Intro to Digital Radiography and PACS

This chapter provides an overview of digital radiography (DR), including both cassette-based and
cassette-less systems, and Picture Archival and Communication Systems (PACS). We'll cover basic
definitions, compare digital and analog imaging, and trace the historical development of both DR and
PACS.

Conventional Radiography

Before diving into digital imaging, let's recap conventional film/screen imaging.

Conventional radiography uses film and intensifying screens. Film is placed against intensifying
screens that emit light when struck by x-rays, exposing the film. The film is then chemically processed
to reveal the image.

Digital Imaging

Digital imaging is any acquisition process that produces an electronic image viewable and
manipulable on a computer.

It was first used in medicine with the introduction of the computed tomography (CT) scanner by
Godfrey Hounsfield in the 1970s.

Historical Development

• CT Scanners: Early units took hours to acquire a single slice and days to reconstruct the
image.

• MRI: Introduced commercially in the early 1980s.

• Fluoroscopy: Improved due to analog-to-digital converters, enabling real-time imaging and

digital storage.

• Ultrasound and Nuclear Medicine: Easily converted to digital early on via frame-grabbing.

Digital Radiography

Albert Jutras in Canada conceptualized moving images digitally via teleradiology in the 1950s. The
U.S. military further developed early PACS to move images between VA hospitals and from
battlefields. Early analog radiographs were scanned into computers for digital transmission.

Computed Radiography (CR)

Computed radiography (CR), or cassette-based DR, uses storage phosphor plates to produce
projection images.

• Requires CR cassettes, phosphor plates, CR readers, and a quality control workstation.

• Storage phosphor plates store x-ray energy for later readout.

• First commercially introduced in the U.S. in 1983 by Fuji Medical Systems.

Digital Radiography (DR)

Digital radiography (cassette-less) systems use an x-ray absorber material coupled to a flat panel
detector or a charged coupled device (CCD) to form the image.
DR is divided into:

• Indirect Capture: X-rays are converted into light, which is then detected by a CCD or thin-film
transistor (TFT) array and converted into an electrical signal.

• Direct Capture: X-rays are directly converted into an electrical signal, typically using a
photoconductor.

Digital subtraction angiography (DSA) was one of the first clinical applications for digital images.

Comparison of CR and DR with Conventional Radiography

Factor Conventional Radiography Computed Radiography (CR) Digital Radiograp

Equipment Traditional x-ray room Traditional x-ray room Retrofitted x-ray

Latent Image Formation Film + intensifying screen Storage phosphor plate Direct/Indirect ca

Processing Chemical CR reader Computer at con

Exposure Latitude Nonlinear Linear Linear

Contrast Control kVp Look-up table Look-up table

Density Control mAs Image processing algorithms Image processing

Scatter Radiation Important for dose reduction Important for dose reduction Important for do

Noise Seen with low mAs Seen with inadequate mAs Seen with inadeq

• Latent Image Formation:

• In conventional radiography, x-rays strike the intensifying screen, producing light.

Light and x-ray photons interact with silver halide grains, ejecting electrons that are
attracted to sensitivity specks.

• In CR, a photostimulable phosphor plate stores energy. A laser scans the plate,
releasing the stored energy as light, which is then converted into an electrical signal.

• DR uses either indirect capture (scintillator converts x-rays to light, then to an

electrical signal) or direct capture (photoconductor directly converts x-rays to an
electrical signal).

• Image Processing:

• Conventional radiography uses chemicals.

• CR and DR use computer processing.

 • Exposure Latitude:

• Conventional radiography has a nonlinear response.

• CR and DR have a linear response with a wide exposure latitude.

• Contrast and Density Control:

• Conventional radiography primarily controls contrast with kVp and density with mAs.

• CR and DR control contrast with look-up tables (LUTs) and density with image
processing algorithms.

Picture Archival and Communication Systems

A picture archival and communication system is a networked group of computers, servers, and
archives used to manage digital images.

A PACS accepts images in DICOM (Digital Imaging and Communications in Medicine) format from
various departments. It serves as a fileroom, reading room, duplicator, and courier.

PACS Uses

• Reading stations

• Physician review stations

• Web access

• Technologist quality control stations

• Administrative stations

• Archive systems

• Interfaces with hospital and radiology systems

Basic Computer Principles

How Does the Computer Work?

In its basic form, a computer consists of input, output, and processing devices.

• Input devices: keyboards, mice, microphones, barcode readers, touch screens, and image
scanners

• Output devices: monitors, printers, and speakers

• Processing: done in the central processing unit (CPU)

The computer takes data from the user and processes it using a machine language of 1s and 0s,
known as binary code.

Binary Code: The machine language of 1s and 0s that computers use to process data.

The computer processing is performed by a series of transistors, which are switches that are either
on or off.

• If the transistor circuit is closed and current passes through, it is assigned a value of 1.
 • If no current passes because of the circuit being open, it is assigned a value of 0.

Each 1 and 0 represents a bit.

Bit: A single unit of data.

A byte is made up of eight bits and is the amount of memory needed to store one alphanumeric
character.

Byte: Eight bits; the amount of memory needed to store one alphanumeric character.

Because one character takes up a byte of memory, memory is generally talked about in kilobytes,
megabytes, gigabytes, and even terabytes.

Hardware Components

"The Box"

The computer encasement is made from a heavy metal and has two major functions:

1. To hold all of the components in a relatively cool, clean, and safe environment

2. To shield the outside environment from the radio frequencies being emitted by the
electronic components of the computer

The box comes in two major configurations:

• Desktop model: Generally positioned in a horizontal box. The biggest disadvantage of the
desktop model is the space it takes up on the desk; the smaller the box, the less room for
expansion and upgrades.

• Tower model: In a vertical box. The tower model consistently provides adequate room for
expansion of components, and it is easily placed out of the way and off the work surface.

The Motherboard

The motherboard is the largest circuitry board inside the computer, and it contains many important
small components to make the computer function properly. Key components include:

• CPU

• Basic Input/Output System (BIOS)

• Memory

• Bus

• Ports

• Complementary Metal Oxide Semiconductor (CMOS)

The CPU

The central processing unit (CPU), or microprocessor, is a small chip found on the motherboard. The
microprocessor is the brain of the computer. It consists of a series of transistors that are arranged to
manipulate data received from the software.

The CPU’s basic tasks are to:

 1. Read data from storage

2. Manipulate the data

3. Move the data back to storage or send it to external devices, such as monitors or printers

The BIOS

The basic input/output system (BIOS) contains a simple set of instructions for the computer.

The microprocessor uses the BIOS during the boot-up process of the computer to help bring the
computer to life. The BIOS also runs the start-up diagnostics on the system to make sure all of the
peripherals are functioning properly. After the computer has booted up, the BIOS oversees the basic
functions of receiving and interpreting signals from the keyboard and interchanging information with
various ports. The BIOS is the intermediary between the operating system (OS) and the hardware.

The Bus

The bus is a series of connections, controllers, and chips that creates the information highway of the
computer.

There are several buses throughout the computer that connect the microprocessor, the system
memory, and various peripherals. Most modern PCs have what is called a peripheral component
interconnect (PCI) bus on the motherboard to serve as the connection of information to the various
adapters. Other buses found within the computer are for the small computer system interface (SCSI)
connections, the accelerated graphics port (AGP) for video adapters, and the universal serial bus
(USB) for a variety of devices.

Memory

The memory in the computer is used to store information currently being processed within the CPU.
This memory is also known as random access memory (RAM).

The RAM is short-term storage for open programs. The microprocessor has a small amount of
memory within itself but not enough to tackle the large amounts of data being generated by high-
level programs. The RAM will take the data from the CPU so that the CPU can handle the processing
needs of the programs that are running. The RAM is only temporary; once the computer has been
turned off, the RAM is wiped clean.

Ports

The computer’s ports are a collection of connectors sticking out of the back of the PC that link
adapter cards, drives, printers, scanners, keyboards, mice, and other peripherals that may be used.

Different Types of Ports:

Port Type Description

A 25-pin connector found on the back of most modern PCs. It is most often used for printer connec
Parallel Port send 8 bits of data through the connection.
Port Type Description

Can be universally used for many of the components plugged into the computer, such as a mouse.
Serial Port are of the 9-pin variety, but some can have up to 25-pin connectors.

USB (Universal A common interface connection used between most devices commonly used today. The advantage
Serial Bus) that multiple devices may be connected into one port.

Ports that can be found on the motherboard and connect the hard drive, floppy drive, and CD-ROM
IDE (Integrated board. A series of ribbon cable runs throughout the computer to connect the IDE devices to the IDE
Drive Elect.) motherboard.

The fastest and most versatile way for a PC to communicate with its peripherals. A single SCSI contr
SCSI Port up to seven devices through a daisy chain connection.

CMOS

The complementary metal oxide semiconductor (CMOS) is a special type of memory chip that uses a
small rechargeable or lithium battery to retain information about the PC’s hardware while the
computer is turned off.

The CMOS is also the location of the system clock that keeps track of the date and time. The system
clock uses a vibrating quartz crystal to set the speed for the CPU. A single tick of the clock represents
the time it takes to turn a transistor on and off.

Sound Card

The sound card contains all of the circuitry for recording and reproducing sound on the PC. It may be
in the form of an expansion card, or it may be built into several chips found on the motherboard.
Ports are located externally to connect amplified speakers, headphones, microphone, and a compact
disk (CD) player input into the computer. The sound card interprets many different file types such as
waveform audio (WAV) files, moving picture experts group audio layer 3 (MP3) files, and musical
instrument digital interface (MIDI) files.

Network Card

The network interface card (NIC) can come either as an expansion card plugged into a slot or as part
of the PC motherboard circuitry. The network card will have an RJ-45 adapter jack at the rear of the
PC for the acceptance of a twisted-pair wire with RJ-45 connector. This network card will enable this
PC to connect to other PCs that are on the same network.

Power Supply

The power supply delivers all electricity to the PC and contains a fan to help keep the inside of the
computer cool.

It contains a transformer that converts the wall outlet alternating current (AC) to direct current (DC)
in the voltages appropriate for each powered device. All components, from the motherboard to the
hard drive, get their power directly from the main supply through different colored wires that end in
plastic shielded connectors. The power supplies deliver $+/- 12V, +/- 5V, and in some machines +3.3
V. Power supplies are rated in watts. Most power supplies deliver between 150 to 300 W, but some
computers require a 400-W power supply. The power supply is designed to take the brunt of the
force if the computer ever receives a power surge.

