for application debugging purposes, there is a lack of methodology to obtain and synthesize the pertinent data from the large volumes of log data generated by these multiple components within a PACS. We have designed a HIPAA-compliant architecture specifically for tracking and auditing the image workflow of clinical imaging systems such as PACS. As an initial first step, we developed HIPAA-compliant auditing system (H-CAS) based on parts of this HIPAA-compliant architecture. H-CAS was implemented within a test-bed PACS simulator located in the Image Processing and Informatics lab at the University of Southern California. Evaluation scenarios were developed where different user types performed legal and illegal access of PACS image data within each of the different components in the PACS simulator. Results were based on whether the scenarios of unauthorized access were correctly identified and documented as well as on normal operational activity. Integration and implementation pitfalls were also noted and included.

Wireless Remote Control of Clinical Image Workflow: Using a PDA for Off-Site Distribution and Disaster Recovery

This paper describes a picture archiving and communication system (PACS) tool based on Web technology that remotely manages medical images between a PACS archive and remote destinations. Successfully implemented in a clinical environment and also demonstrated for the past 3 years at the conferences of various organizations, including the Radiological Society of North America, this tool provides a very practical and simple way to manage a PACS, including off-site image distribution and disaster recovery. The application is robust and flexible and can be used on a standard PC workstation or a Tablet PC, but more important, it can be used with a personal digital assistant (PDA). With a PDA, the Web application becomes a powerful wireless and mobile image management tool. The application's quick and easy-to-use features allow users to perform Digital Imaging and Communications in Medicine (DICOM) queries and retrievals with a single interface, without having to worry about the underlying configuration of DICOM nodes. In addition, this frees up dedicated PACS workstations to perform their specialized roles within the PACS workflow. This tool has been used at Saint John's Health Center in Santa Monica, California, for 2 years. The average number of queries per month is 2,021, with 816 C-MOVE retrieve requests. Clinical staff members can use PDAs to manage image workflow and PACS examination distribution conveniently for off-site consultations by referring physicians and radiologists and for disaster recovery. This solution also improves radiologists' effectiveness and efficiency in health care delivery both within radiology departments and for off-site clinical coverage.

Image-matching as a medical diagnostic support tool (DST) for brain diseases in children

Imaging-matching is an important research area in imaging informatics. We have developed and evaluated a novel diagnostic support tool (DST) based on medical image matching using MR brain images. The approach consists of two steps, database generation and image matching. The database contains pre-diagnosed MR brain images. As the images are added to the database, they are registered to the 3D Talairach coordinate system. In addition, regions of interests (ROI) are generated, and image-processing techniques are used to extract relevant image parameters related to the brain and diseases from the ROIs and from the entire MR image. The second step is to retrieve relevant information from the database by performing image matching. In this step, the physician first submits a query image. The DST computes the similarity between the query image and each of the images in the database, and then presents the most similar images to the user. Since the database contains pre-diagnosed images, the retrieved cases tend to contain relevant diagnostic information. To evaluate the usefulness of the DST in a clinical setting, pediatric brain diseases were used. The database contains 2500 pediatric patients between ages 0 and 18 with brain Magnetic Resonance (MR) images of known brain lesions. A testbed was established at the Children's Hospital Los Angeles (CHLA) for acquiring MR images from the PACS server of patients with known lesions. These images were matched against those in the DST pediatric brain MR database. An expert pediatric neuroradiologist evaluated the matched results. We found that in most cases, the image-matching method was able to quickly retrieve images with relevant diagnostic content. The evaluation method and results are given.

Informatics in radiology (infoRAD): A complete continuous-availability PACS archive server

The operational reliability of the picture archiving and communication system (PACS) server in a filmless hospital environment is always a major concern because server failure could cripple the entire PACS operation. A simple, low-cost, continuous-availability (CA) PACS archive server was designed and developed. The server makes use of a triple modular redundancy (TMR) system with a simple majority voting logic that automatically identifies a faulty module and removes it from service. The remaining two modules continue normal operation with no adverse effects on data flow or system performance. In addition, the server is integrated with two external mass storage devices for short- and long-term storage. Evaluation and testing of the server were conducted with laboratory experiments in which hardware failures were simulated to observe recovery time and the resumption of normal data flow. The server provides maximum uptime (99.999%) for end users while ensuring the transactional integrity of all clinical PACS data. Hardware failure has only minimal impact on performance, with no interruption of clinical data flow or loss of data. As hospital PACS become more widespread, the need for CA PACS solutions will increase. A TMR CA PACS archive server can reliably help achieve CA in this setting.

A continuous available (CA) server for medical imaging applications

RATIONALE AND OBJECTIVES

The trend of medical imaging research and application is toward large database management and manipulation, which requires a robust image server to receive image data from sources and to deliver them to users reliably and in a timely fashion. This article describes the design, implementation, and clinical applications of a continuous available (CA) image server for these purposes.

