Nanotechnology control of self organized biomolecules and biomaterials for medical research

Nanotechnology entails the manufacturing and manipulation of matter at length scales ranging from single atoms to micron-sized objects. The ability to address properties on the biologically-relevant nanometer scale has made nanotechnology attractive for Nanomedicine. This is perceived as a great opportunity in healthcare especially in diagnostics, therapeutics and more in general to develop personalized medicine. Nanomedicine has the potential to enable early detection and prevention, and to improve diagnosis, mass screening, treatment and follow-up of many diseases. From the biological standpoint, nanomaterials match the typical size of naturally occurring functional units or components of living organisms and, for this reason, enable more effective interaction with biological systems. Nanomaterials have the potential to influence the functionality and cell fate in the regeneration of organs and tissues. To this aim, nanotechnology provides an arsenal of techniques for intervening, fabricate, and modulate the environment where cells live and function. Unconventional micro- and nano-fabrication techniques allow patterning biomolecules and biocompatible materials down to the level of a few nanometer feature size. Patterning is not simply a deterministic placement of a material; in a more extended acception it allows a controlled fabrication of structures and gradients of different nature. Gradients are emerging as one of the key factors guiding cell adhesion, proliferation, migration and even differentiation in the case of stem cells. The main goal of this thesis has been to devise a nanotechnology-based strategy and tools to spatially and temporally control biologically-relevant phenomena in-vitro which are important in some fields of medical research.

Biodegradable systems for the development of functional materials

This PhD work was aimed to design, develop, and characterize gelatin-based scaffolds, for the repair of defects in the muscle-skeletal system. Gelatin is a biopolymer widely used for pharmaceutical and medical applications, thanks to its biodegradability and biocompatibility. It is obtained from collagen via thermal denaturation or chemical-physical degradation. Despite its high potential as biomaterial, gelatin exhibits poor mechanical properties and a low resistance in aqueous environment. Crosslinking treatment and enrichment with reinforcement materials are thus required for biomedical applications. In this work, gelatin based scaffolds were prepared following three different strategies: films were prepared through the solvent casting method, electrospinning technique was applied for the preparation of porous mats, and 3D porous scaffolds were prepared through freeze-drying. The results obtained on films put into evidence the influence of pH, crosslinking and reinforcement with montmorillonite (MMT), on the structure, stability and mechanical properties of gelatin and MMT/gelatin composites. The information acquired on the effect of crosslinking in different conditions was utilized to optimize the preparation procedure of electrospun and freeze-dried scaffolds. A successful method was developed to prepare gelatin nanofibrous scaffolds electrospun from acetic acid/water solution and stabilized with a non-toxic crosslinking agent, genipin, able to preserve their original morphology after exposure to water. Moreover, the co-electrospinning technique was used to prepare nanofibrous scaffolds at variable content of gelatin and polylactic acid. Preliminary in vitro tests indicated that the scaffolds are suitable for cartilage tissue engineering, and that their potential applications can be extended to cartilage-bone interface tissue engineering. Finally, 3D porous gelatin scaffolds, enriched with calcium phosphate, were prepared with the freeze-drying method. The results indicated that the crystallinity of the inorganic phase influences porosity, interconnectivity and mechanical properties. Preliminary in vitro tests show good osteoblast response in terms of proliferation and adhesion on all the scaffolds.

Efficient ultrasonic signal processing techniques for aided medical diagnostics

Ultrasound imaging is widely used in medical diagnostics as it is the fastest, least invasive, and least expensive imaging modality. However, ultrasound images are intrinsically difficult to be interpreted. In this scenario, Computer Aided Detection (CAD) systems can be used to support physicians during diagnosis providing them a second opinion. This thesis discusses efficient ultrasound processing techniques for computer aided medical diagnostics, focusing on two major topics: (i) Ultrasound Tissue Characterization (UTC), aimed at characterizing and differentiating between healthy and diseased tissue; (ii) Ultrasound Image Segmentation (UIS), aimed at detecting the boundaries of anatomical structures to automatically measure organ dimensions and compute clinically relevant functional indices. Research on UTC produced a CAD tool for Prostate Cancer detection to improve the biopsy protocol. In particular, this thesis contributes with: (i) the development of a robust classification system; (ii) the exploitation of parallel computing on GPU for real-time performance; (iii) the introduction of both an innovative Semi-Supervised Learning algorithm and a novel supervised/semi-supervised learning scheme for CAD system training that improve system performance reducing data collection effort and avoiding collected data wasting. The tool provides physicians a risk map highlighting suspect tissue areas, allowing them to perform a lesion-directed biopsy. Clinical validation demonstrated the system validity as a diagnostic support tool and its effectiveness at reducing the number of biopsy cores requested for an accurate diagnosis. For UIS the research developed a heart disease diagnostic tool based on Real-Time 3D Echocardiography. Thesis contributions to this application are: (i) the development of an automated GPU based level-set segmentation framework for 3D images; (ii) the application of this framework to the myocardium segmentation. Experimental results showed the high efficiency and flexibility of the proposed framework. Its effectiveness as a tool for quantitative analysis of 3D cardiac morphology and function was demonstrated through clinical validation.

