This paper focuses on the application of two image enhancement techniques for the picture archiving and communications systems imaging diagnostic workstation applied to computed radiography (CR) and digital radiography images. The first method is a contrast enhancement technique based on a class of nonlinear intensity transformations described by analytic transfer functions derived from Hurter and Driffield characteristic curves. The second method employs antialiasing techniques preventing the formation of Moiré patterns on subsampled CR images containing antiscatter grid lines, designed to achieve a good balance between artifact suppression and resolution degradation. These techniques are likely to become standard features for all high-end medical imaging workstations in the near future, and thus, we are suggesting that more powerful descriptions of these types of processing should be included in the Digital Imaging and Communications in Medicine standard.
Computed radiography imaging; contrast enhancement; antialiasing; picture archiving and communication systems
This study was undertaken to investigate a useful image blurring index. This work is based on our previously developed method, the Moran peak ratio. Medical images are often deteriorated by noise or blurring. Image processing techniques are used to eliminate these two factors. The denoising process may improve image visibility with a trade-off of edge blurring and may introduce undesirable effects in an image. These effects also exist in images reconstructed using the lossy image compression technique. Blurring and degradation in image quality increases with an increase in the lossy image compression ratio. Objective image quality metrics [e.g., normalized mean square error (NMSE)] currently do not provide spatial information about image blurring. In this article, the Moran peak ratio is proposed for quantitative measurement of blurring in medical images. We show that the quantity of image blurring is dependent upon the ratio between the processed peak of Moran's Z histogram and the original image. The peak ratio of Moran's Z histogram can be used to quantify the degree of image blurring. This method produces better results than the standard gray level distribution deviation. The proposed method can also be used to discern blurriness in an image using different image compression algorithms.
Moran peak ratio; image blurring; image quality
Film digitizers are used to transfer hardcopy x-ray transmission films into a PACS environment. Variability between digitizers is primarily due to a lack of an acquisition standard. By utilizing the Digital Imaging and Communications in Medicine (DICOM) Part 14 Grayscale Standard Display Function (GSDF) as basis from which to judge and modify digitizer output, a methodology using Just Noticeable Differences (JND) can be established that will create custom lookup tables for film digitizers. These modified images can then be judged against the original films using the GSDF to determine if the original films' contrast is preserved. Results based on JND indicated that relative contrast of the original image is preserved.
Digitizer; GSDF; JND; DICOM14
Recent advancements in computed tomography (CT) have enabled quantitative assessment of severity and progression of large airway damage in chronic pulmonary disease. The advent of fast multidetector computed tomography scanning has allowed the acquisition of rapid, low-dose 3D volumetric pulmonary scans that depict the bronchial tree in great detail. Volumetric CT allows quantitative indices of bronchial airway morphology to be calculated, including airway diameters, wall thicknesses, wall area, airway segment lengths, airway taper indices, and airway branching patterns. However, the complexity and size of the bronchial tree render manual measurement methods impractical and inaccurate. We have developed an integrated software package utilizing a new measurement algorithm termed mirror-image Gaussian fit that enables the user to perform automated bronchial segmentation, measurement, and database archiving of the bronchial morphology in high resolution and volumetric CT scans and also allows 3D localization, visualization, and registration.
Bronchial morphology; computed tomography; automation algorithm; automated measurement
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.
HIPAA; security; auditing; monitoring
This work describes our experience in reviewing the performance criteria for display systems and how we have implemented a practical approach to the assessment of the workstation environment in a large tertiary care hospital. The acceptance criteria contained in the draft report of Topic Group 18 of the American Association of Physicists in Medicine (AAPM) were used as a basis for assessment of primary and secondary displays. A telescopic photometer was used to measure the maximum luminance and the contrast ratio of the image for the displays used in our radiology department and in the operating and emergency rooms using the standard Society of Motion Picture and Television Engineers (SMPTE) pattern, in ambient light and with light decreased as much as possible. About half of the displays met the AAPM criteria for minimum luminance and contrast ratio in low light. None of the systems met the contrast ratio criteria in ambient light. The challenges in improving the performance and calibrating displays are discussed.