MATERIALS AND METHODS

The design of the CA image server is based on the concept of a triple modular redundancy server with three redundant server modules. Coupled with a majority voting mechanism in the three modules and failover software, the triple modular redundancy server takes care of all single points of failure hardware components in the CA image server automatically to achieve fault tolerance. Methods and procedures of evaluating the fault tolerance system reliability caused by network connectivity, motherboard, and disk storage failures are described.

RESULTS

Thorough experimental results in laboratory and clinical environments verify that the image server achieves 99.999% hardware up time (or 5 minutes/year down time), satisfying the industrial terminology of hardware continuous availability. Performance of failover of the CA image server is automatically tabulated during these procedures.

CONCLUSION

Applications of CA image server are extensive. Two examples are given including Picture Archiving and Communication System, and off-site back-up archive using the Application Service Provider model. As designed, the CA image server is portable, scalable, affordable, easy to install, and requires no human intervention during failover and system recovery.

Computer-assisted bone age assessment: graphical user interface for image processing and comparison

The current study is part of a project resulting in a computer-assisted analysis of a hand radiograph yielding an assessment of skeletal maturity. The image analysis is based on features selected from six regions of interest. At various stages of skeletal development different image processing problems have to be addressed. At the early stage, feature extraction is based on Lee filtering followed by the random Gibbs fields and mathematical morphology. Once the fusion starts, wavelet decomposition methods are implemented. The user interface displays the closest neighbors to each image under consideration. Results show the sensitivity of different regions to both stages of development and certain feature sensitivity within each region. At the early stage of development, the distal features are more reliable indicators, whereas at the stage of epiphyseal fusion, a larger dynamic range of middle features makes them more sensitive. In the current study, a graphical user interface has been designed and implemented for testing the image processing routines and comparing the results of quantitative image analysis with the visual interpretation of extracted regions of interest. The user interface may also serve as a teaching tool. At the later stage of the project it will be used as a classification tool.

Interactive instruction of cellular physiology for remote learning

The biomedical sciences are a rapidly changing discipline that have adapted to innovative technological advances. Despite these many advances, we face two major challenges: a) the number of experts in the field is vastly outnumbered by the number of students, many of whom are separated geographically or temporally and b) the teaching methods used to instruct students and learners have not changed. Today's students have adapted to technology--they use the web as a source of information and communicate via email and chat rooms. Teaching in the biomedical sciences should adopt these new information technologies (IT), but has thus far failed to capitalize on technological opportunity. Creating a "digital textbook" of the traditional learning material is not sufficient for dynamic processes such as cellular physiology. This paper describes innovative teaching techniques that incorporate familiar IT and high-quality interactive learning content with user-centric instruction design models. The Virtual Labs Project from Stanford University has created effective interactive online teaching modules in physiology (simPHYSIO) and delivered them over broadband networks to their undergraduate and medical students. Evaluation results of the modules are given as a measure of success of such innovative teaching method. This learning media strategically merges IT innovations with pedagogy to produce user-driven animations of processes and engaging interactive simulations.

Medical image security in a HIPAA mandated PACS environment

Medical image security is an important issue when digital images and their pertinent patient information are transmitted across public networks. Mandates for ensuring health data security have been issued by the federal government such as Health Insurance Portability and Accountability Act (HIPAA), where healthcare institutions are obliged to take appropriate measures to ensure that patient information is only provided to people who have a professional need. Guidelines, such as digital imaging and communication in medicine (DICOM) standards that deal with security issues, continue to be published by organizing bodies in healthcare. However, there are many differences in implementation especially for an integrated system like picture archiving and communication system (PACS), and the infrastructure to deploy these security standards is often lacking. Over the past 6 years, members in the Image Processing and Informatics Laboratory, Childrens Hospital, Los Angeles/University of Southern California, have actively researched image security issues related to PACS and teleradiology. The paper summarizes our previous work and presents an approach to further research on the digital envelope (DE) concept that provides image integrity and security assurance in addition to conventional network security protection. The DE, including the digital signature (DS) of the image as well as encrypted patient information from the DICOM image header, can be embedded in the background area of the image as an invisible permanent watermark. The paper outlines the systematic development, evaluation and deployment of the DE method in a PACS environment. We have also proposed a dedicated PACS security server that will act as an image authority to check and certify the image origin and integrity upon request by a user, and meanwhile act also as a secure DICOM gateway to the outside connections and a PACS operation monitor for HIPAA supporting information.