Design of nanoparticle systems with antimicrobial properties

Infektiöse Komplikationen im Zusammenhang mit Implantaten stellen einen Großteil aller Krankenhausinfektionen dar und treiben die Gesundheitskosten signifikant in die Höhe. Die bakterielle Kolonisation von Implantatoberflächen zieht schwerwiegende medizinische Konsequenzen nach sich, die unter Umständen tödlich verlaufen können. Trotz umfassender Forschungsaktivitäten auf dem Gebiet der antibakteriellen Oberflächenbeschichtungen ist das Spektrum an wirksamen Substanzen aufgrund der Anpassungsfähigkeit und Ausbildung von Resistenzen verschiedener Mikroorganismen eingeschränkt. Die Erforschung und Entwicklung neuer antibakterieller Materialien ist daher von fundamentaler Bedeutung.rnIn der vorliegenden Arbeit wurden auf der Basis von Polymernanopartikeln und anorganischen/polymeren Verbundmaterialien verschiedene Systeme als Alternative zu bestehenden antibakteriellen Oberflächenbeschichtungen entwickelt. Polymerpartikel finden Anwendung in vielen verschiedenen Bereichen, da sowohl Größe als auch Zusammensetzung und Morphologie vielseitig gestaltet werden können. Mit Hilfe der Miniemulsionstechnik lassen sich u. A. funktionelle Polymernanopartikel im Größenbereich von 50-500 nm herstellen. Diese wurde im ersten System angewendet, um PEGylierte Poly(styrol)nanopartikel zu synthetisieren, deren anti-adhesives Potential in Bezug auf P. aeruginosa evaluiert wurde. Im zweiten System wurden sog. kontakt-aktive kolloide Dispersionen entwickelt, welche bakteriostatische Eigenschaften gegenüber S. aureus zeigten. In Analogie zum ersten System, wurden Poly(styrol)nanopartikel in Copolymerisation in Miniemulsion mit quaternären Ammoniumgruppen funktionalisiert. Als Costabilisator diente das zuvor quaternisierte, oberflächenaktive Monomer (2-Dimethylamino)ethylmethacrylat (qDMAEMA). Die Optimierung der antibakteriellen Eigenschaften wurde im nachfolgenden System realisiert. Hierbei wurde das oberflächenaktive Monomer qDMAEMA zu einem oberflächenaktiven Polyelektrolyt polymerisiert, welcher unter Anwendung von kombinierter Miniemulsions- und Lösemittelverdampfungstechnik, in entsprechende Polyelektrolytnanopartikel umgesetzt wurde. Infolge seiner oberflächenaktiven Eigenschaften, ließen sich aus dem Polyelektrolyt stabile Partikeldispersionen ohne Zusatz weiterer Tenside ausbilden. Die selektive Toxizität der Polyelektrolytnanopartikel gegenüber S. aureus im Unterschied zu Körperzellen, untermauert ihr vielversprechendes Potential als bakterizides, kontakt-aktives Reagenz. rnAufgrund ihrer antibakteriellen Eigenschaften wurden ZnO Nanopartikel ausgewählt und in verschiedene Freisetzungssysteme integriert. Hochdefinierte eckige ZnO Nanokristalle mit einem mittleren Durchmesser von 23 nm wurden durch thermische Zersetzung des Precursormaterials synthetisiert. Durch die nachfolgende Einkapselung in Poly(L-laktid) Latexpartikel wurden neue, antibakterielle und UV-responsive Hybridnanopartikel entwickelt. Durch die photokatalytische Aktivierung von ZnO mittels UV-Strahlung wurde der Abbau der ZnO/PLLA Hybridnanopartikel signifikant von mehreren Monaten auf mehrere Wochen verkürzt. Die Photoaktivierung von ZnO eröffnet somit die Möglichkeit einer gesteuerten Freisetzung von ZnO. Im nachfolgenden System wurden dünne Verbundfilme aus Poly(N-isopropylacrylamid)-Hydrogelschichten mit eingebetteten ZnO Nanopartikeln hergestellt, die als bakterizide Oberflächenbeschichtungen gegen E. coli zum Einsatz kamen. Mit minimalem Gehalt an ZnO zeigten die Filme eine vergleichbare antibakterielle Aktivität zu Silber-basierten Beschichtungen. Hierbei lässt sich der Gehalt an ZnO relativ einfach über die Filmdicke einstellen. Weiterhin erwiesen sich die Filme mit bakteriziden Konzentrationen an ZnO als nichtzytotoxisch gegenüber Körperzellen. Zusammenfassend wurden mehrere vielversprechende antibakterielle Prototypen entwickelt, die als potentielle Implantatbeschichtungen auf die jeweilige Anwendung weiterhin zugeschnitten und optimiert werden können.

