Administration of a CT Division1

¹ From the Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. Received February 7, 2001; revision requested March 12; revision received April 10; accepted May 2. Address correspondence to the author (e-mail: william_mayo-smith@brown.edu).

	ABSTRACT

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A computed tomography (CT) division can be viewed as a business subsidiary of a larger corporation—the radiology department. While a large amount of radiologic literature has been devoted to specific CT techniques and applications, there has been less of a focus on the operational structure required to achieve quality and efficiency in a CT division. This report includes discussion of the managerial structure, equipment purchases, continuing education, protocols, billing, and quality assurance measures that can be used to administer a CT division.

　

Index terms: Computed tomography (CT) • Computed tomography (CT), quality assurance • Economics, medical • Radiology and radiologists, departmental management • Radiology and radiologists, How I Do It

	INTRODUCTION

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Computed tomography (CT) is becoming the "conventional radiography" of the new millennium. Since the introduction of CT in the mid-1970s, there have been important advances in technology and research that have led to numerous new indications for the examination. While a large amount of radiologic literature has been devoted to specific CT techniques and applications, there has been less of a focus on the operational structure required to achieve quality and efficiency in a CT division (1–5). CT is the procedure of choice for evaluation in oncology and trauma patients (6–10) and has become the primary modality for imaging thoracic and abdominal diseases (11–18). The increased volume and complexity of cases has caused a corresponding increase in the degree of logistic support necessary to provide this service. The capital and operating expenses associated with a CT division are substantial (19). In addition, people with various skills, including physicians, technologists, and support personnel, are required for integrated patient care.

The purpose of this communication is to describe one method of operating a CT division, and the report includes topics on managerial structure, equipment purchases, continuing education, protocols, billing, and quality assurance (QA) measures. These components are applied to our academic department, where we perform over 45,000 CT examinations per year using four helical scanners. We have one CT scanner in the emergency department (operating 24 hours per day), one in an outpatient physician office building adjacent to the hospital (operating Monday through Friday, 7:30 AM to 6:00 PM), and two in our central department (operating Monday through Friday, 7:30 AM to 11:00 PM, and Saturday and Sunday, 7:30 AM to 5:00 PM). Our department is a hybrid of "organ system" and "modality" models. All attending radiologists are board certified and have subspecialty fellowship training. Attending physicians assigned to the CT division will read all CT studies and perform all CT-guided procedures that day. For a very complicated examination, a subspecialist working elsewhere in the department may be consulted. Eight radiologists rotate through the CT division described in this manuscript. Other CT rotations include emergency and pediatric radiology.

	MANAGERIAL STRUCTURE

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The function of a CT division with over $5 million in capital equipment, an annual operating budget of $1.7 million, and 30 employees (technologists, secretaries, and transporters; not including physicians) requires a coordinated managerial structure to ensure efficient delivery of patient care. To ignore a managerial structure or to "let the division run itself" is a recipe for disaster. Our division structure includes (a) a physician division head, (b) a chief technologist, and (c) a lead technologist. A diagram of our divisional managerial structure is outlined in Figure 1. The physician division head oversees operation of the CT division, interacts on a daily basis with the chief and lead technologists, and reports directly to the department chairman. This physician is responsible for the overall function of the division, including equipment purchasing, personnel, education, QA, protocol development, and research.

fig.ommitted Figure 1. Diagram shows the management structure of a CT division.

 
The chief CT technologist implements principles defined by the physician division head. This person’s responsibilities include hiring and evaluating technologists, establishing the technologists’ schedule, purchasing supplies for the division, and verifying the accuracy of examination codes prior to billing. The chief technologist also prepares an annual budget in conjunction with the departmental administrator. In addition, this person gathers QA information to report to the physician director and departmental QA committee.

The lead technologist is a working technologist who is the "point" person for day-to-day operations. He or she knows the overall schedule, can add patients to the schedule, and can move technologists to the appropriate location depending on workflow. He or she supervises all technologists and secretaries and interacts directly with the physicians in the CT division.

	EQUIPMENT

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CT scanners are like expensive personal computers: What you have today will be outdated tomorrow. Like computers, the equipment must be maintained and upgraded. The physician division head should stay abreast of technical innovation, as well as new indications for CT imaging, so that the need for an upgrade can be anticipated before it becomes urgent. This is a fact of running a CT division that should be recognized as part of the job. Keeping equipment current is important for several reasons:

1. The newer equipment may allow improved patient care. Multidetector CT has allowed increased patient coverage in less time with higher resolution images. Helical CT has enabled us to use less intravenous contrast agent when performing a CT examination (20,21).