Some historical remarks on picture archiving and communication systems

This Special Issue contains one Editorial and 15 papers. The Editorial reviews some key events, conferences, and publications which propel PACS to its current status. The fifteen papers describe current and future PACS research and development trends grouped in four categories: system-wide trends and clinical experience, tools, key technologies, and PACS-based applications. We see that PACS has gradually become a necessary tool for daily clinical operation, its future trends will be in the development of research methods to fully utilize its large image database for better healthcare delivery.

Enterprise PACS and image distribution

Around the world now, because of the need to improve operation efficiency and better cost effective healthcare, many large-scale healthcare enterprises have been formed. Each of these enterprises groups hospitals, medical centers, and clinics together as one enterprise healthcare network. The management of these enterprises recognizes the importance of using PACS and image distribution as a key technology in cost-effective healthcare delivery in the enterprise level. As a result, many large-scale enterprise level PACS/image distribution pilot studies, full design and implementation, are underway. The purpose of this paper is to provide readers an overall view of the current status of enterprise PACS and image distribution. reviews three large-scale enterprise PACS/image distribution systems in USA, Germany, and South Korean. The concept of enterprise level PACS/image distribution, its characteristics and ingredients are then discussed. Business models for enterprise level implementation available by the private medical imaging and system integration industry are highlighted. One current system under development in designing a healthcare enterprise level chest tuberculosis (TB) screening in Hong Kong is described in detail.

Concept of a PACS and imaging informatics-based server for radiation therapy

Radiation Therapy (RT) is an image-based treatment. It requires images from projection X-rays, computed tomography, magnetic resonance, positron emission tomography, Linear Accelerator for tumor localization, treatment planning and verification of treatment plans. During the treatment process, patient's images are transmitted to every necessary station in the RT department. However, images of the same patient are generally scattered and there is no permanent home base for them due to the nature and traditional organization of the RT department. The advance in diagnostic picture archiving and communication system and the establishment of RT DICOM Standard provide an opportunity to define and design an RT server as a means to organize RT images and related data. This paper describes the RT workflow and the concept of the DICOM RT server. An example of RT treatment of nasopharyngeal carcinoma based on the RT server concept is given.

Digital radiology at the University of California, Los Angeles: a feasibility study. 1983

This paper describes a set of feasibility studies on converting the Department of Radiological Sciences, UCLA from a film based operation to a digital based operation. The studies address the following topics: the departmental facility, the operating procedure and cost, a cost effective analysis and a proposed digital based operating system. In addition, we examine three prototype projects being carried out in our department. These include: a digital archiving and communication system, a hybrid archiving and communication system, and a multiple image viewing system.

Computer automated approach to the extraction of epiphyseal regions in hand radiographs

Epiphyseal region is the most sensitive region to developmental changes of the skeletal system. Extraction of this area is the very first step in any computerized image analysis. In this report a fully automated analysis of a hand radiograph resulting in extraction of distal and middle regions of the II, III, and IV phalanx is presented. The processing is performed in 3 stages. First, the trend of background is removed from radiograph to obtain a binary hand mask. At this stage a labeling procedure is necessary to eliminate artifacts (markers). Then, II, III, and IV phalanges are identified in the binary image, and the phalangeal axes are drawn. Finally, the intensity profile along each phalangeal axis is analyzed, and, on its basis, distal and middle regions are located. The presented procedure is designed as a part of currently developed system for automatic bone age assessment; however, it also can be as a preprocessing step in other diseases the diagnoses of which may require a computer assistance.

Skeletal age determinations in children of European and African descent: applicability of the Greulich and Pyle standards

This study assesses the value of the Greulich and Pyle method in determining the skeletal ages of healthy American children of European and African descent born after the year 1980. The hand and wrist radiographs of 534 children (265 boys, 269 girls; 260 European-Americans [EA], 274 African-Americans [AA]), ages 0 to 19 y, were analyzed by two experienced pediatric radiologists blinded to the chronological age of the subjects. A difference score was calculated for each subject by subtracting chronological age from the mean bone ages scores provided by the two raters. One group t-tests were performed to verify the hypothesis that the mean difference score was equal to zero. Skeletal age determinations by the two radiologists showed a high degree of agreement by intraclass correlation coefficient (r = 0.994). The range of values for differences in skeletal and chronological ages was very wide, indicating great individual variability. Comparisons between skeletal and chronological age only reached statistical significance in EA prepubertal girls, whose skeletal ages were delayed, on average, by three months (t = -2.9; p = 0.005). Mean difference between skeletal and chronological age in prepubertal children of African descent was 0.09 +/- 0.66 y, while that in children of European descent was -0.17 +/- 0.67 y; (t = 3.13; p = 0.0019). On average, the bone ages of 10% of all prepubertal AA children were 2 SD above the normative data in the Greulich and Pyle atlas, while the bone ages of 8% of all prepubertal EA children were 2 SD below. In contrast to the racial differences observed in prepubertal children, EA postpubertal males had significantly greater values for bone age than AA postpubertal males (t = 2.03; p = 0.05). In conclusion, variations in skeletal maturation in prepubertal children are greater than those reflected in the Greulich and Pyle atlas; prepubertal American children of European descent have significantly delayed skeletal maturation when compared with those of African descent; and, postpubertal EA males have significantly advanced skeletal maturation when compared with postpubertal AA males. New standards are needed to make clinical decisions that require reliable bone ages and to accurately represent a multiethnic pediatric population.