Hard Drive

The hard drive is the main repository for programs and documents on a PC.

The hard drive is made up of many hard, thin magnetic platters that are stacked one on top of the
other with only enough space for a read-write head to glide over the surface of the disks. The disks
are spun at a fast speed by a small motor, and the read/write head glides to the area that houses the
particular information needed and reads or writes as asked.

CD/DVD Drive

A CD is a thin injection-molded polycarbonate plastic disk. The disk is impressed from a mold to form
microscopic bumps that indicate either a 1 or 0 to the computer. Over the bumps is a reflective layer
of aluminum, and over that is a clear protective coat of acrylic. A CD can hold up to 74 minutes of
music or approximately 780 MB of data.

A digital versatile disk (DVD) holds up to seven times more than the CD, which equates to about 9.4
(single-sided) to 17 GB (double-sided) of data. A DVD has multiple layers of polycarbonate plastic.
Aluminum is used behind the inner layers, and gold is used behind the outer layers. The gold is
semireflective so that it allows the laser to penetrate through to the inner layers of plastic.

There are three main types of CD/DVD drives available in today’s market:

• ROM (read-only memory)

• R (write once–read many)

• RW (read and write many times)

With an R or RW drive, information that needs to be saved, transported, or archived can be “burned”
(information written on a disk). The information is burned onto the disk, starting in the center and
spiraling out to the edge of the disk. The laser burns a tiny depression (pit) into the disk to represent
the data being saved. A burned disk will be a series of pits and lands, or areas that were not burned
by the laser. Two-sided DVDs can be burned on both sides to double the capacity of the disk.

How CD/DVD Drives Work

The drive consists of a disk tray, a motor, a read head, and possibly a write head. After the door
closes, a motor constantly varies the speed of the disk so that the portion above the read head spins
at a constant speed no matter its location over the disk. The laser beam of the read head penetrates
the disk and strikes the reflective layer. If the laser strikes a land area, the light reflects back; if the
laser strikes a pit, the light is scattered. The light reflected back is read by a light-sensing diode that
translates the impulses into 1s and 0s for the computer to generate into recognizable data.

Peripherals

Keyboard

There are two basic types of keyboards:

 • Soft

• Click: If there is an audible sound when the keys are depressed

Most modern keyboards connect using an IBM programming system 2 (PS/2) connection and
connect into the back of the box. Some keyboards use the USB connection because of its versatility
and ease of use. With the advent of wireless connections, keyboard makers use either infrared or
radiofrequency (RF) signals.

When the keys are depressed on the keyboard, a signal is sent through the switch to the
motherboard, where it is interpreted in the keyboard microprocessor.

Mouse

A mouse is a device with two or sometimes three buttons that allows the user to move the
computer’s cursor to activate and perform functions within the computer’s software.

There are five types of mouse connections:

• Serial mouse: uses a standard serial connection

• Bus mouse: uses a dedicated controller card that is connected to the motherboard

• PS/2 mouse: a special connection for mice that does not use the standard serial port

• USB mouse: attaches to a USB port

• Infrared mouse: uses the computer’s infrared port (wireless)

There are three types of mice commonly used:

• Mechanical: This mouse uses a hard rubber ball inside an opening on the bottom that is
surrounded by sensing devices. The ball moves around based on the movement of the user’s
hand over the mouse and triggers the sensors within the mouse to move the cursor on the
screen.

• Optical: This mouse has a high-intensity diode that bounces light off surfaces and back to a
receiver inside the mouse. As with the mechanical mouse, the cursor is made to move by the
movements of the mouse over a hard surface and by the light that is reflected back to the
sensors within the mouse.

• Optomechanical: This mouse is a hybrid of mechanical and optical mouse. It uses a rubber
ball that interacts with rollers that trigger the optical sensors within the mouse. Light is
reflected back to the sensors based on the movement of the rollers.

Scanners

Scanners are devices that capture drawings or written paper documents and convert them into a
digital image or document that can be edited. Special image scanners in radiology departments are
used to convert an analog (film) image into a digital image. The purpose is to provide a way to
compare a hardcopy image with a digital image on a PAC system (PACS).

Speakers

Speakers receive sound data from a sound card that is either built into the motherboard or is an
expansion card. The sound data are converted from an electrical signal to a series of vibrations in the
speaker to create sound. Speakers have become an integral part of the modern PC because they give
audible signals from the software to alert us to various tasks.

Microphones

Microphones are used to record voice or to use voice dictation software. Voice dictation software is
becoming more common in radiology departments. The technology has progressed to a point that
most people’s voices can be recognized by the system’s software.

Monitors

There are two major types of monitors:

• Cathode Ray Tube (CRT)

• Liquid Crystal Display (LCD)

A third type, the plasma screen, is quickly gaining acceptance.

Key measurements related to onscreen viewing:

• Pixel: A basic picture element on a display.

• Dot Triad: A grouping of one red dot, one green dot, and one blue dot.

• Resolution: The number of pixels on a display. The more pixels in an image, the higher the
resolution of the image and the more information that can be displayed.

• Matrix: A rectangular or square table of numbers that represents the pixel intensity to be
displayed on the monitor.

• Dot Pitch: The measurement of how close the dots are located to one another within a pixel;
the smaller the dot pitch of a display, the finer the resolution.

• Refresh Rate/Vertical Scanning Rate: The measure of how fast the monitor rewrites the
screen or the number of times that the image is redrawn on the display each second. The
refresh rate helps to control the flicker seen by the user; the higher the refresh rate, the less
flicker.

• Aspect Ratio: The ratio of the width of the monitor to the height of the monitor. Most CRT
monitors have an aspect ratio of 4:3; LCD monitors have a ratio of 16:9.

• Viewable Area: Measured diagonally from one corner of the display to the opposite corner.

CRT

The CRT monitors are the most popular monitors on the market. The CRT consists of a cathode and
anode within a vacuum tube. The CRT works much like an x-ray tube, in that the cathode boils off a
cloud of electrons and then a potential difference is placed on the tube. A stream of electrons is sent
across to the monitor’s anode, which is a sheet of glass coated with a phosphor layer. The electrons
strike the phosphor on the glass, causing the glass to emit a color, which is determined by the
intensity of the interaction and area with which the electrons interacted.

The electrons interact with either a red, green, or blue dot to form the color and image that is being
sent from the video card signal. The electron beam starts in the upper left corner and scans across
the glass from side to side and top to bottom, and once it reaches the bottom, it starts back over at
the top left.

LCD

An LCD monitor produces images by shining or reflecting light through a layer of liquid crystal and a
series of color filters. An LCD has two pieces of polarized glass with a liquid crystal material between
the two. Light is allowed through the first layer of glass, and when a current is applied to the liquid
crystal, it aligns and allows light in varying intensities through to the next layer of glass through color
filters to form the colors and images seen on the display.

Plasma Displays

The plasma displays are made up of many small fluorescent lights that are illuminated to form the
color of the image. The plasma display varies the intensities of the various light combinations to
produce a full range of color.

Monitor Advantages and Disadvantages

Monitor
Type Advantages Disadvantages

Less expensive, Better color representation, More Bulky, The larger the viewing area, the deeper an
responsive than LCD, Can provide multiple resolutions, unit, Not easily adjusted for viewing at different
CRT More rugged and can sustain rough handling angles

Takes up less space than a CRT, Consumes less power than Costs more than CRT, Less of a viewing angle, No
CRT, Produces less heat than CRT, Surface produces little CRTs, Each display is only capable of working wit
LCD or no glare resolution, Requires a smaller frame around disp

Wide screen with a thin depth, Brighter than LCD, Can be

Plasma viewed at varying angles, Light weight High cost, Low availability

Operating Systems

An operating system (OS) is the software that controls the computer hardware and acts as a bridge
between applications and the hardware.

Three major OSs in use today:

• Windows by Microsoft

• Macintosh OS

• UNIX/Linux

PCs generally run a Windows version of an OS, such as Windows 95, 98, 2000, ME, XP, or NT.

Four types of OSs:

• Real-time OS: Used to control specific machinery, scientific instruments, and industrial
systems, such as digital x-ray consoles found on modern x-ray equipment.
 • Single-user, single-task: Designed so that a computer can effectively do one task for one
person at a time, such as a Palm OS for the hand-held personal organizer.

• Single-user, multitask: Designed for one user to perform multiple functions at the same
time, such as the OS on a PC.

• Multiuser: Designed to handle multiple users performing multiple tasks at the same time,
such as UNIX.## Operating Systems

Computers need an operating system (OS) to function fully. The OS takes over after the computer
wakes up, allowing it to perform tasks. All other software runs using the OS.

Early vs. Modern OS

• Early OSs, like Microsoft Disk Operating System (MS-DOS), were command-based and
difficult to use. Users had to type in word commands for simple tasks.

• Today, most computers use a graphical user interface (GUI), which is icon-based and uses a
mouse for pointing and clicking. GUIs also have drop-down word menus.

Common Operating Systems

• Windows: Traditionally used in IBM-type PCs.

• Windows NT, UNIX, or Linux: Used in large workstations for completing multiple tasks.

• UNIX: A robust OS developed by Bell Laboratories and given out free to universities. It's
primarily used by industry for larger server applications. Some PACS vendors began their
software on UNIX-based systems but have since migrated to the Windows platform because
of cost, ease of use, and customer demand.

• Linux: Derived from UNIX by a Finnish computer science student. It is open-source software,
meaning programmers can make changes as long as the changes are shared.

OS in Medical Imaging

All digital medical imaging devices have an OS running behind the user interface, which may be one
of the three discussed above or a proprietary system developed specifically for a particular device.
Most modern PACSs use a Windows-based platform, but some may still use UNIX on their large
servers because of its exceptional multitasking capabilities.

Computers in the Radiology Department

Computers are used throughout radiology departments to improve patient care. A simple computer
can do the job in most areas, but some applications require a specialty workstation to handle
complicated tasks. Most radiology imaging equipment has a built-in computer or a separate
computer attached for various applications.

Choosing Equipment

Computer hardware and software are chosen to match the applications used by the staff. Comfort,
cost, quality, and purpose are addressed when choosing equipment.