Hundertneunundzwanzig Xe NMR for investigations of complex and dynamic systems

In this work, the remarkable versatility and usefulness of applications of Xe-129 NMR experiments is further extended. The application of Xe-129 NMR spectroscopy to very different system is studied, including dynamic and static, solid and liquid, porous and non-porous systems. Using the large non-equilibrium polarization created by hyperpolarization of Xe-129, time-resolved NMR measurements can be used for the online-monitoring of dynamic systems. In the first part of this work, several improvements for medical applications of hyperpolarized Xe-129 are achieved and their feasibility shown experimentally. A large gain in speed and reproducibility of the accumulation process of Xe-129 as ice and an enhancement of the usable polarization in any experiment requiring prior accumulation are achieved. An enhancement of the longitudinal relaxation time of Xe-129 is realized by admixture of a buffer gas during the storage of hyperpolarized Xe-129. Pursuing the efforts of simplifying the accumulation process and enhancing the storage time of hyperpolarized Xe-129 will allow for a wider use of the hyperpolarized gas in (medical) MRI experiments. Concerning the use of hyperpolarized Xe-129 in MRI, the influence of the diffusion coefficient of the gas on parameters of the image contrast is experimentally demonstrated here by admixture of a buffer gas and thus changing the diffusion coefficient. In the second part of this work, a polymer system with unique features is probed by Xe-129 NMR spectroscopy, proving the method to be a valuable tool for the characterization of the anisotropic properties of semicrystalline, syndiotactic polystyrene films. The polymer films contain hollow cavities or channels with sizes in the sub-nanometer range, allowing for adsorption of Xe-129 and subsequent NMR measurements. Despite the use of a ’real-world’ system, the transfer of the anisotropic properties from the material to adsorbed Xe-129 atoms is shown, which was previously only known for fully crystalline materials. The anisotropic behavior towards atomar guests inside the polymer films is proven here for the first time for one of the phases. For the polymer phase containing nanochannels, the dominance of interactions between Xe-129 atoms in the channels compared to interactions between Xe atoms and the channel walls are proven by measurements of a powder sample of the polymer material and experiments including the rotation of the films in the external magnetic field as well as temperature-dependent measurements. The characterization of ’real-world’ systems showing very high degrees of anisotropy by Xe-129 are deemed to be very valuable in future applications. In the last part of this work, a new method for the online monitoring of chemical reactions has been proposed and its feasibility and validity are experimentally proven. The chemical shift dependence of dissolved Xe-129 on the composition of a reaction mixture is used for the online monitoring of free-radical miniemulsion polymerization reactions. Xe-129 NMR spectroscopy provides an excellent method for the online monitoring of polymerization reactions, due to the simplicity of the Xe-129 NMR spectra and the simple relationship between the Xe-129 chemical shift and the reaction conversion. The results of the time-resolved Xe-129 NMR measurements are compared to those from calorimetric measurements, showing a good qualitative agreement. The applicability of the new method to reactions other than polymerization reactions is investigated by the online monitoring of an enzymatic reaction in a miniemulsion. The successful combination of the large sensitivity of Xe-129, the NMR signal enhancements due to hyperpolarization, and the solubility of Xe-129 gives access to the large new field of investigations of chemical reaction kinetics in dynamic and complex systems like miniemulsions.