Isolation and characterization of the Pin1/Ess1p homologue inSchizosaccharomyces pombe

Pin1/Ess1p is a highly conserved WW domain-containing peptidyl-prolyl isomerase (PPIase); its WW domain binds specifically to phospho-Ser/Thr-Pro sequences and its catalytic domain isomerizes phospho-Ser/Thr-Pro bonds. Pin1 PPIase activity can alter protein conformation in a phosphorylation-dependent manner and/or promote protein dephosphorylation. Human Pin1 interacts with mitotic phosphoproteins, such as NIMA, Cdc25 and Wee1, and inhibits G2/M progression in Xenopus extracts. Depletion of Pin1 in HeLa cells and deletion of ESS1 in S. cerevisiae result in mitotic arrest. In addition, Pin1/Ess1p play roles in transcription in S. cerevisiae and in mammalian somatic cells. The S. pombe genome sequence has an open reading frame (ORF) that has 47% identity with Pin1. Expression of this ORF rescued the growth defect caused by ess1 deletion in S. cerevisiae, indicating that S. pombe Pin1p is a functional Pin1 homologue. Overexpression of pin1+ in S. pombe caused slow growth and a G1 delay. Deletion of pin1+ (pin1Δ) did not affect cell cycle progression or cell growth, but increased sensitivity to the cyclophilin inhibitor, cyclosporin A, suggesting that cyclophilin family PPIases have overlapping functions with the Pin1p PPIase. Deletion of pin1+ did not affect the DNA replication checkpoint, but conferred a modest increase in UV sensitivity. Furthermore, the pin1Δ allele caused a synthetic growth defect when combined with either cdc25-22 or wee1-50 but not the cdc24-1 temperature-sensitive mutant. The pin1Δ strain showed increased sensitivity to the PP1/PP2A family phosphatase inhibitor, okadaic acid, suggesting that Pin1p plays a role in protein dephosphorylation as a result of its ability to increase the population of phospho-Ser/Thr-Pro peptide bonds in the trans conformation that is required for PP2A-mediated dephosphorylation. Our genetic data also suggest that Pin1p might function as a positive regulator of Cdc25p and Wee1p.

Authenticity and integrity of digital mammography images

Data security becomes more and more important in telemammography which uses a public high-speed wide area network connecting the examination site with the mammography expert center. Generally, security is characterized in terms of privacy, authenticity and integrity of digital data. Privacy is a network access issue and is not considered in this paper. We present a method, authenticity and integrity of digital mammography, here which can meet the requirements of authenticity and integrity for mammography image (IM) transmission. The authenticity and integrity for mammography (AIDM) consists of the following four modules. 1) Image preprocessing: To segment breast pixels from background and extract patient information from digital imaging and communication in medicine (DICOM) image header. 2) Image hashing: To compute an image hash value of the mammogram using the MD5 hash algorithm. 3) Data encryption: To produce a digital envelope containing the encrypted image hash value (digital signature) and corresponding patient information. 4) Data embedding: To embed the digital envelope into the image. This is done by replacing the least significant bit of a random pixel of the mammogram by one bit of the digital envelope bit stream and repeating for all bits in the bit stream. Experiments with digital IMs demonstrate the following. 1) In the expert center, only the user who knows the private key can open the digital envelope and read the patient information data and the digital signature of the mammogram transmitted from the examination site. 2) Data integrity can be verified by matching the image hash value decrypted from the digital signature with that computed from the transmitted image. 3) No visual quality degradation is detected in the embedded image compared with the original. Our preliminary results demonstrate that AIDM is an effective method for image authenticity and integrity in telemammography application.

Computer-assisted bone age assessment: image preprocessing and epiphyseal/metaphyseal ROI extraction

Clinical assessment of skeletal maturity is based on a visual comparison of a left-hand wrist radiograph with atlas patterns. Using a new digital hand atlas an image analysis methodology is being developed. To assist radiologists in bone age estimation. The analysis starts with a preprocessing function yielding epiphyseal/metaphyseal regions of interest (EMROIs). Then, these regions are subjected to a feature extraction function. Accuracy has been measured independently at three stages of the image analysis: detection of phalangeal tip, extraction of the EMROIs, and location of diameters and lower edge of the EMROIs. Extracted features describe the stage of skeletal development more objectively than visual comparison.