• A radiologist needs a monitor with high brightness, high resolution, and a large screen to
view digital images for diagnosis.
 • A file room clerk only needs a basic monitor.

Networking and Communication Basics

People use networks every day to transfer information, either from person to person or from
computer to computer.

A computer network is defined as (1) two or more objects sharing resources and information, or (2)
computers, terminals, and servers that are interconnected by communication channels sharing data
and program resources.

Devices other than computers can also be found on a network, such as printers, scanners, and
barcode readers.

Network Classifications

Networks can be classified based on geographic boundaries or the roles that hardware components
play.

Geographic Classifications

Network
Type Definition Characteristics Exa

A small area networked with cables or Least expensive to install, faster than a WAN due to
Local Area wireless access points that allow computers smaller size, fastest communication technology PAC
Network to share information and devices on the same because less equipment and fewer resources are a ra
(LAN) network. needed. roo

A network that spans a large area (city, state, Connected through telephone lines, satellite links, or
Wide Area nation, continent, or the world) and connects other communication cables. Higher operating costs Con
Network computers not physically attached through due to long-distance communication links and the LAN
(WAN) conventional network cables. need for high-speed equipment. citie

Component Role Classification

Network
Type Definition Characteristics Example

A small medical o
Peer-to- Each computer is considered Least expensive and simplest to set up, suitable for computers check
Peer equal, with no computer having small offices or home networks. Limited scope; should verifying insuranc
Network ultimate control over another. not connect more than 10 peers to avoid bottlenecks. and documenting

Centralized storage and retrieval, allowing users to

Server- access files from a central location. The server must be A radiology depa
A centralized computer (the
Based high quality and high capacity, but client computers PACS to read and
server) controls the operations,
Network can be less expensive. throughout the h
files, and sometimes the
Network
Type Definition Characteristics Example

programs of the attached

computers.

The server processes the resource as requested by the

A centralized computer controls client and returns only the results back to the client.
Client- the network operations, but the This smaller exchange of information cuts down the
Based server processes the resource as load on the network and allows more room for other
Network requested by the client. requests. N/A

Typical Components of a Network

Types of Computers on a Network

Computer
Type Definition Purpose

A computer that manages resources for May house applications, provide storage for files, or manage var
other computers, servers, and tasks. Often dedicated to one task and is usually the most robus
Server networked devices. network.

A device that requests services and Can be another computer, a printer, or any networkable device t
Thin-Client resources from a server. server to complete its tasks.

A computer that can work Networked to share resources such as printing and take advanta
independently of the network and security. Generally a high-end computer that does high-level pro
Thick-Client process and manage its own files. specific purposes. Specialty application workstations in healthca

Network Connectivity

Communication Medium

Once files and resources are to be shared, the equipment is connected via a communication
medium. The physical connection is one of four types:

• Coaxial Cable: Similar to cable television wiring, it consists of a center conducting wire
surrounded by insulation and a grounded shield of braided wire. The shield minimizes
electrical and radio frequency interference. It's sturdy and often found in network
infrastructure.

• Twisted-Pair Wire: Similar to telephone wire, but consists of four twisted pairs of copper
wire that are insulated and bundled together with an RJ-45 termination. The minimum
recommended standard is Cat 5 cable and is the most commonly used connection medium in
LANs.
 • Fiberoptic Cable: Uses glass threads to transmit data. It's faster than metal counterparts but
more expensive and fragile. Often used in network infrastructure, network closets, and large
archive/computer rooms.

• Wireless Connections: Use infrared or radio frequencies for communication. No physical

cabling is needed, but each device must contain the appropriate wireless
transmitter/receiver. Advantages include mobility and convenience, but it has a limited
range.

Network Interface Card (NIC)

The network interface card (NIC) provides the interface between the computer and the network
medium; it provides the physical connection between the network and computer.

NIC works with networking software to establish and manage the data, chop it into packets, and
handle addressing issues.

Network Hub

A network hub is the simplest device that connects several pieces of equipment for network
communication.

It has several wiring ports to receive and transmit data. When the hub receives data, it sends it to all
connected devices. Commonly used in small office and home applications.

Network Switch

A network switch sends data only to the devices to which the data are directed.

It reads the destination address from the data and selects a direct path to the intended target,
reducing network traffic and speeding up the overall connection.

Network Bridge

A network bridge segments larger networks into smaller networks to reduce traffic.

It is a physical (wired) connection from one network segment to another, recognizing the destination
address and sending data to it.

Network Router

A network router can read portions of messages and direct them to their intended target, even if the
device is on a separate network and uses a different network protocol.

It also helps segment the network for access only for approved devices.

Network Communication

Each computer on the network is assigned a unique address, a combination of a physical address
from the computer's hardware and a node address given by the network. One type of addressing
is Internet Protocol (IP) addressing, which is made up of four octets (groups of 8 bits) of numbers
(e.g., 144.162.21.107).

The data travel along the network using an agreed-on set of rules known as a network protocol.

A packet is a piece of the data with added information, such as the destination address, the source
address, the sequence of the packets, and whether there were any errors in transmission.
The protocol is delivered in layers of communication known as protocol stacks. Typically, a network
communication model is explained using seven layers (OSI Model), but we will simplify the model
and concentrate on the bottom four layers.

• Layer 4: Transport Layer: Ensures data packets are sequenced correctly and do not contain
errors. The most common transport-layer protocol is the transmission control protocol (TCP).

• Layer 3: Network Layer: Breaks up the data into frames and decides which network path the
frame will take to its destination. IP is concerned with sending the message to the correct
address.

• Layer 2: Data Link Layer: Packages the data so that they can be transmitted over the physical
layer. Ethernet is an example protocol that performs at layer 2 and layer 1 levels.

• Layer 1: Physical Layer: Consists of the networking media and the components required to
pass on a signal from one end of the network to the other. This is the layer that moves bits
from one place to another.

Network Topology

Topology is the physical (geometric) layout of the connected devices on a network.

There are four common topology configurations: bus, ring, star, and mesh.

Topology
Type Definition Characteristics

All devices are physically attached to and A single point of failure; if the wire breaks, the entire netwo
Bus listen for communication on a single wire. not need switches or hubs.

Each device passes its received messages to the next node o

Ring Devices are connected in a circle. there is a break in the ring, the entire network comes to a ha

Devices are connected to a central hub or Can be thought of as a bus topology with the bus collapsed
Star switch. This is the most commonly used network topology.

Has redundancy built in with the multiple connections. The

Multiple pathways interconnecting devices on this topology, and it is used most often to connect netwo
Mesh and networks. networks.

Application Interfacing

DICOM

DICOM stands for digital imaging and communications in medicine.

DICOM has become an almost universally accepted standard for exchanging medical images among
networked medical devices. DICOM is layered on top of TCP/IP, the most common network
communication standard used, and it has multiple layers like TCP/IP. DICOM was developed by the
American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA).
DICOM (3.0) was better than its predecessors for several reasons:

• It required a communications protocol that runs on top of TCP/IP, permitting the devices to
make use of commercial hardware and software.

• It required strict contents of the image “header” and the structure of the pixel data itself for
each type of modality, therefore improving interoperability.

• It required a conformance system, so that a user could determine from the vendor’s
documentation whether the devices would operate together.

• It embraced an open standard of development between the vendors and users to come to a
consensus on the direction of the standards.

The DICOM standard is made up of 16 different parts ranging from image display to media storage.
The DICOM standard defines so-called service classes or functions that a device can perform on a
defined information object (like a CT image). The allowed service/object pairs (SOPs) for a device are
spelled out explicitly in the device’s DICOM conformance statement. A device performs either as a
service class user (SCU) for a given service and object or as a service class provider (SCP) or as both.
The SCU and SCP are commonly referred to as roles. Network communications (i.e., transactions) in
DICOM are always between an SCP and an SCU. The most common service classes seen in modalities
and PACS are:

• Image storage

• Query/retrieval

• Print

• Modality worklist

• Modality performed procedure

• Storage commitment

• Interchange media storage

Each of these services defines a specific transaction for the modality and PACS, and because of the
standardization provided by DICOM, device interoperability is possible (or at least more likely).

HL-7

I am unable to provide a definition for HL-7, as it was not explicitly defined in the provided text.

DICOM and Image Communication

Uniquely Identifying Images

DICOM ensures modalities can communicate with existing image-viewing devices. It provides
specifications for uniquely identifying each study, series, and image.

• Unique Identifiers (UIDs): DICOM uses UIDs to globally identify each image set. These UIDs
prevent confusion when images are sent to multiple systems.

Each study is identified by a study instance UID, which breaks down into series instance UIDs and
further into instance UIDs.
 • UID Construction: Numbers are created based on vendor number, equipment serial number,
date, time, patient/processing number, and the study, series, or image number.

A typical study instance UID may look like this: $1.2.840.8573.4567.1.20051011764589.8765.1.58$

Compression Technologies

DICOM provides a framework for using compression technologies on image data.

• JPEG Lossless Compression: Accommodates Joint Photographic Experts Group (JPEG) lossless
compression of 2:1.

This is the most common technique used within hospitals because there is no image degradation
upon viewing after decompression.

• Lossy Compression: May be necessary to shrink file sizes for external networks. Higher
compression values can cause some loss of image detail.

Modality Worklist Management

• Manual Demographics Entry: Technologists may manually enter patient demographics,

risking error.

• Modality Worklist: Modalities can pull information directly from the Radiology Information
System (RIS) when supporting the service class of modality worklist management.

The RIS can interface via DICOM or through a gateway that interfaces with the Health Level 7 (HL-7)
device and the DICOM device.

Health Level 7 (HL-7)

Overview

HL-7 is an American National Standards Institute (ANSI)–accredited Standards Developing

Organization (SDO).

It is used in most health care applications such as medical devices, imaging, insurance, and
pharmacy.

Scope

The HL-7 standard oversees most clinical and administrative data such as demographics, reports,
claims, and orders.

• Communication: Generally used in communication between the Hospital Information System

(HIS) and the Radiology Information System (RIS).

Systems and Records

• Hospital Information System (HIS):

Holds the patient’s full medical information, from hospital billing to the inpatient ordering system.

• Radiology Information System (RIS):

Holds all radiology-specific patient data, from patient scheduling information to the radiologist’s
dictated and transcribed report.
 • Electronic Medical Record (EMR):

Either a part of the HIS or runs along with it and contains all of the patient’s record, including lab
results, radiology reports, pathology results, and nurses’ and doctors’ notes.