Comparison of three optical tracking systems in a complex navigation scenario

Three-dimensional rotational X-ray imaging with the SIREMOBIL Iso-C3D (Siemens AG, Medical Solutions, Erlangen, Germany) has become a well-established intra-operative imaging modality. In combination with a tracking system, the Iso-C3D provides inherently registered image volumes ready for direct navigation. This is achieved by means of a pre-calibration procedure. The aim of this study was to investigate the influence of the tracking system used on the overall navigation accuracy of direct Iso-C3D navigation. Three models of tracking system were used in the study: Two Optotrak 3020s, a Polaris P4 and a Polaris Spectra system, with both Polaris systems being in the passive operation mode. The evaluation was carried out at two different sites using two Iso-C3D devices. To measure the navigation accuracy, a number of phantom experiments were conducted using an acrylic phantom equipped with titanium spheres. After scanning, a special pointer was used to pinpoint these markers. The difference between the digitized and navigated positions served as the accuracy measure. Up to 20 phantom scans were performed for each tracking system. The average accuracy measured was 0.86 mm and 0.96 mm for the two Optotrak 3020 systems, 1.15 mm for the Polaris P4, and 1.04 mm for the Polaris Spectra system. For the Polaris systems a higher maximal error was found, but all three systems yielded similar minimal errors. On average, all tracking systems used in this study could deliver similar navigation accuracy. The passive Polaris system showed ? as expected ? higher maximal errors; however, depending on the application constraints, this might be negligible.

Frequency of and predictors for patient-reported medical and medication errors in Switzerland

OBJECTIVES: To analyse the frequency of and identify risk factors for patient-reported medical errors in Switzerland. The joint effect of risk factors on error-reporting probability was modelled for hypothetical patients. METHODS: A representative population sample of Swiss citizens (n = 1306) was surveyed as part of the Commonwealth Fund’s 2010 lnternational Survey of the General Public’s Views of their Health Care System’s Performance in Eleven Countries. Data on personal background, utilisation of health care, coordination of care problems and reported errors were assessed. Logistic regression analysis was conducted to identify risk factors for patients’ reports of medical mistakes and medication errors. RESULTS: 11.4% of participants reported at least one error in their care in the previous two years (8% medical errors, 5.3% medication errors). Poor coordination of care experiences was frequent. 7.8% experienced that test results or medical records were not available, 17.2% received conflicting information from care providers and 11.5% reported that tests were ordered although they had been done before. Age (OR = 0.98, p = 0.014), poor health (OR = 2.95, p = 0.007), utilisation of emergency care (OR = 2.45, p = 0.003), inpatient-stay (OR = 2.31, p = 0.010) and poor care coordination (OR = 5.43, p <0.001) are important predictors for reporting error. For high utilisers of care that unify multiple risk factors the probability that errors are reported rises up to p = 0.8. CONCLUSIONS: Patient safety remains a major challenge for the Swiss health care system. Despite the health related and economic burden associated with it, the widespread experience of medical error in some subpopulations also has the potential to erode trust in the health care system as a whole.

Electron transport in molecular systems

The remarkable advances in nanoscience and nanotechnology over the last two decades allow one to manipulate individuals atoms, molecules and nanostructures, make it possible to build devices with only a few nanometers, and enhance the nano-bio fusion in tackling biological and medical problems. It complies with the ever-increasing need for device miniaturization, from magnetic storage devices, electronic building blocks for computers, to chemical and biological sensors. Despite the continuing efforts based on conventional methods, they are likely to reach the fundamental limit of miniaturization in the next decade, when feature lengths shrink below 100 nm. On the one hand, quantum mechanical efforts of the underlying material structure dominate device characteristics. On the other hand, one faces the technical difficulty in fabricating uniform devices. This has posed a great challenge for both the scientific and the technical communities. The proposal of using a single or a few organic molecules in electronic devices has not only opened an alternative way of miniaturization in electronics, but also brought up brand-new concepts and physical working mechanisms in electronic devices. This thesis work stands as one of the efforts in understanding and building of electronic functional units at the molecular and atomic levels. We have explored the possibility of having molecules working in a wide spectrum of electronic devices, ranging from molecular wires, spin valves/switches, diodes, transistors, and sensors. More specifically, we have observed significant magnetoresistive effect in a spin-valve structure where the non-magnetic spacer sandwiched between two magnetic conducting materials is replaced by a self-assembled monolayer of organic molecules or a single molecule (like a carbon fullerene). The diode behavior in donor(D)-bridge(B)-acceptor(A) type of single molecules is then discussed and a unimolecular transistor is designed. Lastly, we have proposed and primarily tested the idea of using functionalized electrodes for rapid nanopore DNA sequencing. In these studies, the fundamental roles of molecules and molecule-electrode interfaces on quantum electron transport have been investigated based on first-principles calculations of the electronic structure. Both the intrinsic properties of molecules themselves and the detailed interfacial features are found to play critical roles in electron transport at the molecular scale. The flexibility and tailorability of the properties of molecules have opened great opportunity in a purpose-driven design of electronic devices from the bottom up. The results that we gained from this work have helped in understanding the underlying physics, developing the fundamental mechanism and providing guidance for future experimental efforts.