Nitrate reduction by Citrobacter diversus under aerobic environment

A new aerobic denitrifier, Citrobacter diversus, was isolated from both nitrification and denitrification sludge. To monitor the variation in the concentration of nitrogen oxides, aerobic denitrification by C. diversus was carried out in a batch reactor. When the nitrate concentration was greater than 180 mg N l(-1), the nitrate reduction rate became stable. The effect of the C/N ratio on the denitrification activity was also investigated. The results showed that the optimum denitrification activity was obtained when the C/N ratio was 4-5. The range of the C/N ratio was higher than that for traditional anoxic denitrification. The effect of the dissolved oxygen concentration was further studied; and it was found that the range of dissolved oxygen concentrations, both for specific growth rates and for specific denitrification rates, was 2-6 mg(-1). From these results, it can be concluded that both the concentration of dissolved oxygen and the C/N ratio are key factors in the aerobic denitrification by C. diversus.

A new approach to teleconferencing with intravascular US and cardiac angiography in a low-bandwidth environment

A common problem in radiology teleconferencing is the difficulty of transmitting a large volume of data over communication channels with a relatively low bandwidth. Although videoconferencing systems are easily implemented, they generally require lossy image compression, which can lead to significantly altered findings. A teleconsultation and teleconferencing system was developed that uses a store-and-forward approach with high-quality dynamic medical images obtained with intravascular ultrasonography and cardiac angiography. The system allows use of high-resolution dynamic images while preserving their original quality and can be adapted to different clinical applications with varying requirements. The system involves a standard preparation procedure to transmit images from one location to another prior to a conference; once the conference starts, however, the system becomes fully automatic and synchronizes the display and manipulation of images in both locations without further image data transmission. In general radiologic applications, the system is superior to videoconferencing systems in that it does not require specialized hardware and dedicated high-bandwidth communication links. Further investigation with large-scale studies will be required to determine whether these benefits can lead to more widespread acceptance of such a system in routine clinical practice and whether teleconferencing itself can enhance the effectiveness of clinical procedures.

Digital hand atlas and web-based bone age assessment: system design and implementation

Bone age assessment is a procedure frequently performed in pediatric patients to evaluate their growth disorder. A simple method commonly used in bone age assessment is atlas matching by a radiological examination of a left-hand radiograph against a small reference set of Greulich-Pyle atlas patterns of normal standards. The method however can lead to significant deviation in age assessment, due to a variety of observers with different levels of training. The Greulich-Pyle atlas developed in the 1950s based on middle upper class white populations, is also not fully applicable for children of today, especially regarding the standard development in other racial groups. In this paper, we present our system design and initial implementation of a digital hand atlas and computer-aided diagnostic (CAD) system for Web-based bone age assessment. The CAD system is built on top of existing picture archiving and communication system (PACS), as well as recent advances in Internet technology. It consists of a hand atlas database, a CAD module and a Java-based Web user interface. The digital atlas is based on a large new set of clinically normal hand images of diverse ethnic groups. A relational image database system is used to organize hand images, their extracted quantitative features and patient data. The digital atlas removes the disadvantages of the currently out-of-date Greulich-Pyle atlas and allows the bone age assessment to be computerized. The Java-based Web user interface allows users to interact with the hand image database from browsers. Users can use a Web browser to push a clinical hand image to the CAD server for a bone age assessment. Quantitative features on the examined image, which reflect the skeletal maturity, are then extracted and compared with patterns from the atlas database to assess the bone age. The digital atlas method based on open system Internet technology provides an alternative to supplement or replace the traditional one for a quantitative, accurate and cost-effective assessment of bone age.

Network latency and operator performance in teleradiology applications

Teleradiology applications often use an interactive conferencing mode with remote control mouse pointers. When a telephone is used for voice communication, latencies of the data network can create a temporal discrepancy between the position of the mouse pointer and the verbal communication. To assess the effects of this dissociation, we examined the performance of 5 test persons carrying out simple teleradiology tasks under varying simulated network conditions. When the network latency exceeded 400 milliseconds, the performance of the test persons dropped, and an increasing number of errors were made. This effect was the same for constant latencies, which can occur on the network path, and for variable delays caused by the Nagle algorithm, an internal buffering scheme used by the TCP/IP protocol. Because the Nagle algorithm used in typical TCP/IP implementations causes a latency of about 300 milliseconds even before a data packet is sent, any additional latency in the network of 100 milliseconds or more will result in a decreased operator performance in teleradiology applications. These conditions frequently occur on the public Internet or on overseas connections. For optimal performance, the authors recommend bypassing the Nagle algorithm in teleradiology applications.