• Interfaces with most ancillary service systems to retrieve reports for viewing in a
common format.

• PACS have begun interfacing with EMRs to present images to referring physicians
through the same common system.

Computed Radiography (CR) Equipment

Cassette

• Description: The CR cassette looks like the conventional radiography cassette and consists of
a durable, lightweight plastic material (Figure 4-1).

• Backing: Backed by a thin sheet of aluminum that absorbs x-rays (Figure 4-2).

• Antistatic Material: Instead of intensifying screens inside, there is antistatic material (usually
felt) that protects against static electricity buildup, dust collection, and mechanical damage
to the plate (Figure 4-3).

Imaging Plate

Construction

In CR, the radiographic image is recorded on a thin sheet of plastic known as the imaging plate. The
imaging plate consists of several layers:

Layer Description

Protective Very thin, tough, clear plastic that protects the phosphor layer.

Layer of photostimulable phosphor that "traps" electrons during exposure. Usually made of phospho
barium fluorohalide family (e.g., barium fluorohalide, chlorohalide, or bromohalide crystals). May als
that differentially absorbs the stimulating light to prevent as much spread as possible and functions m
Phosphor/Active dye added to conventional radiographic screens.

Sends light in a forward direction when released in the cassette reader. This layer may be black to red
Reflective stimulating light and the escape of emitted light. Some detail is lost in this process.

Conductive Material that absorbs and reduces static electricity.

Newer plates may contain a color layer, located between the active layer and the support, that absor
Color light but reflects emitted light.

Support Semirigid material that gives the imaging sheet some strength.
Layer Description

Backing Soft polymer that protects the back of the cassette.

Allows the technologist to match the image information with the patient-identifying barcode on the e
request (Figure 4-5). For each new examination, the patient-identifying barcode and the barcode labe
must be scanned and connected to the patient position or examination menu. The cassette will also b
green or blue stickers indicating the top and left side of the cassette or with a label on the back of the
indicating the top and right sides of the patient (Figure 4-6). These stickers serve to orient the cassett
Barcode Label the patient and the patient’s right side so that the image orientation is in line with the computer algo

Image Acquisition

The patient is x-rayed in the same way as in conventional radiography, and the patient is positioned
using appropriate positioning techniques. The cassette is placed either on the tabletop or within the
table Bucky. The patient is then exposed using the proper combination of kilovoltage peak (kVp),
milliamperage seconds (mAs), and distance. In CR, the remnant beam interacts with electrons in the
barium fluorohalide crystals within the imaging plate.

• Electron Stimulation: This interaction stimulates, or gives energy to, electrons in the crystals,
allowing them to enter the conductive layer, where they are trapped in an area of the crystal
known as the color or phosphor center.

This trapped signal will remain for hours, even days, although deterioration begins almost
immediately. In fact, the trapped signal is never completely lost. That is, a certain amount of an
exposure remains trapped so that the imaging plate can never be completely erased.

• Residual Electrons: However, the residual trapped electrons are so few in number that they
do not interfere with subsequent exposures.

Reader

With CR systems, no chemical processor or darkroom is necessary. Instead, following exposure, the
cassette is fed into a reader (Figure 4-7) that removes the imaging plate and scans it with a laser to
release the stored electrons.

Laser

A laser, or light amplification of stimulated emission of radiation, is a device that creates and
amplifies a narrow, intense beam of coherent light (Figure 4-8).

• Process: The atoms or molecules of a crystal such as ruby or garnet or of a gas, liquid, or
other substance are excited so that more of them are at high energy levels rather than low
energy levels. Surfaces at both ends of the laser container reflect energy back and forth as
atoms bombard each other, stimulating the lower energy atoms to emit secondary photons
in the same frequency as the bombarding atoms.

When the energy builds sufficiently, the atoms discharge simultaneously as a burst of coherent light;
it is coherent because all of the photons are traveling in the same direction at the same frequency.
 • Requirements: The laser requires a constant power source to prevent output fluctuations.
The laser beam passes through beam-shaping optics to an optical mirror that directs the
laser beam to the surface of the imaging plate (Figure 4-9).

Reading the Imaging Plate

When the cassette is put into the reader, the imaging plate is extracted and scanned with a helium
laser beam or, in more recent systems, solid-state laser diodes.

• Laser Characteristics: The beam, about 100 μm wide with a wavelength of 633 nm (or 670 to
690 nm for solid state), scans the plate with red light in a raster pattern and gives energy to
the trapped electrons.

The red laser light is emitted at approximately 2 eV, which is necessary to energize the trapped
electrons.

• Emission: This extra energy allows the trapped electrons (Figure 4-10) to escape the active
layer where they emit visible blue light at an energy of 3eV as they relax into lower energy
levels.

• Translation: As the imaging plate moves through the reader, the laser scans across the
imaging plate multiple times. The plate movement through the scanner is known as
translation because it moves in a parallel manner at a certain rate through the reader.

This scan process produces lines of light intensity information that are detected by a photomultiplier
that amplifies the light and sends it to a digitizer.

• Coordination: The translation speed of the plate must be coordinated with the scan direction
of the laser, or the spacing of the scan lines will be affected.

• Laser Beam Deflection: A beam deflector moves the laser beam rapidly back and forth
across the imaging plate to stimulate the phosphors. Mirrors are used to ensure that the
beam is positioned consistently.

Because the type of phosphor material in the imaging plate has an effect on the amount of energy
required, the laser and the imaging plate should be designed to work together.

• Light Collection: The light collection optics direct the released phosphor energy to an optical
filter and then to the photodetector (Figure 4-11).

Typical throughput is 50 cassettes/hr. Some manufacturers claim up to 150 cassettes/hr, but based
on average hospital department workflow, 50/hr is much more realistic.

Digitizing the Signal

Digitizing a signal means assigning a numerical value to each light photon.

Analog refers to a device or system that represents changing values as continuously variable physical
quantities.

• Digitizing Process: Each phosphor storage center is scanned, and the released electrons
enter a digitizer that divides the analog image into squares (matrix) and assigns each square
in the matrix a number based on the brightness of the square.

Each square is called a pixel or picture element.

 • Pixel Count: The typical number of pixels in a matrix ranges from about 512 × 512 to 1024 ×
1024 for CT but can be as large as 2500 × 2500 for radiography.

The more pixels there are, the greater the image resolution. The image is digitized both by position
(spatial location) and by intensity (gray level).

• Bit Depth: Each pixel contains bits of information, and the number of bits per pixel that
define the shade of each pixel is known as bit depth.

If a pixel has a bit depth of 8, then the number of gray tones that pixel can produce is 2 to the power
of the bit depth, or 2828, or 256 shades of gray.

• Gray Level: Each pixel can have a gray level between 0 (2020) and 4096 (212212). The gray
level will be a factor in determining the quality of the image.

Spatial Resolution

The amount of detail present in any image is known as its spatial resolution.

• Determinants: Phosphor layer thickness and pixel size determine resolution in CR. The
thinner the phosphor layer, the higher the resolution.

In film/screen radiography, resolution at its best is limited to approximately 10 line pairs (lp)/mm. In
CR, resolution is approximately 2.55 to 5 lp/mm, resulting in less detail.

• Dynamic Range: More tissue densities on the digital radiograph are seen, giving the
appearance of more detail due to the wider dynamic recording range.

Speed

In conventional radiography, speed is determined by the size and layers of crystals in the film and
screen. In CR, speed is not exactly the same because there is no intensifying screen or film.

• Light Emission: The phosphors emit light according to the width and intensity of the laser
beam as it scans the plate, resulting in a relative “speed” that is roughly equivalent to a 200-
speed film/screen system.

CR system “speeds” are a reflection of the amount of photostimulable luminescence (PSL) given off by
the imaging plate while being scanned by the laser.

• Exposure and Luminescence: For example, Fuji Medical Systems (Tokyo, Japan) reports that
a 1-mR exposure at 80 kVp and a source-to-image distance of 72 inches will result in a
luminescence value of 200, hence the “speed” number.

• Cassette Speed: In CR, most cassettes have the same “speed”; however, there are special
extremity or chest cassettes that produce greater resolution. These are typically 100 relative
“speed.”

Erasing the Image

• Process: The process of reading the image returns most but not all of the electrons to a
lower energy state, effectively removing the image from the plate.

• Maintenance: Imaging plates are extremely sensitive to scatter radiation and should be
erased to prevent a buildup of background signal.
The plates should be run at least once a week under an erase cycle to remove background radiation
and scatter.

• Erasure Mode: CR readers have an erasure mode that allows the surface of the imaging plate
to be scanned without recording the generated signal. Systems automatically erase the plate
by flooding it with light to remove any electrons still trapped after the initial plate reading
(Figure 4-14).

Cassettes should be erased before using if the last time of erasure is unknown.

Preprocessing, Processing, and Forwarding

• Process: Once the imaging plate has been read, the signal is sent to the computer where it is
preprocessed. The data then go to a monitor where the technologist can review the image,
manipulate it if necessary (postprocessing), and send it to the quality control (QC) station
and ultimately to the picture archiving and communications system (PACS).

Computed Radiography Image Acquisition

Part Selection

Once the patient has been positioned and the plate has been exposed, you must select the
examination or body part from the menu choices on your workstation.

• Importance: Selecting the proper body part and position is important for the proper
conversion to take place.

• Image Recognition: Image recognition is accomplished through complex mathematical

computer algorithms, and if the improper part and/or position is selected, the computer will
misinterpret the image.

• Consequences: Improper menu selections may lead to overexposure of the patient and/or
repeats.

Technical Factors

Kilovoltage Peak Selection

Kilovoltage peak (kVp), milliamperage seconds (mAs), and distance are chosen in exactly the same
manner as for conventional film/screen radiography.

• kVp Range: kVp values now range from around 45 to 120. It is not recommended that kVp
values less than 45 or greater than 120 be used because those values may be inconsistent.

• Optimum Range: The k-edge of phosphor imaging plates ranges from 30 to 50 keV so that
exposure ranges of 60 to 110 kVp are optimum.

• Attenuation: The process of attenuation of the x-ray beam is exactly the same as in
conventional film/screen radiography.