PACS; displays; digital imaging; contrast; luminance
The aim of this study is to determine if network-enabled personal digital assistants (PDAs) can be used to facilitate the timely delivery of urgent radiological exam results by reducing the interval from when the radiologist's initial interpretation is available to when it is first viewed by an emergency department (ED) physician. A web- and Java message service (JMS)-based application was built to replace the original fax-based wet-read procedure. The new system allows radiologists to enter wet-reads from the picture archiving and communication system (PACS) display station and to track discrepancies between the wet-read and final report. It also notifies the ED physicians when exam results are available via the PDAs and permits them to view the full text of the wet-read and final reports from the devices. The new system is compared to the original procedure with the results showing improvements with the wireless method. Furthermore, feedback from a qualitative survey of PDA users was positive, suggesting that PDAs may provide one means for accessing urgent clinical data at the point of care.
integrated systems; Java Message Service (JMS); urgent exams; Personal Digital Assistant (PDA); mobile computing; Radiology Information System (RIS); Picture Archiving and Communication System (PACS); results reporting; handheld devices
A few years ago, the Digital Imaging and Communications in Medicine standard introduced a network transaction that is initiated by modality equipment, mainly at the beginning and at the end of the acquisition. This transaction, the Modality Performed Procedure Step (MPPS), is sent to the Picture Archiving and Communication System and/or to the Radiology Information System. It carries information about what really has been performed by the modality equipment during acquisition. In this paper, we present MPPS and discuss its benefits. We show how MPPS enables efficient radiology workflow and how it ensures accuracy and completeness of imaging information. We think our paper helps bridge the gap between MPPS implementation and deployment. By understanding all the MPPS benefits, the end user becomes aware of the great enhancement in patient care that this transaction provides.
Digital Imaging and Communications in Medicine, DICOM; Modality Performed Procedure Step, MPPS; Workflow; Picture Archiving and Communication System, PACS; Radiology Information System, RIS; Integrating Healthcare Enterprise, IHE
We elected to explore new technologies emerging on the general consumer market that can improve and facilitate image and data communication in medical and clinical environment. These new technologies developed for communication and storage of data can improve the user convenience and facilitate the communication and transport of images and related data beyond the usual limits and restrictions of a traditional picture archiving and communication systems (PACS) network. We specifically tested and implemented three new technologies provided on Apple computer platforms. (1) We adopted the iPod, a MP3 portable player with a hard disk storage, to easily and quickly move large number of DICOM images. (2) We adopted iChat, a videoconference and instant-messaging software, to transmit DICOM images in real time to a distant computer for conferencing teleradiology. (3) Finally, we developed a direct secure interface to use the iDisk service, a file-sharing service based on the WebDAV technology, to send and share DICOM files between distant computers. These three technologies were integrated in a new open-source image navigation and display software called OsiriX allowing for manipulation and communication of multimodality and multidimensional DICOM image data sets. This software is freely available as an open-source project at http://homepage.mac.com/rossetantoine/OsiriX. Our experience showed that the implementation of these technologies allowed us to significantly enhance the existing PACS with valuable new features without any additional investment or the need for complex extensions of our infrastructure. The added features such as teleradiology, secure and convenient image and data communication, and the use of external data storage services open the gate to a much broader extension of our imaging infrastructure to the outside world.
PACS; teleradiology; iPod; webcam; ASP
The purpose of this research is to enable users to semiautomatically segment the anatomical structures in magnetic resonance images (MRIs), computerized tomographs (CTs), and other medical images on a personal computer. The segmented images are used for making 3D images, which are helpful to medical education and research. To achieve this purpose, the following trials were performed. The entire body of a volunteer was scanned to make 557 MRIs. On Adobe Photoshop, contours of 19 anatomical structures in the MRIs were semiautomatically drawn using MAGNETIC LASSO TOOL and manually corrected using either LASSO TOOL or DIRECT SELECTION TOOL to make 557 segmented images. In a similar manner, 13 anatomical structures in 8,590 anatomical images were segmented. Proper segmentation was verified by making 3D images from the segmented images. Semiautomatic segmentation using Adobe Photoshop is expected to be widely used for segmentation of anatomical structures in various medical images.