Real-time teleconsultation with high-resolution and large-volume medical images for collaborative healthcare

Real-time consultation between referring physicians or radiologists with an expert is critical for timely and adequate management of problem cases. During consultation, both sides need to: 1) synchronously manipulate high-resolution digital radiographic images or large volume MR/CT images; 2) perform interpretation interactively; and 3) converse with audio. We present a specifically designed teleconsultation system in a digital imaging and communication in medicine picture archiving and communication systems clinical environment. The system uses bidirectional remote control technology to meet critical teleconsultation application requirements with high-resolution and large-volume medical images operated in a limited-bandwidth network setting. We give the system design and implementation methods, and also describe the teleconsultation procedure and protocol used in this system. Finally, laboratory and clinical evaluation results are discussed.

Teleconferencing with dynamic medical images

Dynamic images, a sequence of static images displayed in rapid succession and perceived as a continuous motion by the human eye, are widely used in medicine. One of the primary objectives of telemedicine is the transmission of such images to a distant location to manage clinical problems remotely. A broad variety of methods is available to acquire, store, transmit, and display these images. However, the context of the clinical problem determines which of these methods can be deployed in a telemedicine solution. This paper discusses the advantages and disadvantages of the different technologies and presents an example of a teleconferencing system for interventional cardiology. This system acquires cardiac angiography and intravascular ultrasound images and transmits them over an existing Internet connection to a distant location. It is specifically optimized for clinical conferencing, where time is limited for each case presentation during the conference, compared to the relatively long time available for the conference preparation. The system takes advantage of this characteristic by transmitting the images well in advance of the clinical conference and displaying them synchronously in both locations during the conference. This allows for the preservation of the original image quality.

Phosphorylation and spindle pole body localization of the Cdc15p mitotic regulatory protein kinase in budding yeast

Cdc15p is an essential protein kinase and functions with a group of late mitotic proteins that includes Lte1p, Tem1p, Cdc14p and Dbf2p/Dbf20p to inactivate Cdc28p-Clb2p at the end of mitosis in budding yeast [1] [2]. Cdc14p is activated and released from the nucleolus at late anaphase/telophase to dephosphorylate important regulators of Cdc28p-Clb2p such as Hct1p/Cdh1p, Sic1p and Swi5p in a CDC15-dependent manner [3] [4] [5] [6] [7]. How Cdc15p itself is regulated is not known. Here, we report that both the phosphorylation and localization of Cdc15p are cell cycle regulated. The extent of phosphorylation of Cdc15p gradually increases during cell-cycle progression until some point during late anaphase/telophase when it is rapidly dephosphorylated. We provide evidence suggesting that Cdc14p is the phosphatase responsible for the dephosphorylation of Cdc15p. Using a Cdc15p fusion protein coupled at its carboxyl terminus to green fluorescent protein (GFP), we found that Cdc15p, like its homologue Cdc7p [8] in fission yeast, localizes to the spindle pole bodies (SPBs) during mitosis. At the end of telophase, a portion of Cdc15p is located at the mother-bud neck, suggesting a possible role for Cdc15p in cytokinesis.

RNA polymerase I-promoted HIS4 expression yields uncapped, polyadenylated mRNA that is unstable and inefficiently translated in Saccharomyces cerevisiae

The HIS4 gene in Saccharomyces cerevisiae was put under the transcriptional control of RNA polymerase I to determine the in vivo consequences on mRNA processing and gene expression. This gene, referred to as rhis4, was substituted for the normal HIS4 gene on chromosome III. The rhis4 gene transcribes two mRNAs, of which each initiates at the polymerase (pol) I transcription initiation site. One transcript, rhis4s, is similar in size to the wild-type HIS4 mRNA. Its 3' end maps to the HIS4 3' noncoding region, and it is polyadenylated. The second transcript, rhis4l, is bicistronic. It encodes the HIS4 coding region and a second open reading frame, YCL184, that is located downstream of the HIS4 gene and is predicted to be transcribed in the same direction as HIS4 on chromosome III. The 3' end of rhis4l maps to the predicted 3' end of the YCL184 gene and is also polyadenylated. Based on in vivo labeling experiments, the rhis4 gene appears to be more actively transcribed than the wild-type HIS4 gene despite the near equivalence of the steady-state levels of mRNAs produced from each gene. This finding indicated that rhis4 mRNAs are rapidly degraded, presumably due to the lack of a cap structure at the 5' end of the mRNA. Consistent with this interpretation, a mutant form of XRN1, which encodes a 5'-3' exonuclease, was identified as an extragenic suppressor that increases the half-life of rhis4 mRNA, leading to a 10-fold increase in steady-state mRNA levels compared to the wild-type HIS4 mRNA level. This increase is dependent on pol I transcription. Immunoprecipitation by anticap antiserum suggests that the majority of rhis4 mRNA produced is capless. In addition, we quantitated the level of His4 protein in a rhis4 xrn1delta genetic background. This analysis indicates that capless mRNA is translated at less than 10% of the level of translation of capped HIS4 mRNA. Our data indicate that polyadenylation of mRNA in yeast occurs despite HIS4 being transcribed by RNA polymerase I, and the 5' cap confers stability to mRNA and affords the ability of mRNA to be translated efficiently in vivo.