Milliamperage Seconds Selection

The mAs is selected according to the number of photons needed for a particular part.
 • Quantum Mottle: If there are too few photons, the result will be a lack of sufficient
phosphor stimulation. When insufficient light is produced, the image is grainy, a condition
known as quantum mottle or quantum noise.

Automatic Exposure Controls

CR systems typically utilize automatic exposure controls (AECs), just as many film/screen systems do.

• Backscatter: Backscatter from the cassette/detector will influence the amount of mAs
necessary to create the image.

Equipment Selection

Imaging Plate Selection

Two important factors should be considered when selecting the CR imaging cassette: type and size.

• Types: Most manufacturers produce two types of imaging plates: standard and high
resolution.

• High-Resolution Plates: Typically limited to a certain size range and are most often used for
extremities, mammography, and other examinations requiring increased detail.

• CR Cassette Selection CR cassette selection is the same but even more critical. CR digital
images are displayed in a matrix of pixels (Figure 5-4), and the pixel size is an important
factor in determining the resolution of the displayed image.

• Reader Scanning The CR reader scans

Computed Radiography (CR) Imaging Plates

Imaging Plate Selection

• The imaging plate is scanned at a constant frequency, around 2000 x 2000 pixels.

• Using the smallest imaging plate possible results in the highest sampling rate for each
examination.

• The computer algorithm uses a matrix corresponding to the selected imaging plate size to
process the image.

• A 2000 x 2000 matrix on an 8" x 10" cassette leads to smaller pixel sizes, thus increasing
resolution.

• If a hand is imaged on a 14" x 17" cassette, the entire cassette is read according to a 14" x
17" matrix size with larger pixels, resulting in a very large image.

• Reducing the image size after exposure decreases the resolution.

• Selecting the appropriate image plate eliminates scatter outside the initial collimation and
enhances image resolution.

• Cassette selection affects the image size on both hardcopy and softcopy.

• Newer units use cassette-less CR imaging plate technology, typically for chest imaging.

Cassette-less Units
 • The imaging plate is enclosed within the unit.

• Storage phosphors have a needle-like structure, guiding light with minimal spread.

• These units have a complex reader with line-scan readouts and charge-coupled device (CCD)
detectors.

• This technology is similar to digital radiography (DR) systems.

Grid Selection

Moiré Pattern

A moiré pattern is a wavy artifact that occurs when grid lines projected onto the imaging plate
interfere with the image because the grid lines and scanning laser are parallel.

• Digital images are displayed in rows of picture elements or pixels.

• The oscillating motion of a moving grid (Bucky) blurs grid lines, eliminating interference.

• CR imaging plates record a high number of x-ray photons, making grid use crucial.

• Selecting appropriate stationary grids reduces interference.

• Grid selection factors include frequency, ratio, focus, and size.

Frequency

Grid frequency refers to the number of grid lines per centimeter or lines per inch.

• Higher frequency means finer grid lines and less interference.

• Typical grid frequency is between 80 and 152 lines/inch.

• Some manufacturers recommend no fewer than 103 lines/inch and suggest frequencies
greater than 150.

• Higher frequency reduces positioning latitude, increasing the risk of grid cutoff errors,
especially in mobile radiography.

• If the grid frequency is too close to the laser scanning frequency, it increases the risk of
moiré effects.

Ratio

Grid ratio is the relationship between the height of the lead strips and the space between them.

• Higher ratio absorbs more scatter radiation.

• Higher ratio makes positioning more critical, so it's not ideal for mobile radiography.

• A 6:1 grid ratio is suitable for mobile radiography.

• A 12:1 grid ratio is appropriate for departmental grids that are more stable and less prone to
mispositioning.

Focus

• Most grids are parallel and focused.

 • Parallel grids are less critical to beam centering but should not be used at distances less than
48 inches.

• Focused grids have lead strips angled to coincide with the x-ray beam's diversion and must
be used within specific distances with a precisely centered beam.

Size

• The physical size of the grid matters in CR examinations.

• Smaller cassettes result in a higher sampling rate.

• When using cassettes 10" x 12" or smaller, select a high-frequency grid to eliminate scatter.

• CR imaging plates record a wider range of exposure, including scatter.

Collimation

• Larger tissue volumes and higher kVp increase the likelihood of Compton interactions
(scatter).

• Grids absorb scatter exiting the patient, but collimation reduces the irradiation area and
tissue volume where scatter is created.

Collimation reduces the area of the beam reaching the patient using lead shutters encased in a
housing attached to the x-ray tube.

• Collimation increases contrast by reducing scatter and the amount of grid cleanup needed
for increased resolution.

• Postexposure image manipulation, known as shuttering, adds a black background around

collimation edges but doesn't replace proper preexposure collimation.

• Appropriate collimation reduces patient dose.

Side/Position Markers

• Use conventional lead markers as in film/screen systems.

• Marking the patient at the time of exposure identifies the patient's side and the technologist.

• Markers on the images used in court cases lend credibility to the technologist's expertise.

Exposure Indicators

• The amount of light emitted by the imaging plate results from radiation exposure.

• This light is converted into a signal to calculate the exposure indicator number, which varies
by vendor.

• The total signal indicates how much radiation was absorbed by the plate.

• The base exposure indicator number represents the middle of the detector operating range.

Exposure Indicator Systems

System Exposure Indicator Description Relationship to Exposure

Fuji/Philips/Konica Amount of luminescence emitted at 1 mR at Inverse: Higher S number,

Minolta S (Sensitivity) Number 80 kVp, with a value of 200. change of 200 doubles or

1-mR exposure at 80 kVp with

aluminum/copper filtration yields an EI of Direct: EI + 300 doubles ex
Kodak Exposure Index (EI) 2000. halves exposure.

Logarithm of the Exposure of 20 μGy at 75 kVp with copper Direct: Each step of 0.3 ab
Agfa Median Exposure (lgM) filtration yields lgM of 2.6. doubles or halves exposur

Image Data Recognition and Preprocessing

• The image recognition phase establishes parameters for collimation borders/edges and
histogram formation.

A histogram is a graphic representation of the numerical tone values of an x-ray exposure.

• All CR systems have this phase.

• Agfa uses the term "collimation," Kodak uses "segmentation," and Fuji uses "exposure data
recognition."

• All systems define a region of interest to recognize the part being examined and subtract the
exposure outside this region.

Fuji Imaging Systems - Data Recognition Modes

1. Automatic Data Recognition:

• Automatically determines the image recording range.

• The radiographer selects whether the field is divided for multiple exposures and in
what pattern the exposure will be made.

• Automatically adjusts reading latitude (L) and sensitivity (S).

• Automatically recognizes collimation and performs complete histogram analysis.

• Good collimation practices are crucial because overcollimation and undercollimation

lead to data recognition errors.

• Lead markers must be in the exposure area.

• Avoid overlapping exposures, as they negatively affect the histogram.

• Each exposure region is processed to identify its shape and approximate center.

• Data recognition occurs diagonally from the center out.

• Pixels exceeding a preset threshold are interpreted as collimation.

• Exposure data outside collimation points are subtracted in the histogram analysis.
 2. Semiautomatic Mode:

• The latitude value of the histogram is fixed, and a small reading area is used.

• No collimation detection.

• Proper kilovoltage (kVp) is essential to maintain subject contrast because the latitude
value does not change.

• Useful for odontoid, L5/S1 spot film, sinuses, and tightly collimated examinations.

• Center the part to be examined carefully.

• Not recommended for high absorption objects like prostheses.

• Different semiautomatic modes may be available with varying region of interest sizes
or multiple areas of interest.

3. Multiple Manual Selection Mode:

• The technologist selects the area of interest, and the image is derived from the
selected areas imaged in semiautomatic mode.

• Fuji calls this the Semi-X mode.

• The user selects from nine different areas on the imaging plate.

• Precautions for semiautomatic mode apply.

• Note the cassette orientation label about the area of interest.

• Helpful in cross-table examinations when the body part may not align with
automatically selected imaging plate regions.

4. Fixed Mode:

• The user selects the exposure index, or sensitivity number, and latitude value from a
menu.

• No histogram analysis and no recognition of imaging plate division.

• Similar to film/screen: image density directly reflects the technique used.

• Useful when imaging cross-table hips, C7-T1 lateral view of the cervical spine, body
parts with a lot of metal, and parts that cannot be centered.

Artifacts

Artifacts are any undesirable densities on the processed image other than those caused by scatter
radiation or fog.

• Common types include imaging plate artifacts, plate reader artifacts, image processing
artifacts, and printer artifacts, in addition to operator errors.

Imaging Plate Artifacts

• Cracks appear as areas of lucency on the image as the imaging plate ages.

• Replace the imaging plate when cracks occur in clinically useful areas.
 • Adhesive tape can leave residue, and static can cause hair to cling to the imaging plate.

• Backscatter can cause dark line artifacts.

Plate Reader Artifacts

• Extraneous line patterns can be caused by problems in the plate reader's electronics.

• Horizontal white lines may be caused by dirt on the light guide.

• Loading multiple imaging plates in a single cassette results in double exposure.

• Incorrect erasure settings leave a residual image.

• The moiré pattern error results from grid lines being parallel to the plate reader's laser scan
lines.

Printer Artifacts

• Fine white lines may appear due to debris on the mirror in the laser printer.

Operator Errors

• Insufficient collimation results in unattenuated radiation striking the imaging plate.

• Exposing the cassette with the back toward the source results in a white grid-type pattern
and white areas.

• Underexposure produces quantum mottle, and overexposure affects contrast.

• Proper technical factors are critical for patient dose and image quality.

Cassetteless Digital Imaging Systems

Types of Cassetteless Systems

• Direct systems

• Indirect systems

Direct Conversion

• Uses TFT arrays of amorphous selenium (a-Se).

• Absorb x-ray photons and immediately convert them to an electrical signal.

Indirect Conversion

• Use a scintillator to convert x-rays into visible light.

• The light is then converted into an electric charge.

CCDs (Charge-Coupled Devices)

• Act as miniature cameras.

• Convert light produced by x-ray interaction with photostimulable phosphors into an

electrical charge.

• Require optical coupling and image size reduction.

 • Widely available and relatively low cost.

CMOS (Complementary Metal Oxide Silicon)

• Developed by NASA.

• Uses specialized pixel sensors.

• Convert x-rays into light photons and store them in capacitors when struck with x-ray
photons.