2. The newer helical equipment allows faster throughput. Decreased scanning time allows more patients to be imaged during the day. This vastly affects the aggregate CT operation, however, because the rest of the processes must be adjusted to the increased ability to acquire images. Thus, faster scanning will result in more examinations per day. However, this will mean more images to print and store; more patients to greet, prepare, and discharge; more patients to schedule; more examination reports to transcribe; and more examinations to bill. Daily CT operations are like a chain, where the weakest link will be the rate-limiting step.

3. Newer equipment allows for the development of research opportunities and additional techniques, such as CT angiography (22–27). In the interventional arena, development of CT fluoroscopy has allowed procedures to be performed more rapidly and accurately (28–31).

4. Newer equipment, while more complicated, improves the morale of all people working in the division. Technologists, residents, fellows, and attending physicians like to work in an area that is state of the art.

5. Advanced CT imaging is an essential resource for all clinical colleagues as they look for assistance in the diagnosis and treatment of disease.

6. The image of an entire department, as well as that of the CT division, is enhanced by the presence of state-of-the-art equipment.

State-of-the-art equipment is important within a CT division; however, what is important is not always easy to obtain. It is the role of the division director to lobby the department chairman, hospital president, capital equipment committee, and chief executive officer of the health care network with regard to the importance of current CT equipment. The return on investment for a CT scanner is high, and the efficient use of CT scanners can add to hospital revenue, decrease the length of hospital stay, and result in shorter emergency room visits (32–34). Capital equipment purchases are made after discussion with vendor sales personnel, site visits, and, most important, contact with colleagues from other institutions. Attendance at the technical exhibits at the Radiological Society of North America scientific assembly, with scheduled appointments, is an efficient way to see all the equipment in one location at one time. Once the list of vendors has been reduced to several candidates, a request for purchase, or RFP, for the chosen vendors will allow the director to make educated choices about which vendor to choose. The service contract is an important part of the purchase and should be scrutinized closely.

	SCHEDULING, PROTOCOL DEVELOPMENT AND SELECTION, PERFORMANCE, AND DICTATION OF EXAMINATIONS

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With the proliferation of CT scanners in the community, referring physicians have many choices as to where to have CT performed. Referring physicians will send patients where the examination can be easily scheduled and rapidly performed, and its results efficiently reported. Difficulty in scheduling will lead to lack of referrals.

The CT division secretary, who has a good working knowledge of examinations and examination preparations, performs scheduling in our division. The radiologists and technologists are an immediate resource for questions about complicated cases. For add-on examinations, secretaries work with the lead technologist to place patients in an appropriate time slot (usually the evening for inpatients and the day for outpatients). In addition, secretaries perform other functions such as greeting patients, answering telephone questions, entering patient information into the radiology information system (RIS), retrieving prior studies, faxing reports, and so forth. We have found local scheduling for inpatients and outpatients more useful than a departmental centralized scheduling model, since centralized schedulers are remote from the CT division and have no awareness of patient flow. Patients scheduled for multiple imaging examinations are forwarded to the appropriate area after CT is scheduled; thus, the referring office must make only one phone call to schedule multiple examinations. The future of scheduling clearly involves use of the Internet. With correct passwords and booking codes, referring physicians will be able to book into an open schedule online. We are not currently performing this but hope to in the future.

Choosing the correct CT examination protocol has become more complicated as the technology has advanced. Whereas there was one way to perform chest CT in the past, there are now multiple techniques that differ depending on whether one is looking for a nodule, pulmonary embolus, endobronchial tumor, or aortic dissection. CT protocols have evolved with the introduction of new CT technology (35–39). At our institution, we currently use 63 CT protocols, depending on the anatomy imaged and the indications for the examination. These protocols, which were developed by the physician director in concert with the chief technologist and other radiologists, are grouped by body part and constantly evolve with equipment and research advances. Protocols are important to maintain consistency in examination performance, no matter which radiologist is working. The protocol manual is available to residents in the interpretation area and technologists in the control room and can also be accessed at our Web site at www.brownct.org.