Semiautomatic segmentation; Adobe Photoshop; MRIs; CTs; anatomical images; segmented images; three-dimensional images
Acquiring, implementing, and maintaining a picture archiving and communication system (PACS) is an enduring and complex endeavor. A large-scale project such as this requires efficient and effective communication among a large number of stakeholders, sharing of complex documentation, recording ideas, experiences, and events such as meetings, and project milestones to succeed. Often, mass-market technologies designed for other purposes can be used to solve specific complex problems in healthcare. In this case, we wanted to explore the role of popular weblogging or “blogging” software to meet our needs. We reviewed a number of well-known blog software packages and evaluated them based on a set of criteria. We looked at simplicity of installation, configuration, and management. We also wanted an intuitive, Web-based interface for end-users, low cost of ownership, use of open source software, and a secure forum for all PACS team members. We chose and implemented the Invision Power Board for two purposes: local PACS administrative purposes and for a national PACS users' group discussion. We conclude that off the shelf, state-of-the-art, mass-market software such as that used for the currently very popular purpose of weblogging or “blogging” can be very useful in managing the variety of communications necessary for the successful implementation of PACS.
PACS; documentation; project planning; knowledge base; weblog
The need for specialized individuals to manage picture archiving and communications systems (PACS) has been recognized with the creation of a new professional title: PACS administrator. This position requires skill sets that bridge the current domains of radiology technologists (RTs), information systems analysts, and radiology administrators. Health care organizations, however, have reported difficfiulty in defining the functions that a PACS administrator should perform—a challenge compounded when the tries to combine this complex set of capabilities into one individual. As part of a larger effort to define the PACS professional, we developed an extensive but not exclusive consensus list of business, technical, and behavioral competencies desirable in the dedicated PACS professional. Through an on-line survey, radiologists, RTs, information technology specialists, corporate information officers, and radiology administrators rated the importance of these competencies. The results of this survey are presented, and the implications for implementation in training and certification efforts are discussed.
PACS administrator; PACS; radiology management; information systems management
Image quality assurance has traditionally been a high priority in medical imaging departments. Recently, it has often been neglected with the transition from hard copy (film) to soft copy (computer) display systems, which could potentially result in difficulty in reading images or even misdiagnosis. This transition therefore requires careful management such that comparable image quality is achieved at a minimum. It is particularly difficult to maintain appropriate image quality in the clinical settings outside of medical imaging departments because of the volume of display systems and the financial restraints that prohibit the widespread use of dedicated computers and high-quality monitors. In this study, a protocol to test and calibrate display systems was developed and validated by using an inexpensive calibration tool. Using this protocol, monitors were identified in a hospital in which image quality was found to be inadequate for medical image viewing. It was also found that most monitors could achieve a substantial increase in image quality after calibration. For example, the 0 and 5% luminance difference was discernable on 30% of the piloted display systems before calibration, but it was discernable on 100% post calibration. In addition, about 50% of the piloted display systems did not have the maximum luminance (white level) suitably set, and 35% of them did not have the minimum luminance (dark level) suitably set. The results indicate that medical display systems must be carefully selected and strictly monitored, maintained, and calibrated to ensure adequate image quality.
Image quality; display system; calibration; quality control; quality assurance; monitor; medical imaging; softcopy; cathode ray tube; liquid crystal display; DICOM 14; Grayscale Standard Display Function; SMPTE; luminance
Full-field digital mammography (FFDM) systems are currently being used to acquire mammograms in digital format, but digital displays are less than ideal compared to traditional film-screen display. Certain physical properties of softcopy displays [e.g., modulation transfer function (MTF)] are less than optimal compared to film. We developed methods to compensate for some of these softcopy display deficiencies, based on careful physical characterization of the displays and image-processing software. A series of 100 FFDM and 60 digitized images was shown to six observers—half experienced (mammographers) and half inexperienced (radiology residents). The observers had to decide if a mass or microcalcification cluster was present and classify it as benign or malignant. A window could be activated that brought the image detail within the window to full resolution and corrected for the nonisotropic MTF of the Cathode Ray Tube (CRT) display. Experienced readers had better diagnostic performance and took less time to view the images. Experienced readers used window/level more than inexperienced readers, but inexperienced readers used magnification and the MTF compensation tool more often. Use of the magnification and the MTF tool increased reader decision confidence. Experienced and inexperienced readers use image-processing tools differently, with certain tools increasing reader confidence. Understanding how observers use image-processing tools may help in the development of better and more automated user interfaces.