Multilevel adaptive process control of acquisition and post-processing of computed radiographic images in picture archiving and communication system environment

Computed radiography (CR) has become a widely used imaging modality replacing the conventional screen/film procedure in diagnostic radiology. After a latent image is captured in a CR imaging plate, there are seven key processes required before a CR image can be reliably archived and displayed in a picture archiving and communication system (PACS) environment. Human error, computational bottlenecks, software bugs, and CR system errors often crash the CR acquisition and post-processing computers which results in a delay of transmitting CR images for proper viewing at the workstation. In this paper, we present a control theory and a fault tolerance algorithm, as well as their implementation in the PACS environment to circumvent such problems. The software implementation of the control theory and the algorithm is based on the event-driven, multilevel adaptive processing structure. The automated software has been used to provide real-time monitoring and control of CR image acquisition and post-processing in the intensive care unit module of the PACS operation at the University of California, San Francisco. Results demonstrate that the multilevel adaptive process control structure improves CR post-processing time, increases the reliability of the CR images delivery, minimizes user intervention, and speeds up the previously time-consuming quality assurance procedure.

Automatic background recognition and removal (ABRR) in computed radiography images

A novel method to automatically recognize and remove background signals in computed radiography (CR) images caused by X-ray collimation during projection radiographic examinations is presented. There are three major steps in this method. In the first step, a statistical curve is derived based on many hierarchical CR sample images as a first approximation to loosely separate image and background pixels. Second, signal processing methods, including specific sampling, filtering, and angle recognition, are used to determine edges between image and background pixels. Third, adaptive parameter adjustments and consistent and reliable estimation rules are used to finalize the location of edges and remove the background. In addition, this step also evaluates the reliability of the complete background removal operation. With this novel method implemented in a clinical picture archiving and communication system (PACS) at the University of California at San Francisco, we achieved 99% correct recognition of CR image background, and 91% full background removal without removing any valid image information.

Full-field direct digital telemammography: technical components, study protocols, and preliminary results

The early detection of breast cancer increases the survival rate in women. Today, film-screen mammography is the most common and effective technique for the detection of breast cancer. However, the film-screen image recording system of current mammography has several technical limitations that can reduce the breast cancer diagnostic accuracy. A state-of-the-art technology, full-field direct digital mammography (FFDDM) has the potential to increase the sensitivity of clinical and screening examinations and emerge as a film-screen mammography replacement. It is believed that efficiently delivering the superior image quality of FFDDM to expert mammographers will significantly increase the breast cancer diagnostic accuracy. This concept motivates the studies of FFDDM telemammography. In this paper, we will report the FFDDM telemammography project that is being conducted in our facility. The fundamental technology of the FFDDM system and the characteristics of FFDDM images are described. Our research approach is through three protocols: telediagnosis, teleconsultation, and telemanagement. Each of these study protocols is defined. To conduct this FFDDM telemammography project, an asynchronous transfer-mode-network-based telemammography system is developed across two remote campuses in our facility. The architecture of this system is detailed. Unlike other medical imaging modalities, the matrix of an FFDDM image is huge. How to present the image information to mammographers via currently available display media is a challenging task. Our display approaches for the FFDDM images are described. Some preliminary study results from the current phase of this study are reported.

Medical image informatics infrastructure design and applications

Picture archiving and communication systems (PACS) is a system integration of multimodality images and health information systems designed for improving the operation of a radiology department. As it evolves, PACS becomes a hospital image document management system with a voluminous image and related data file repository. A medical image informatics infrastructure can be designed to take advantage of existing data, providing PACS with add-on value for health care service, research, and education. A medical image informatics infrastructure (MIII) consists of the following components: medical images and associated data (including PACS database), image processing, data/knowledge base management, visualization, graphic user interface, communication networking, and application oriented software. This paper describes these components and their logical connection, and illustrates some applications based on the concept of the MIII.