An accurate patient history is critical to perform the correct CT examination, but a reliable history is often difficult to obtain. We have adopted several strategies to obtain an accurate history in our practice.

1. CT division secretaries request as accurate a history as possible at the time of booking.

2. The RIS automatically prints a page of conclusions for the last 10 radiologic studies, and this page accompanies each CT requisition. Thus, the person selecting the protocol for the examination immediately knows what prior examinations have been performed and the results of those examinations.

3. Using an accurate history, we attempt to select the protocols for all examinations 24 hours in advance to ensure that the correct examination has been ordered. The RIS-generated requisition includes the referring physician’s name, pager number, and direct office number to facilitate phone contact.

4. We have access to the hospital information system (HIS) in the CT suite, so patient information including discharge summaries, surgery notes, and pathology results can be readily accessed at the time the examination protocol is determined.

5. When in doubt, do the obvious thing. We have found that the patients are quite knowledgeable about their own disease process, symptoms, and treatments. To this end, we have developed a questionnaire that is filled out by patients in the waiting room (Fig 2). Specific questions include location and duration of symptoms, history of cancer or surgery, and locations and dates of prior imaging examinations. We have found the questionnaire to be helpful in obtaining accurate data, particularly since patients usually know more aggregate history than does the single referring specialist who scheduled the examination. An example of our patient questionnaire can be downloaded from our Web site (www.brownct.org).

fig.ommitted Figure 2. CT patient questionnaire, with questions on location of symptoms, prior treatments, and dates and locations of prior imaging examinations.

 
After the examination protocol is correctly determined, a technologist performs the study. To maintain adequate throughput, a radiologist does not review results of routine examinations before the patient leaves the CT table. For patients with a complicated history (eg, potential abscess to be drained), the study will be checked while the patient is still on the table, to determine if additional imaging or intervention is required. At our institution the technologist, using a standard contrast agent consent form, obtains patient consent for intravenous administration of a contrast agent. Technologists screen serum creatinine levels in inpatients and use of metformin (glucophage) in all patients. For contrast agent–enhanced studies, our technologists establish intravenous access, preferably outside the CT suite to maintain throughput. Technologists enter the type, volume, and rate of contrast agent administration on the computer requisition, as well as the proper International Classification of Diseases, Ninth Revision (ICD-9) code. For examinations performed with an intravenous contrast agent, we routinely use a power injector for neck, chest, and abdominal applications. Oral contrast agents are available at all of our CT sites and are also sent to referring clinics and physician offices. We do not routinely use a rectal contrast agent but will administer it if required for accurate study interpretation. The technologist will also note if there are any complications during the study, such as vomiting, patient motion, and others. This allows accurate transmission of information when scans are obtained in the late evening but reports are dictated the next morning.

A key concept is the accurate linking of all information about the patient and CT study to one location. The RIS-generated CT requisition is this link. On this printed requisition are (a) patient demographics and location; (b) the referring physician’s name, pager number, and direct phone number; (c) the conclusions of the previous 10 radiology reports; (d) the handwritten CT protocol to be followed and the name of the radiologist prescribing the protocol; and (e) the handwritten contrast agent and examination information, including ICD-9 codes and the technologist’s name for QA purposes.

Our division is currently film based, with plans to move to a picture archiving and communication system, or PACS, within the year. A PACS should improve efficiency by electronically linking the HIS and RIS and allowing us to move, retrieve, and store images electronically. A PACS should also decrease the need for radiology file-room personnel.

Residents, fellows, and attending physicians perform dictations and are encouraged to be brief and cogent. The first portion of our dictations includes a brief relevant history learned from the referring physician, HIS, and the patient questionnaire. An accurate history has also been shown to affect interpretation (40,41), and by using this method we have found that we often know more information about the patient than we have been given by the referring doctor.

When multiple examinations are performed in one patient, our dictated CT report has a separate paragraph for each examination. This reduces confusion among our referring physicians and insurers as they audit our reports. Thus, for a patient who undergoes chest, abdominal, and pelvic CT, a single report will be dictated, with separate paragraphs for each examination. The conclusion will state the most important findings from all the examinations (42). To facilitate coding, we dictate the appropriate ICD-9 code as the last sentence of the impression if a low-osmolar contrast agent was administered. It is departmental policy to call referring physicians with important results, as has been described by others (43). As a service to our referring doctors, the dictating radiologist’s pager number is listed at the end of the report. Our department uses a standard dictation system that relays the dictation through a phone line to a central transcription site. Reports are signed on our computer system by the radiologist and then faxed to the physician’s office. These reports are also available on the HIS. We do not currently use voice recognition technology, because these systems can be expensive and actually increase physician time to complete a dictation. Improvements in this technology will undoubtedly increase speed, decrease cost, and lead to more widespread use of voice recognition systems in the near future.