Observer performance; mammography; softcopy display; optimization
The modulation transfer function (MTF) of a medical imaging display is typically determined by measuring its response to square waves (bar patterns), white noise, and/or line stimuli. However, square waves and white noise methods involve capture and analysis of multiple images and are thus quite tedious. Measurement of the line-spread function (LSF) offers a good alternative. However, as previously reported, low-frequency response obtained from the LSF method is not as good as that obtained from measurement of edge-spread function (ESF). In this paper, we present two methods for evaluating the MTF of a medical imaging display from its ESF. High degree of accuracy in the higher frequency region (near the Nyquist frequency of the system) was achieved by reducing the noise. In the first method, whichis a variant of the Gans' original method, the periodic raster noise is reduced by subtracting a shifted ESF from the ESF. The second method employs a low-pass differentiator (LPD). A novel near maximally flat LPD with the desired cut-off frequency was designed for this purpose. Noise reduction in both the methods was alsoachieved by averaging over large portions of the image data to form the ESF. Experimental results show that the MTF obtained by these methods is comparable to that obtained from the square wave response. Furthermore, the MTFs of rising and falling edges of a cathode ray tube (CRT) were measured. The results show that the rising and falling vertical MTFs are practically the same, whereas the rising horizontal MTF is poorer than the falling horizontal MTF in the midfrequency region.
Cathode ray tube (CRT); liquid crystal display (LCD); modulation transfer function (MTF); edge-spread function (ESF); line-spread function (LSF); Gans' method; low-pass differentiator; image quality
Two image datasets (one thick section dataset and another volumetric dataset) were typically reconstructed from each single CT projection data. The volumetric dataset was stored in a mini-PACS with 271-Gb online and 680-Gb nearline storage and routed to radiologists’ workstations, whereas the thick section dataset was stored in the main PACS. Over a 5-month sample period, 278 Gb of CT data (8976 examinations) was stored in the main PACS, and 738 Gb of volumetric datasets (6193 examinations) was stored in the mini-PACS. The volumetric datasets formed 32.8% of total data for all modalities (2.20 Tb) in the main PACS and mini-PACS combined. At the end of this period, the volumetric datasets of 1892 and 5162 examinations were kept online and nearline, respectively. Mini-PACS offers an effective method of archiving every volumetric dataset and delivering it to radiologists.
Multidetector row computed tomography; volumetric dataset; mini-PACS
The National Lung Screening Trial is evaluating the effectiveness of low-dose spiral CT and conventional chest X-ray as screening tests for persons who are at high risk for developing lung cancer. This multicenter trial requires quality assurance (QA) for the image quality and technical parameters of the scans. The electronic system described here helps manage the QA process. The system includes a workstation at each screening center that de-identifies the data, a DICOM storage service at the QA Coordinating Center, and Web-based systems for presenting images and QA evaluation forms to the QA radiologists. Quality assurance data are collated and analyzed by an independent statistical organization. We describe the design and implementation of this electronic QA system, emphasizing issues relating to data security and privacy, the various obstacles encountered in the installation of a common system at different participating screening centers, and the functional success of the system deployed.