• Each pixel has its own amplifier, which is switched on and off by circuitry within the pixel,
converting the light photons into electrical charges.

• Voltage from the amplifier is converted by an analog-to-digital converter located within the
pixel.

• Highly efficient and takes up less fill space than CCDs.

Detective Quantum Efficiency (DQE)

How efficiently a system converts the x-ray input signal into a useful output image.

• A measurement of the percentage of x-rays that is absorbed when they hit the detector.

• CR systems have a wider DQE latitude due to their linear, wide-latitude input/output
characteristic, allowing them to convert incoming x-rays into "useful" output over a much
wider range of exposure than screen/film systems.

• Higher quantum efficiency can produce higher quality images at lower dose.

• DR direct capture technology increases DQE the most because it does not have the light
conversion step.

• The DQE of detectors changes with kilovoltage peak (kVp), but generally the DQE of
selenium- and phosphor-based systems is higher than for CR, CCD, and CMOS systems.

• CCD has problems with low light capture.

Detector Size

• Must be large enough to cover the entire area to be imaged.

• Must be small enough to be practical.

• For chest x-rays, the detector needs to be at least 17 × 17 inches.

Spatial Resolution

• Varies depending on the detector’s physical characteristics.

• a-Se (direct detectors) and CsI (indirect detectors) have higher spatial resolution than CR
detectors but lower than film/screen radiography.

• Excessive image processing can lead to excessive noise.

• Achieved by using the appropriate technical factors and materials.

Pixel Size and Matrix Size

• The amount of resolution in an image is determined by the size of the pixels and the spacing
between them, or pixel pitch.

• Larger matrices combined with small pixel size will increase resolution.

• The larger the matrix, the larger the size of the image.

• Typically, 2000 pixels/row are adequate for most diagnostic examinations.

• Smaller pixel sizes may be necessary for mammographic examinations.

Technical Factor and Equipment Selection

• Selection of kVp, milliamperage seconds (mAs), distance, collimation, and anatomic markers
is the same for cassetteless systems as it is for cassette-based systems.

• Collimation may be more critical because the cassetteless systems are more sensitive to
scatter radiation.

• When grids are used, there is always the possibility that the grid lines will interfere with the
pixel rows, resulting in the moiré pattern error.

Potential Cassetteless Image Acquisition Errors

• Each step of the conversion has the potential of signal loss.

• The major cause of noise in this system is electronic noise.

• Incomplete charge transfer will cause inaccuracies in pixel values in subsequent exposures.

• If exposures are taken in too rapid sequences, there may not be enough time for each
previous exposure to transfer the entire signal, resulting in what is known as electronic
memory artifact.

• Not all cassetteless systems are appropriate for high speed, rapid succession imaging such as
fluoroscopy.

Digital Radiographic Image Processing and Manipulation

• Once x-ray photons have been converted into electrical signals, these signals are available for
processing and manipulation.

• Preprocessing takes place in the computer where the algorithms determine the image
histogram.

• Postprocessing is done by the technologist through various user functions.

Computed Radiography (CR) Reader Functions

• The computed radiography (CR) imaging plate records a wide range of x-ray exposures.

• Exposure data recognition processes only the optimal density exposure range.

• The data recognition program searches for anatomy recorded on the imaging plate by finding
the collimation edges and then eliminates scatter outside the collimation.
 • Failure of the system to find the collimation edges can result in incorrect data collection, and
images may be too bright or dark.

• The data within the collimated area produce a graphic representation of the optimal
densities called a histogram.

CR Image Sampling

• The plate is scanned, and the image’s location and its orientation are determined.

• The size of the signal is then determined, and a value is placed on each pixel.

• A histogram is generated from the image data, which allows the system to find the useful
signal by locating the minimum (S1) and maximum (S2) signal within the anatomical regions
of interest on the image.

Histogram Analysis

• A graph on which the x-axis is the amount of exposure read.

• The y-axis is the number of pixels for each exposure.

• Low energy (kilovoltage peak [kVp]) gives a wider histogram.

• High energy (kVp) gives a narrower histogram.

• The shape of the histogram is anatomy specific.

• The raw data used to form the histogram are compared with a “normal” histogram of the
same body part by the computer.

The Nyquist Theorem

When sampling a signal (such as the conversion from an analog to a digital image), the sampling
frequency must be greater than twice the bandwidth of the input signal so that the reconstruction of
the original image will be nearly perfect.

• In digital imaging, at least twice the number of pixels needed to form the image must be
sampled.

• If too few pixels are sampled, the result will be a lack of resolution.

• The number of conversions that occur in CR results in loss of detail.

Digital Radiography Image Sampling

• Although both indirect and direct radiography lose less signal to light spread, the Nyquist
theorem is still applied to ensure that sufficient signal is sampled.

• Because the sample is preprocessed by the computer immediately, signal loss is minimized
but still occurs.

Aliasing

When the spatial frequency is greater than the Nyquist frequency and the sampling occurs less than
twice per cycle, information is lost and a fluctuating signal is produced.
 • A wraparound image is produced, which appears as two superimposed images that are
slightly out of alignment, resulting in a moiré effect.

Automatic Rescaling

When exposure is greater or less than what is needed to produce an image, automatic rescaling
occurs in an effort to display the pixels for the area of interest.

• Images are produced with uniform density and contrast, regardless of the amount of
exposure.

• Problems occur with rescaling when too little exposure is used, resulting in quantum mottle,
or when too much exposure is used, resulting in loss of contrast and loss of distinct edges
because of increased scatter production.

• Rescaling is no substitute for appropriate technical factors.

Look-Up Table (LUT)

A histogram of the luminance values derived during image acquisition.

• The LUT is used as a reference to evaluate the raw information and correct the luminance
values.

• All pixels (each with its own specific gray value) are changed to a new gray value.

• The resultant image will have the appropriate appearance in brightness (density) and
contrast.

• There is a LUT for every anatomic part.

↔️ Latitude

The amount of error that can be made and still result in the capture of a quality image.

• DR histograms show a very wide range of exposure because of automatic rescaling of the
pixels.

• The exposure latitude is slightly greater than that of screen/film exposures.

• In CR if the exposure is more than 50% below the ideal exposure, quantum mottle results.

• If the exposure is more than 200% above the ideal exposure, contrast loss results.

Modulation Transfer Function (MTF)

The ability of a system to record available spatial frequencies.

• MTF is a way to quantify the contribution of each system component to the efficiency of the
entire system.

• MTF is a ratio of the image to the object, so that a perfect system would have an MTF of 1 or
100%.

Quality Control Workstation Functions

Image Processing Parameters

 • Digital systems have a greater dynamic range than film/screen imaging.

• The initial digital image appears linear when graphed because all shades of gray are visible,
giving the image a very wide latitude.

• Digital systems use various contrast enhancement parameters.

Contrast Manipulation

• Involves converting the digital input data to an image with appropriate density and contrast
using contrast enhancement parameters.

• Image contrast is controlled by using a parameter that changes the steepness of the
exposure gradient.

Spatial Frequency Resolution

Detail or sharpness

• In film/screen radiography, sharpness is controlled by various factors such as focal spot size,
screen and/ or film speed, and object-image distance (OID).

• The digitized image can be further controlled for sharpness by adjusting processing
parameters.

Spatial Frequency Filtering

Edge Enhancement

• Occurs when fewer pixels in the neighborhood are included in the signal average.

• Also known as high-pass filtering.

• Increases contrast and edge enhancement.

• Useful for enhancing large structures like organs and soft tissues, but it can be noisy.

Smoothing

• Also known as low-pass filtering.

• Occurs by averaging each pixel’s frequency with surrounding pixel values to remove high-
frequency noise.

• The result is a reduction of noise and contrast.

• Useful for viewing small structures such as fine bone tissues.

Basic Functions of the Processing System

Window and Level

• Window level controls how light or dark the image is.

• Window width controls the ratio of black and white, or contrast.

Background Removal or Shuttering

 • Automatic shuttering is used to blacken out the white collimation borders, effectively
eliminating veil glare.

• Background removal is also beneficial because it results in an overall smaller number of

pixels and reduces the amount of information to be stored.

Image Orientation

• Image orientation refers to the way anatomy is oriented on the imaging plate.

Image Stitching

• Multiple images can be “stitched” together using specialized software programs when the
anatomy or area of interest is too large to fit on one cassette.

Image Annotation

• The image annotation function allows selection of preset terms and/or manual text input.

Magnification

• One technique functions as a magnifying glass.

• The other technique is a “zoom” technique that allows magnification of the entire image.

Image Management

Patient Demographic Input

• Proper identification of the patient is even more critical with digital images than with
conventional hard copy film/screen images.

• Patient demographics include things like patient name, health care facility, patient
identification number, date of birth, and examination date.

PACS Fundamentals

Fundamentals

A picture archiving and communication system (PACS) is increasingly vital in modern hospitals.
Although the initial cost is substantial, the benefits for physicians and patients outweigh the expense.
A PACS is essentially an electronic version of the radiologist reading room and the file room.

PACS consists of digital acquisition, display workstations, and storage devices interconnected
through a network.

The first PACSs emerged in the early 1980s, initially serving single modalities and were
predominantly found in large research institutions. Standardization became essential as vendors
developed proprietary systems, leading to the creation of DICOM.

Digital imaging and communications in medicine (DICOM) is a universally accepted standard for
exchanging medical images among modalities, viewing stations, and archives.

DICOM was first completed in 1985 and continues to be refined.

A PACS can be broken down into:

 • Image acquisition

• Display workstations

• Archive servers

Image Acquisition

Most images are acquired in digital format and can be transferred via a computer network.
Modalities like ultrasound, CT, MRI, and nuclear medicine have long utilized PACS. Early PACS
implementations often involved mini-PACS networks for ultrasound.

As CT and MRI image sets grew, radiologists began viewing images directly on modality consoles,
prompting vendors to develop extra console stations. These evolved into mini-PACS and eventually
full-blown systems. With the advent of computed radiography (CR) and direct/indirect capture digital
radiography (DR), a completely digital radiology department is now feasible.

Display Workstations

A display workstation is any computer used by healthcare workers to view digital images.

It's the most interactive component of a PACS, used both inside and outside radiology. Display
stations receive images from the archive or modalities and present them for viewing, equipped with
software for image manipulation.