GTP hydrolysis controls stringent selection of the AUG start codon during translation initiation in Saccharomyces cerevisiae

We have isolated and characterized two suppressor genes, SUI4 and SUI5, that can initiate translation in the absence of an AUG start codon at the HIS4 locus in Saccharomyces cerevisiae. Both suppressor genes are dominant in diploid cells and lethal in haploid cells. The SUI4 suppressor gene is identical to the GCD11 gene, which encodes the gamma subunit of the eIF-2 complex and contains a mutation in the G2 motif, one of the four signature motifs that characterizes this subunit to be a G-protein. The SUI5 suppressor gene is identical to the TIF5 gene that encodes eIF-5, a translation initiation factor known to stimulate the hydrolysis of GTP bound to eIF-2 as part of the 43S preinitiation complex. Purified mutant eIF-5 is more active in stimulating GTP hydrolysis in vitro than wild-type eIF-5, suggesting that an alteration of the hydrolysis rate of GTP bound to the 43S preinitiation complex during ribosomal scanning allows translation initiation at a non-AUG codon. Purified mutant eIF-2gamma complex is defective in ternary complex formation and this defect correlates with a higher rate of dissociation from charged initiator-tRNA in the absence of GTP hydrolysis. Biochemical characterization of SUI3 suppressor alleles that encode mutant forms of the beta subunit of eIF-2 revealed that these mutant eIF-2 complexes have a higher intrinsic rate of GTP hydrolysis, which is eIF-5 independent. All of these biochemical defects result in initiation at a UUG codon at the his4 gene in yeast. These studies in light of other analyses indicate that GTP hydrolysis that leads to dissociation of eIF-2 x GDP from the initiator-tRNA in the 43S preinitiation complex serves as a checkpoint for a 3-bp codon/anticodon interaction between the AUG start codon and the initiator-tRNA during the ribosomal scanning process.

Neuroradiology workstation reading in an inter-hospital environment: a nineteen month study

Two workstations (WS) each with two, 2500 line display monitors were installed in the in-patient and the out-patient neuroradiology reading areas for inter-hospital workstation readings. These WSs are part of the display component of a hospital-integrated picture archiving and communication system (PACS). Direct digital neuro images from 10 CT and MR scanners located at various buildings from two medical centers are first transmitted to the PACS database and then distributed to these two WSs automatically. This paper attempts to answer two questions. First, do the WSs facilitate neuroradiology operation? Second, does it cost less for preparing WS reading than that for the traditional film reading? Two parameters, the "time required before images become available for reading after the examination" and a "workstation utilization index" were derived as a means for answering these two questions. Nineteen months of clinical data were collected and analyzed. The results demonstrate that the workstation utilization index goes up from 40% in September 1994 when the WS was first introduced to over 80% in March 1996. This upward trend substantiates the hypothesis that these WSs do facilitate the neuroradiology operation. The derived results also exhibit that it costs much less to prepare images for WS reading than for film reading. Other indirect results derived from this study including the WS utilization hours, WS functions used, and the time duration of each WS session are also presented.

An automated PACS image acquisition and recovery scheme for image integrity based on the DICOM standard

The data quality and completeness of acquired images, which we refer to as integrity, is considered as the most important requirement in the image acquisition design of the Picture Archiving and Communication System (PACS). The Digital Imaging and Communications in Medicine (DICOM) standard significantly simplifies the task of acquiring radiological images from a DICOM compliant imaging system into the PACS. However, human interaction with the imaging system by changing the DICOM communication settings can result in missing images during the PACS image acquisition. A scheme based on the DICOM Query and Retrieve (Q/R) service class was developed to automatically identify and recover missing images. In addition, grouping sequential scanned images such as a CT and MR image series is another potential process that can miss images because of no indication of the end of series. Two methods are presented for determining the end of series and the pros and cons of each method are discussed in detail. Two experiments in a real clinical environment were conducted; one with and one without the Q/R implementation. The statistical results indicate two highlights from this work. First, the Q/R scheme faithfully recovered all missing images caused by human interaction with the DICOM compliant imaging system. Second, there was no single image slice missed when grouping slices into a series using the presented grouping algorithm in the two experimental periods.

Performance of asynchronous transfer mode (ATM) local area and wide area networks for medical imaging transmission in clinical environment

Asynchronous transfer mode (ATM) technology emerges as a leading candidate for medical image transmission in both local area network (LAN) and wide area network (WAN) applications. This paper describes the performance of an ATM LAN and WAN network at the University of California, San Francisco. The measurements were obtained using an intensive care unit (ICU) server connecting to four image workstations (WS) at four different locations of a hospital-integrated picture archiving and communication system (HI-PACS) in a daily regular clinical environment. Four types of performance were evaluated: magnetic disk-to-disk, disk-to-redundant array of inexpensive disks (RAID), RAID-to-memory, and memory-to-memory. Results demonstrate that the transmission rate between two workstations can reach 5-6 Mbytes/s from RAID-to-memory, and 8-10 Mbytes/s from memory-to-memory. When the server has to send images to all four workstations simultaneously, the transmission rate to each WS is about 4 Mbytes/s. Both situations are adequate for radiologic image communications for picture archiving and communication systems (PACS) and teleradiology applications.