Clinical trial; quality assurance; VPN; NLST
Liquid crystal displays (LCD) are rapidly replacing cathode ray tube displays (CRT) for medical imaging. LCD technology has improved significantly in the last few years and has important advantages over CRT. However, there are still some aspects of LCD that raise questions as to the usefulness of liquid crystal displays for very subtle clinical diagnosis such as mammography. One drawback of modern LCD displays is the existence of spatial noise expressed as measurable stationary differences in the behavior of individual pixels. This type of noise can be described as a random stationary image superposed on top of the medical image being displayed. It is obvious that this noise image can make subtle structures invisible or add nonexistent patterns to the medical image. In the first case, subtle abnormalities in the medical image could remain undetected, whereas in the second case, it could result into a false positive. This paper describes a method to characterize the spatial noise present in high-resolution medical displays and a technique to solve the problem. A medical display with built-in compensation for the spatial noise at pixel level was developed and improved image quality is demonstrated.
LCD; medical; uniformity; noise; pixel; compensation; mammography
Online teaching files are an important source of educational and referential materials in the radiology community. The commonly used Digital Imaging and Communications in Medicine (DICOM) file format of the radiology community is not natively supported by common Web browsers. The ability of the Web server to convert and parse DICOM is important when the DICOM-converting tools are not available. In this paper, we describe our approach to develop a Web-based teaching file authoring tool. Our server is built using Apache Web server running on FreeBSD operating system. The dynamic page content is produced by Hypertext Preprocessor (PHP). Digital Imaging and Communications in Medicine images are converted by ImageMagick into Joint Photographic Experts Group (JPEG) format. Digital Imaging and Communications in Medicine attributes are parsed by dicom3tools and stored in PostgreSQL database. Using free software available from the Internet, we build a Web service that allows radiologists to create their own online teaching file cases with a common Web browser.
Teaching files; Web-based; Hypertext Preprocessor (PHP); Digital Imaging and Communications in Medicine (DICOM)
Within the coming decade, traditional dictation supported by human transcription for radiology reports will be replaced by one or more computerized methods. This paper discusses the cognitive and process efficiency problems arising from currently available technology including speech recognition and menu-driven interfaces. A specific concept for interaction with the reporting interface is proposed. This is called the „talking template” and departs from other designs by providing for all interactions to be mediated through audible prompts and microphone controls. The radiologist can recapture efficiency and cognitive focus by dictating while viewing images without the „look away” problem inherent in other interfaces.
Radiology reporting; user interface; process efficiency; cognitive function; talking template
Purpose: This study was conducted to assess the clinical impact of breast density and density of the lesion’s background on the performance of a computer-aided detection (CAD) system in the detection of breast masses (MA) and microcalcifications (MC). Materials and Methods: A total of 200 screening mammograms interpreted as BI-RADS 1 and suspicious mammograms of 150 patients having a histologically verified malignancy from 1992 to 2000 were selected by using a sampler of tumor cases. Excluding those cases having more than one lesion or a contralateral malignancy attributable to statistical reasons, 127 cases with 127 malignant findings were analyzed with a CAD system (Second Look 5.0, CADx Systems, Inc., Beavercreek, OH). Of the 127 malignant lesions, 56 presented as MC and 101 presented as MA, including 30 cases with both malignant signs. Overall breast density of the mammogram and density of the lesion’s background were determined by two observers in congruence (density a: entirely fatty, density b: scattered fibroglandular tissue, density c: heterogeneously dense, density d: extremely dense). Results: Within the unsuspicious group, 100/200 cases did not have any CAD MA marks and were therefore truly negative (specificity 50%), and 151/200 cases did not have any CAD MC marks (specificity 75.5%). For these 200 cases, the numbers of marks per image were 0.41 and 0.37 (density a), 0.38 and 0.97 (density b), 0.44 and 0.91 (density c), and 0.58 and 0.68 (density d) for MC and MA marks, respectively (Fisher’s t-test: n.s. for MC, p < 0.05 for MA). Malignant lesions were correctly detected in at least one view by the CAD system for 52/56 (92.8%) MC and 91/101 (90.1%) MA. Detection rate versus breast density was: 4/6 (66.7%) and 18/19 (94.7%) (density a), 32/33 (97.0%) and 49/51 (96.1%) (density b), 14/15 (93.3%) and 23/28 (82.1%) (density c), and 2/2 (100%) and 1/3 (33.3%) (density d) for MC and MA, respectively. Detection rate versus the lesion’s background was: 19/21 (90.5%) and 36/38 (94.7%) (density a), 34/36 (94.4%) and 59/62 (95.2%) (density b), 8/9 (88.9%) and 20/24 (83.3%) (density c), and 9/10 (90%) and 4/8 (50%) (density d) for groups 2 and 3, respectively. Detection rates differed significantly for masses in heterogeneously dense and extremely dense tissue (overall or lesion’s background) versus all other densities (Fisher’s t-test: p < 0.05). A significantly lowered FP rate for masses was found on mammograms of entirely fatty tissue. Conclusion: Overall breast density and density at a lesion’s background do not appear to have a significant effect on CAD sensitivity or specificity for MC. CAD sensitivity for MA may be lowered in cases with heterogeneously and extremely dense breasts, and CAD specificity for MA is highest in cases with extremely fatty breasts. The effects of overall breast density and density of a lesion’s background appear to be similar.