Archive Servers

An archive server is the file room of the PACS.

It contains a database server or image manager, short-term and long-term storage, and a workflow
manager. The archive serves as the central hub, housing historical and current data, and often acts as
the point where all images are received before being distributed for interpretation.

The common components of an archive are:

• Long-term archive

• Short-term archive

• Workflow manager

• Database server

Workflow

Workflow describes how a process is done, step by step.

Film-Based Workflow

Traditional radiology departments were designed for film and chemical processing, featuring
passboxes, darkrooms, and multiviewer lightboxes.

A typical film-based workflow includes:

1. Order entry: A paper prescription or computer order is entered into the radiology
information system (RIS), generating a requisition. Requisitions contain patient information,
ordering physician details, examination specifics, and chief complaint.
 2. Technologist preparation: The technologist prepares the room and retrieves the patient.

3. Patient verification: The technologist verifies patient information and inquires about the
need for copies.

4. Examination and processing: The technologist performs the examination and processes the
film.

5. Critique and repeats: The technologist critiques each film and repeats exposures if
necessary.

6. Copying: Copies are made if needed, and the patient is released with the films.

7. Film jacket retrieval: The technologist retrieves the film jacket with historic images from the
file room or off-site storage.

8. Reading: Current films are hung on a multiviewer lightbox with historic images for
comparison. The radiologist dictates a report.

9. Filing: Films are placed back into the film jacket and filed.

10. Transcription: A transcriptionist transcribes the report into the RIS.

11. Review and finalization: The radiologist reviews, corrects, and signs the report, which is then
printed and placed in the patient's film jacket and sent to the ordering physician.

Generic PACS Workflow

The PACS workflow differs significantly from the film-based workflow:

1. Order entry: Similar to film-based, but the order is input into the RIS, which sends a message
to the PACS to retrieve historic images and place them on the short-term archive.

2. Technologist preparation: The technologist prepares the room, retrieves the patient, and
records the patient history.

3. Examination and processing: The technologist performs the examination, and images are
processed and sent to the appropriate PACS device, tagged with information from the RIS.

4. Reading: The radiologist retrieves images from an electronic worklist, along with historic
images and reports, and compares them.

5. Reporting: The radiologist dictates a report using transcription or voice recognition software,
reviews, corrects, and signs the report.

The PACS workflow can reduce the time from examination to final report to just a couple of hours,
compared to a couple of days with the film-based workflow.

System Architecture

System architecture refers to the hardware and software infrastructure of a computer system.

In a PACS, this includes acquisition devices, storage, display workstations, and an image management
system.

Client/Server-Based Systems
In a client/server-based system, images are sent directly to the archive server after acquisition and
are centrally located. Display workstations function as clients, accessing images from a centralized
worklist.

• Advantages:

• Examinations are available anywhere without intervention.

• Only one person can open a study for reading at a time.

• Historic images are readily available with new ones.

• Disadvantages:

• The archive server is a single point of failure.

• The system is network-dependent, leading to potential bottlenecks.

• The archive server can become bottlenecked due to high request volumes.

Distributed Systems 흩어진

In a distributed or stand-alone system, images are sent to designated reading stations and review
stations based on order origin.

• Advantages:

• Local reading is not interrupted if the archive server goes down.

• Copies of examinations exist in multiple locations, reducing data loss.

• The system is less network-dependent.

• Disadvantages:

• Reliance on correct image distribution.

• Each workstation has a different worklist, limiting simultaneous access.

• Inconvenience in reading additional studies on different workstations.

• Dependence on query-and-retrieve for nonscheduled examinations.

• Potential for two radiologists to read the same examination unknowingly.

Web-Based Systems

A web-based system is similar to client/server, but both images and client display software are held
centrally.

• Advantages:

• Hardware flexibility, as any device with a web browser can be used.

• The same application can be used on-site and for teleradiology.

• Disadvantages:

• Limited functionality due to software not being locally installed.

 • Network bandwidth limits data transmission.

Teleradiology is the reading of images from outside the hospital walls.

Display Workstations

The display workstation is the most interactive part of a PACS, featuring a monitor, computer, mouse,
and keyboard.

Early PACS implementations used multiple monitors to match the viewing capacity of traditional
lightboxes. The number of monitors has decreased due to improved software and hardware.

The monitor is crucial. Cathode ray tube (CRT) and liquid crystal display (LCD) monitors are common.
LCDs are becoming more popular due to their size, resolution, and lower heat production.

Other monitor qualities are:

• Reduced maintenance

• Greater light

• Ambient light compatibility

Resolution and orientation are key factors. Cross-sectional imaging is often read on 1K square
monitors, while CR and DR are read on at least 2K portrait monitors.

A pixel is a basic picture element on a display.

Resolution is the number of pixels on a display.

A matrix is a rectangular table of numbers representing pixel intensity.

Common screen resolutions include:

Resolution Description

1280 × 1024 (1K) Basic resolution for standard applications

1600 × 1200 (2K) Higher resolution for detailed imaging

2048 × 1536 (3K) Enhanced resolution for medical diagnostics

2048 × 2560 (5K) Ultra-high resolution for mammography

Medical displays are generally higher quality. Mammography requires 5K resolution, while cross-
sectional images need only 1K.

Display stations can be categorized by primary use:

• Radiologist Reading Stations: Used for primary diagnosis with high-quality hardware.

• Physician Review Stations: A step-down model with the ability to view current and previous
reports and images.
 • Technologist Quality Control (QC) Stations: Used by technologists to review images.

• Image Management Stations: Used by file room personnel.

Radiologist Reading Stations

Used by radiologists for primary diagnosis, featuring the highest quality hardware, robust computers,
and customizable peripherals. Access to RIS and dictation systems is common, with software
integrating these functions.

Physician Review Stations

A step-down model allowing physicians to view current and previous reports and images, often
integrating RIS functions with PACS software.

Workstations

Workstations are a key component of PACS (Picture Archiving and Communication System),
facilitating image viewing and manipulation for various healthcare professionals.

PACS Workstation Types

Display workstations are categorized by their primary use:

• Reading Stations: Used by radiologists.

• Review Stations: Used by referring physicians.

• Technologist QC Stations: Used by technologists to review images.

• Image Management Stations: Used by file room personnel.

Physician Review Workstations

These workstations allow physicians to view images and radiologist reports, improving patient care
continuity and speed.

• Software can be on a stand-alone station or accessed via web browser.

• High-volume areas like ER and ICU have dedicated PACS workstations.

• May have high-end or lower-end monitors due to cost.

• Enable viewing of the same images in multiple locations simultaneously.

Technologist QC Stations

These stations are used by technologists to review images before sending them to radiologists.

• Review images after acquisition but before radiologist review.

• Improve or adjust image quality.

• Verify patient demographic information.

• Often placed between CR and DR modalities.

• Generally have a 1K monitor.

• Used to query and retrieve historic images for comparison.

File Room/Image Management Stations

These stations manage images within the PACS environment.

• Used to look up examinations for physicians.

• Print copies of images for patients.

• Correct patient demographics.

• Moving towards burning CDs instead of printing films.

• Ensure the archive's data is accurate.

Common Functions

PACS workstations have functions broken down into four categories:

• Navigation functions

• Image manipulation and enhancement functions

• Image management functions

• Advanced workstation functions

Navigation Functions

Used to move through images, series, studies, and patients.

• Worklist: Used to navigate through patients.

• Customizable for each user.

• Use of grab bars on the right side of Windows to scroll through a list and the activation of the
scroll wheel on the mouse to scroll through the list are common features.

• Mouse: Offers shortcut features in a menu of frequently used tasks and applications.

Hanging Protocols

A hanging protocol is how a set of images will be displayed on the monitor.

Users can customize hanging protocols for each modality, showing previous and current
examinations.

Study Navigation

• A study in PACS is the current or previous examination being viewed

• Images can be paged through with the scroll wheel or arrows or run through in stacks

• Many vendors call the stack mode of scrolling through images cine

The term cine comes from the word cinematic, and it means to move through frame by frame of the
series of images.

• Images can be moved through manually using the mouse, but most vendors have an
automatic setting that runs through the images at a preset pace
 • Icons allow users to move among a patient’s various studies or open the next unread patient
in the worklist after having read the current study

• Another navigation tool that is commonly found is a close patient or close study icon

Image Manipulation and Enhancement Functions

Functions used to change the appearance of the image:

• Window/level: Adjusts brightness and contrast.

• The window represents the range of gray values that are being viewed.

• The level represents the center value of the range.

• Annotations: Adds text or graphics to the image.

• Should NOT be used to label left or right.

• Flip and rotate: Orients the image.

• Pan, zoom, and magnify: Increases the size of an area.

• Measurements: Measures structures on the image.

• Distance measurement: Measures structures.

• Angle measurement: Measures the angle between two structures.

• Region of interest (ROI): Determines pixel intensity.

Image Management Functions

Functions to manage patient demographics and images:

• Modify patient demographics (only when absolutely known to be wrong)

• Query/retrieve function to retrieve studies from the archive

• CD-burning option for outside use

• Copy and paste images into documents (remove patient information first)

• Print films for outside use

Advanced Workstation Functions

Advanced functions are usually placed on specialty workstations for the radiologist, but some are
found on the technologist QC station to further enhance the images.

Reading Station Advanced Functions

• Multiplanar reconstruction (MPR): Reconstructs images in another plane.

• Maximum intensity projection and minimum intensity projection (MIP and

MinIp): Visualizes vessels (MIP) and air-filled structures (MinIp).

• Volume rendering technique (VRT): Assigns colors based on tissue intensity.

• Shaded surface display (SSD): Creates a 3D object.

Technologist QC Station Advanced Functions

• Stitching: Combines multiple images into one.

• Image postprocessing: Enhances images.

Archiving

Archiving Components

An archive can be defined as a place where records or documents are preserved

The electronic archive serves as the new file room and warehouse for all digital imaging and
communications in medicine (DICOM) imaging modalities.

• Stores all patient and image data.

• Controls the receipt, storage, and distribution of images.

• Archive technology continues to make drastic improvements each year

The archive is a complex arrangement of computers and storage space that consists of:

• Image manager/controller

• Image storage/server

Image Manager

The image manager contains the master database of everything that is in the archive.