	EDUCATION AND RESEARCH

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Education is important in any radiology department, particularly in CT, where rapid advances in technology have affected the way we image patients. Technologist education is critical for high-quality examinations, particularly in teaching institutions where the technologist may know more about examination performance than does the radiology resident. To promote education, attending physicians give a monthly 1-hour lecture series on current CT topics to our technologists and secretaries. The CT schedule is blocked for 90 minutes during this lecture, attendance is required, and technologists receive continuing medical education credits. Resident and fellow education occurs in the interpretation area and through formal lectures at a noon conference. In addition, we have a resident’s CT manual, which includes (a) the division description, (b) CT protocols, (c) indications for contrast agent administration, (d) indications for use of low-osmolar contrast agents, (e) dictation information, (f) interventional procedure information, (g) educational objectives for residents, (h) specific criteria used to evaluate residents on the CT rotation, and (i) a bibliography of current CT references. A copy of our resident’s CT manual can be seen at our Web site (www .brownct.org). For literature searches, there are computer terminals with Internet access in all reading areas. Residents are evaluated at the end of each 1-month rotation by the CT division attending physicians, and these evaluations are forwarded to the residency director.

Research is a critical part of maintaining and advancing any CT division. Our department and division promote research in the following ways: (a) acquisition of state-of-the-art equipment so new technology can be evaluated; (b) development of vendor–academic center collaborative research agreements, where the vendors provide equipment upgrades and funding so that academic radiologists can perform research using the new technology; (c) provision of "academic time" for faculty demonstrating an interest in and aptitude for research; (d) allowance of time and funding for faculty and resident scientific presentations at national meetings; (e) promotion of collaborative ventures with other academic departments in the university; and (f) a mandatory research requirement for all residents in the program.

	CT INTERVENTIONAL PROCEDURES

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CT-guided interventional procedures, including biopsy, abscess drainage, and radio-frequency ablation, are all performed by the cross-sectional radiologists. The CT division performs more than 550 interventional procedures per year. The use of cross-sectional radiologists as both diagnostic readers and interventional physicians provides continuity, because one physician is responsible for running the division (reading all the studies and performing all the procedures) for the day. Image-guided procedures are performed in both the CT and ultrasonography (US) divisions, and many attending radiologists rotate through both divisions. The majority of liver procedures are performed with US, which is faster and easier to perform. The vascular and interventional radiologists at our institution perform vascular procedures, biliary drainages, and percutaneous nephrostomies.

We use several strategies to make referring physicians aware of our interventional service. If we detect an abnormality on a diagnostic study, the impression includes whether the lesion is amenable to biopsy, drainage, or radio-frequency ablation. This strategy serves two functions: First, it makes referring physicians aware of our services; and second, when a referring physician calls to schedule a biopsy, we can tell from the report whether the intervention is technically feasible even though the images might not be available. Our attending staff also participates in many hospital interdisciplinary conferences, where we often recruit appropriate cases. These conferences are also an important part of patient care, and they elevate the radiologist’s role from simple image reviewer to participant in patient treatment. This changes the perception of the radiologist from that of a person who "sits in a dark room" to that of a physician who is actively involved in patient care.

We require direct communication with a physician when booking any CT-guided intervention. In general, we request that the referring physician bring the images to the CT suite, where we determine whether it is appropriate to perform the intervention. With the referring physician present, we fill out a CT intervention booking form, which includes the following information: (a) patient demographics, (b) the referring physician’s name and his or her direct phone number, (c) a brief accurate patient history, (d) whether the patient needs an translator, (e) whether hematologic screening laboratory tests are needed if the patient is receiving anticoagulation medication, and (f) the name of the radiologist completing the form. A copy of our procedure booking sheet is shown in Figure 3 and can be downloaded from our Web site (www.brownct.org). The booking sheet and images are given to the CT secretary who schedules the examination and keeps the images in the "biopsy slot." The booking sheet is placed in a "tickler" file for the appropriate date. The booking sheet provides continuity when the patient arrives for the procedure and a different attending physician is present.

fig.ommitted Figure 3. CT procedure booking sheet. This data sheet includes patient demographics, referring physician information, and indications for the procedure, as well as consent and laboratory data.