The Houston Academy of Medicine--Texas Medical Center Library management information system.

A management information system (MIS) provides a means for collecting, reporting, and analyzing data from all segments of an organization. Such systems are common in business but rare in libraries. The Houston Academy of Medicine-Texas Medical Center Library developed an MIS that operates on a system of networked IBM PCs and Paradox, a commercial database software package. The data collected in the system include monthly reports, client profile information, and data collected at the time of service requests. The MIS assists with enforcement of library policies, ensures that correct information is recorded, and provides reports for library managers. It also can be used to help answer a variety of ad hoc questions. Future plans call for the development of an MIS that could be adapted to other libraries' needs, and a decision-support interface that would facilitate access to the data contained in the MIS databases.

DEVELOPING A METHOD FOR IDENTIFYING AND REDUCING FUNCTIONAL DISCREPANCIES OF INFORMATION SYSTEMS

Currently more than half of Electronic Health Record (EHR) projects fail. Most of these failures are not due to flawed technology, but rather due to the lack of systematic considerations of human issues. Among the barriers for EHR adoption, function mismatching among users, activities, and systems is a major area that has not been systematically addressed from a human-centered perspective. A theoretical framework called Functional Framework was developed for identifying and reducing functional discrepancies among users, activities, and systems. The Functional Framework is composed of three models – the User Model, the Designer Model, and the Activity Model. The User Model was developed by conducting a survey (N = 32) that identified the functions needed and desired from the user’s perspective. The Designer Model was developed by conducting a systemic review of an Electronic Dental Record (EDR) and its functions. The Activity Model was developed using an ethnographic method called shadowing where EDR users (5 dentists, 5 dental assistants, 5 administrative personnel) were followed quietly and observed for their activities. These three models were combined to form a unified model. From the unified model the work domain ontology was developed by asking users to rate the functions (a total of 190 functions) in the unified model along the dimensions of frequency and criticality in a survey. The functional discrepancies, as indicated by the regions of the Venn diagrams formed by the three models, were consistent with the survey results, especially with user satisfaction. The survey for the Functional Framework indicated the preference of one system over the other (R=0.895). The results of this project showed that the Functional Framework provides a systematic method for identifying, evaluating, and reducing functional discrepancies among users, systems, and activities. Limitations and generalizability of the Functional Framework were discussed.

Using technology to teach technology: design and evaluation of bilingual online physician education about electronic medical records.

The "EMR Tutorial" is designed to be a bilingual online physician education environment about electronic medical records. After iterative assessment and redesign, the tutorial was tested in two groups: U.S. physicians and Mexican medical students. Split-plot ANOVA revealed significantly different pre-test scores in the two groups, significant cognitive gains for the two groups overall, and no significant difference in the gains made by the two groups. Users rated the module positively on a satisfaction questionnaire.

Clinical decision support capabilities of commercially-available clinical information systems.

BACKGROUND: The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized provider order entry (CPOE) systems. Purpose The goal of this project was to describe and quantify the results of a study of decision support capabilities in Certification Commission for Health Information Technology (CCHIT) certified electronic health record systems. METHODS: The authors conducted a series of interviews with representatives of nine commercially available clinical information systems, evaluating their capabilities against 42 different clinical decision support features. RESULTS: Six of the nine reviewed systems offered all the applicable event-driven, action-oriented, real-time clinical decision support triggers required for initiating clinical decision support interventions. Five of the nine systems could access all the patient-specific data items identified as necessary. Six of the nine systems supported all the intervention types identified as necessary to allow clinical information systems to tailor their interventions based on the severity of the clinical situation and the user's workflow. Only one system supported all the offered choices identified as key to allowing physicians to take action directly from within the alert. Discussion The principal finding relates to system-by-system variability. The best system in our analysis had only a single missing feature (from 42 total) while the worst had eighteen.This dramatic variability in CDS capability among commercially available systems was unexpected and is a cause for concern. CONCLUSIONS: These findings have implications for four distinct constituencies: purchasers of clinical information systems, developers of clinical decision support, vendors of clinical information systems and certification bodies.

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

BACKGROUND: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. METHODS: We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. RESULTS: Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). CONCLUSIONS: Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.