CAD; breast density; cancer detection
With the introduction of digital imaging in radiology, CD-Rs are increasingly used to distribute patient materials. This study investigates the application of a new software package and work protocol to integrate out-hospital data into the local PACS (picture archive and communication system) archive, which is hampered by differences in patient numbers. A one-month trial was started to import CD-Rs from two departments (radiotherapy and radiology). Seventy CD-Rs were collected from 20 different hospitals holding data of eight different modality types and published by eight different software packages from different vendors. All CD-Rs were successfully transferred into the PACS. The new software and work protocol provide an easy way of introducing the out-hospital data into the PACS. CD-Rs can be destroyed after transfer to PACS, eliminating physical storage. Furthermore, all data can now be viewed and reported using the default viewers of the hospital and no additional training of staff is required.
PACS; out-patient data; IHE
The PACS implementation process is complicated requiring a tremendous amount of time, resources, and planning. The Department of Defense (DOD) has significant experience in developing and refining PACS acceptance testing (AT) protocols that assure contract compliance, clinical safety, and functionality. The DOD’s AT experience under the initial Medical Diagnostic Imaging Support System contract led to the current Digital Imaging Network–Picture Archiving and Communications Systems (DIN-PACS) contract AT protocol. To identify the most common system and component deficiencies under the current DIN-PACS AT protocol, 14 tri-service sites were evaluated during 1998–2000. Sixteen system deficiency citations with 154 separate types of limitations were noted with problems involving the workstation, interfaces, and the Radiology Information System comprising more than 50% of the citations. Larger PACS deployments were associated with a higher number of deficiencies. The most commonly cited systems deficiencies were among the most expensive components of the PACS.
PACS; acceptance testing; workstation; clinical use determination; monitors; HIS; RIS; DIN-PACS; MDIS
In this paper, we propose a method for automatic determination of position and orientation of spine in digitized spine X-rays using mathematical morphology. As the X-ray images are usually highly smeared, vertebrae segmentation is a complex process. The image is first coarsely segmented to obtain the location and orientation information of the spine. The state-of-the-art technique is based on the deformation model of a template, and as the vertebrae shape usually shows variation from case to case, accurate representation using a template is a difficult process. The proposed method makes use of the vertebrae morphometry and gray-scale profile of the spine. The top-hat transformation-based method is proposed to enhance the ridge points in the posterior boundary of the spine. For cases containing external objects such as ornaments, H-Maxima transform is used for segmentation and removal of these objects. The Radon transform is then used to estimate the location and orientation of the line joining the ridge point clusters appearing on the boundary of the vertebra body. The method was validated for 100 cervical spine X-ray images, and in all cases, the error in orientation was within the accepted tolerable limit of 15°. The average error was found to be 4.6°. A point on the posterior boundary was located with an accuracy of ±5.2 mm. The accurate information about location and orientation of thespine is necessary for fine-grained segmentation of the vertebrae using techniques such as active shape modeling. Accurate vertebrae segmentation is needed in successful feature extraction for applications such as content-based image retrieval of biomedical images.
Vertebrae segmentation; spine X-ray; content-based image retrieval; mathematical morphology