 
For the patient undergoing a procedure, we have an information sheet that explains interventions in lay terms. This has been shown to decrease patient anxiety about unfamiliar examinations (44). Patients may obtain a copy of this information from our referring doctors, from our divisional secretaries, or from our Web site (www.brownct.org).

Our division has a number of guidelines for CT-guided interventions, which are outlined in the resident’s manual. The procedure manual outlines indications for procedures, indications for blood tests, indications for antibiotics before abscess drainage, and policies for follow-up of patients. It also includes a section on management of postprocedural complications. Details of our procedure manual can be seen in our resident’s manual by visiting our Web site (www .brownct.org).

Every morning at 8:00 AM, the images and data sheets for the day’s procedures are reviewed by the attending physician, fellow, resident, and lead technologist. At this time, the different techniques, approaches, and patient positions are planned. The majority of interventional procedures are performed with the use of local anesthetics. For abscess drainage and radio-frequency ablation, conscious sedation is used and overseen by radiologic nurses. One of our four scanners is equipped for CT fluoroscopy, and we use this scanner to perform all our interventional procedures. After the intervention is performed, technical data from the procedure, including biopsy site, needle type, radiologist, complications, and other items, are entered into our custom computer database. This database is useful for help in determining the diagnostic yield of our interventions, for research projects, and for QA purposes.

After the procedure, the patients are monitored in the radiology recovery room, which is also used by the US and vascular and interventional divisions. Inpatients are sent to the floor with preprinted postprocedure order sheets. Outpatients receive postprocedure discharge sheets before discharge to home that include instructions and contact phone numbers. Possession of this information in writing is a comfort to patients and their families. Copies of our patient information and discharge sheet can be downloaded from our Web site (www .brownct.org).

The majority of patients undergoing a CT-guided intervention do not require admission to the hospital. Should the patient experience a complication, our CT attending physicians have admitting privileges at our institution. We follow up admitted patients, request medical or surgical consultations as needed, and discharge patients when appropriate. In general, it is the philosophy of our division that if we create a complication, we treat that complication. In addition, we follow up inpatients who have drainage catheters placed by our service while they are in the hospital. We have a CT intervention board in the interpretation room; on this board are the patient’s name, the date of the procedure, the radiologist’s name, the referring doctor’s name, the amount of drainage, and the plan. Residents and fellows visit the inpatients daily during rounds, leave notes on the patients’ charts, and discuss catheter management at the board with the attending radiologist. Follow-up of patients in the hospital by radiologists has been shown to improve patient care (45). Referring physicians appreciate our close clinical follow-up, and we have found that surgery house officers now come to us for management of catheters rather than to their surgical attending physicians. Clinical management of catheters is also a valuable educational process for radiology residents and fellows.

	BILLING

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The technical component of CT billing is handled by our hospital-based departmental billing staff. Professional fee billing is performed separately by our physician professional services organization working in concert with our hospital billing coordinator. Technical component billing is performed through the HIS, and the following outline traces our process:

1. Outpatient demographics and insurance information are entered into the HIS. After the examination is performed, the technologist enters all CT examination results into the computer system. An appropriate diagnostic code is then entered by radiology billing personnel. Inpatient billing is performed after discharge.

2. Invasive procedures require a diagnostic code, a procedural CPT (Current Procedural Terminology) code, and a procedural ICD-9 code. When the appropriate codes are entered, the charge will be made electronically to the insurance company.

3. Charges are reconciled between the procedures entered at the front end of the computer system and those billed for on a daily basis for each division in our department. Errors in billing are placed in a separate file that is reviewed daily by the billing office.

4. Insurance denials are appealed by the coding and billing coordinator and are submitted back to the payer electronically twice a month. The appropriateness of billing codes is reviewed by the hospital billing coordinator, chief technologist, and physician director.

Billing and budget parameters are reviewed with the physician director, chief technologist, and departmental administrator. Budget items evaluated include examination volumes, revenue, and expenses (including labor, supplies, service contracts, and equipment purchase and depreciation).

	QA PROCEDURES

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As with any organization operating 7 days a week 24 hours a day, there are a number of problems that can arise. QA is a method to monitor progress in organization and address areas that need improvement (46–48). In addition, QA standards are useful measurement parameters to quantify the success or failure of an operation. We have a number of areas that we monitor for QA purposes, including aggregate examination volume, undictated cases, booking delays, intravenous infiltrations, and education. Details of these measures are outlined as follows:

1. Examination volume statistics are monitored on a monthly basis according to location and shift. Decisions on staffing are made as a function of these data. We currently staff our scanners with one or two technologists, depending on the volume and the shift. Our division currently performs 45,000 examinations per year with 20.78 technologist full-time equivalents, for a ratio of 2,165 examinations per technologist full-time equivalent.

2. We monitor delays to schedule outpatients, inpatients, and emergency room patients. When delays have become too long (more than 14 days for outpatients), we have expanded weekend and evening hours of operation. The delay from time of booking to time of examination for outpatient elective examinations ranges from 3 to 6 days, although emergent examinations can be scheduled on a same-day basis. Inpatient examinations are all performed in less than 24 hours, and our average delay for an examination in our emergency room is 2 hours.

3. Delays in moving inpatients to our CT scanners are monitored by our lead technologist. Transporters dedicated to the CT division have been more useful than general hospital transport staff because they are part of the CT "team" and realize the large effect they have on our aggregate operation. Unfortunately, hospital administrators do not recognize that cutbacks in transport personnel can drastically affect CT operations and patient care.

4. Reports on turnaround times are monitored at divisional and departmental levels. In the CT division, our average time from the end of the procedure to the time of dictation is 12.9 hours, that from dictation to transcription is 9.1 hours, and that from transcription to signing of the report is 23.0 hours, for a total of 45 hours.

5. Delays in the transcription of examination results are monitored on a weekly basis. Undictated results can be caused by removal of images by a referring physician, improper printing of results, or improper coding of examinations by a technologist or transcriptionist. A certain number of losses are inevitable, but we have initiated several QA measures to minimize this. Our computer system generates a list of undictated examination reports that are more than 8 but less than 40 days old. This computer search occurs at 3:00 AM every Monday and is printed in the CT division. Secretaries in the division then determine if the undictated case represents a problem with incorrect merging of CT codes, such as a combined report for an examination of the abdomen and three-dimensional reconstruction, or a case that was truly not dictated. Incorrect merging of codes accounts for about 50% of our original undictated cases. Truly undictated cases are then retrieved and interpreted. Our current volume of cases with delayed interpretation is 0.9% (405 of 45,000 studies). Weekly retrieval is more efficient and palatable than retrieval of hundreds of studies at the end of the year.

6. Intravenous infiltrations are monitored in aggregate on a monthly basis and also as according to technologist. Thus, we can easily detect if there is a problem with a particular technologist, in which case follow-up training can be performed. The intravenous infiltration rate of approximately 0.04% (20 of 45,000) per year compares favorably with rates reported in the literature (49).

7. Residents and fellows evaluate the teaching performance of the CT faculty semiannually. They evaluate the attending physician’s teaching skills, availability, efficiency at readout, and mentoring for career and research. The faculty evaluate residents at the conclusion of the residents’ monthly rotation. These evaluations are sent to the department residency director.

8. Aggregate volume statistics are shared with all the staff in our division so that they can take pride in how we are doing. In addition, volume and revenue statistics are shared with hospital administrators to justify the high capital outlay for CT equipment.

	CONCLUSION

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A CT division is a small business operating within the larger radiology department and hospital. The management structure of the division can be organized in a logical fashion to create a team atmosphere and promote efficiency. This can result in improved patient care, excellent educational and research opportunities, high morale for employees, and increased revenue production for the department.

　

	ACKNOWLEDGMENTS

 
No managerial system is created by an individual. The author acknowledges Coralee Enos, RTRCT; all Rhode Island Hospital CT technologists; Drs Brody, Cronan, Ridlen, Dupuy, Murphy, and Mainiero at Brown University; and Drs Hahn, Saini, and Mueller at Massachusetts General Hospital (Boston), who have provided many ideas that formed the foundation of this report.

　

	REFERENCES

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