• Controls the receipt, retrieval, and distribution of the images it stores

• Controls all the DICOM processes running within the archive

• Generally runs a reliable commercial database with structured query language (SQL)

• The database is mirrored

The image manager is the PACS component that interfaces with the radiology information system
(RIS) and the hospital information system (HIS).

The image manager database contains the DICOM header information, such as the patient name,
identification information (ID), examination date, ordering physician, and location.

Process Summary:

1. An order is placed in the RIS for a radiology study.

2. The images are acquired and sent to the archive.

3. The image manager strips the image header from each image and assigns a pointer to each
image or series of images.

4. The database files the information in various fields and communicates back to the RIS to
verify certain information.

5. The study is then queried, and the pointers locate the images on the archive server and send
the images to the workstation.
Image Storage

The image storage or archive server consists of the physical storage device of the archive system.

It commonly consists of two or three tiers of storage:

• Short term

• Mid term

• Long term

Short-Term Storage

The short-term tier is commonly a redundant array of independent (inexpensive) disks (RAID).

A RAID is composed of several magnetic disks or hard drives that are linked together in an array.

Four RAID levels that are most commonly used:

RAID
Level Description

RAID 0 Data are striped across all of the connected disks

All of the data sent to the RAID are mirrored onto two disks. This RAID level has full redundancy, meaning tha
RAID 1 down, the other one takes over and operation of the system continues.

The data are striped across all of the disks just like in RAID 0, but there is one disk that is set aside for error co
RAID 3 is known as the parity disk.

This RAID level is similar to RAID 3 but instead of having the parity written to one disk, it is striped along all of
the RAID. RAID 5 is the most common level used for a PACS archive because it provides adequate redundancy
RAID 5 tolerance.

The striping of data increases the reliability and performance of the system.

Long-Term Storage

Because RAID is becoming more cost-effective, many hospitals use RAID storage for both their short-
term and their long-term archive. Other long-term storage products that are still widely used are
optical disk, tape, and magnetic disk. Optical disk and magnetic tape archive solutions use a jukebox
to hold the tapes or disks; the magnetic disk uses an array. The jukebox has controller software that
interfaces with the image manager to keep track of exactly where each image is located. The jukebox
controller keeps like studies together as much as possible to minimize access time.

Optical Disk

• Magneto-optical Disk

A magneto-optical disk (MOD) is very similar to a compact disk (CD) or digital versatile disk (DVD) in
that it is read optically with a laser, but the disk itself is housed within a plastic cartridge.
MODs tend to be more reliable than some of the other long-term storage options.

• Digital Versatile Disk

Digital versatile disks (DVDs) were first introduced for use in video.

DVDs are the least expensive method for long-term archiving per gigabyte.

• Ultra Density Optical

Ultra density optical (UDO) disk is the new generation MOD.

A UDO disk utilizes blue laser technology in its read and write activities.

Tape

Tape libraries provide the greatest scalability of the long-term archive options. One of the biggest
disadvantages of tape is its unreliability over multiple uses.

Magnetic Tape

Magnetic tape has been around for many years and is still a factor in long-term PACS archiving
systems due to its speed and reliability.

There are several types of magnetic tape technologies available:

• Linear Tape Open (LTO)

• Developed jointly by Hewlett-Packard, IBM, and Quantum.

• Offers an open-format tape storage option, meaning users have multiple sources of
product and media and can mix products from various vendors while maintaining
compatibility and function.

• A high-capacity tape technology. Current LTO-3 technology holds 400 GB of

uncompressed data on a single tape.

• Digital Linear Tape (DLT)

• Invented by Digital Equipment Corporation in 1984 and purchased by Quantum in

1994, who licenses the technology.

• DLT tape drives have storage capacities between 40 and 160 GB, and a newer DLT
technology known as super DLT has a capacity of 160 to 300 GB uncompressed.

• Advanced Intelligent Tape (AIT)

• A high-speed and high-capacity tape made by Sony to compete with the DLT.

• Sony introduced AIT in 1996 with a tape capacity of 25 GB; current AIT-4 technology
has a capacity of 200 GB.

• Sony developed the next generation of AIT tapes, known as SAIT, with an initial
capacity of 500 GB. Sony planned for the fourth generation of SAIT to come out by
2010 with a capacity of 4 TB/tape.

Magnetic Disk
As the price of magnetic disk storage continues to decrease, RAID storage becomes a more feasible
option for long-term storage. When using magnetic disks for long-term storage, the RAID arrays may
be configured into three different but related fashions: Direct Attached Storage (DAS), Network
Attached Storage (NAS), or Storage Area Network (SAN).

• Direct Attached Storage (DAS)

• Coupled to the system just like a short-term RAID.

• Connected directly via cable connections and shows up on the computer as different
partitions for use.

• Typically managed by the same RAID controller because, in essence, the short-term
RAID is just being expanded to have more storage space so that the studies will
remain for a longer period.

• Network Attached Storage (NAS)

• Stand-alone RAID arrays that are attached directly to the network.

• Multiple NAS servers can be attached to one network to provide additional fault
tolerance, and the load can be balanced throughout the servers.

• Storage Area Network (SAN)

• A high-speed, special-purpose network (or subnetwork) that links different kinds of

data storage devices with associated data servers, such as disk array controllers and
tape libraries.

• Becoming more popular in health care because of plummeting costs of magnetic disk
storage.

• Can be used by multiple departments within an institution and provide exceptional

response speed for called-up data.

• The RAID levels can still be taken advantage of when used in conjunction with a SAN.

Archive Considerations

PACS archives are chosen for many reasons, including system need, system cost, and system
compatibility. Many hospitals do not have the capital funds or the personnel to implement and
operate the complex archive needed for a PACS and have sought out other alternatives, such as
an Application Service Provider (ASP).

An ASP is a company that provides outsourcing of archiving and management functions for a pay-
per-use or pay-per-month charge. ASPs give smaller institutions access to the level of hardware and
software they could not otherwise afford.

Moreover, they assume responsibility for the day-to-day management of the archive system. Many
ASP models have a short-term archive located on hospital premises, and the long-term archive is
handled at the off-site location run by the ASP company. The short-term archive may be leased by
the ASP, and the controller will prefetch images from the long-term off-site storage during the
evening and night hours for the next day’s schedule.
Another common use for an ASP is as a disaster recovery mechanism. Disaster recovery involves
making copies of each tape or disk and sending them to another building or off-site location or by
using the ASP model of shipping them to an outside company for storage on a pay-per-use policy.
With proper disaster recovery, a complete copy of the archive is housed in another location and
immediately available if the front-line archive goes down for any reason.

With an ASP, however, the data may be housed in another state in a large storage silo, and the
duplicated data may not be immediately available. There are many facets to disaster recovery, but a
discussion of them is outside of the scope of this textbook.

The most important thing to know is that backups are completed each day on the image manager
database and that there must be some sort of contingency plan should disaster strike the archive
room.

The archive is a complex arrangement of servers, databases, and storage devices. It is the most
integral part of a PACS and is, in general, the most difficult piece to fully understand.

Film Digitizers

Another way to take a projection radiograph to a digital format other than computed radiography
(CR) and digital radiography (DR) is by using a film digitizer.

The film digitizer scans the analog film and produces numeric signals for each part of the scanned
film.

The numbers are fed into a software application that is attached to the scanner, and the scanner
digitally reproduces the image using the numeric signals that represent each part of the radiograph.

There are two major types of film digitizers:

• Laser Technology

• Charge-Coupled Device (CCD) Technology

Both are equal in quality, but currently, the CCD digitizers are less expensive.

Laser Film Digitizers

A laser film digitizer uses a helium-neon laser beam to convert the analog film image into a digital
image. A laser inside the digitizer is bounced off a series of mirrors and scanned across the image. A
photomultiplier tube picks up the light that is transmitted through the film. The laser scans one line
at a time, and the photomultiplier picks up a very small area and then moves to the next area. The
electrical signal is then sent to an analog-to-digital converter where the signal is translated into
numbers based on the optical density of the film and the signal received. The numbers are then
displayed on a monitor based on a look-up table (LUT) that indicates which shade of gray is
associated with each number.

Laser digitizers are considered the gold standard for film digitization and have been around since
approximately 1990. These digitizers can scan at various resolutions up to 5K and 12 bit, depending
on the application need, and can scan an image in less than 25 seconds, depending on the scanning
resolution. The disadvantages of laser digitizers include their expense and service needs, including
maintenance, calibration, and quality control (QC) tests.

CCD Film Digitizers

A CCD film digitizer uses fluorescent bulbs that shine through the film and a CCD array that detects
the light and transforms it into an electrical signal. The signal is then sent to an analog-to-digital
converter and changed into a number that represents the intensity of light that passed through the
film. As with the laser digitizer, the number is referenced against an LUT, and an image is displayed on
a monitor.

The CCD digitizers are less expensive than the laser digitizers but somewhat slower. A CCD digitizer
can take up to 80 seconds to scan one film through the digitizer, and it can also have problems with
extreme light and dark areas on the film. However, the CCD digitizer image quality has improved over
the years, and many radiologists say that the quality is adequate for their needs.

Common Uses of Digitizers

There are many uses for the film digitizer in the modern radiology department. Most departments
list the following reasons for using a digitizer:

• Teleradiology:

Teleradiology is a term used to describe the process of transferring digitized images for delivery at a
distance to radiologists. Many hospitals use the digitizer to transfer films from off-site clinics to the
main department for primary reading. The films are placed in the digitizer, and the image is
transformed into a digital signal and sent via a network back to the main department.

• Comparing Outside or Old Films:

If a hospital has a PACS installed and is reporting the image from a monitor, it is very difficult to
compare a film image with the image on the monitor. Many hospitals will digitize the patient’s old
films so that a comparison can be done much more easily. Patients also frequently come in with
outside films. These are routinely digitized into the archive so that they can be referred to at a later
date and compared with new digital images.

• Film Duplication:

On occasion, it is necessary to make duplicate copies of films. The film can be sent through the
digitizer, and then the image can be printed onto film using a laser film imager.

• Computed Aided Diagnosis (CAD):

A new technology that is gaining momentum is CAD. It is most currently used in mammography and
chest imaging. The film is sent through the digitizer, and a computer will analyze the densities seen
on the image and alert the radiologist of questionable densities.

Imagers

Imagers, also known as film printers, receive an image from a workstation and print the image based
on printer LUTs and preset print layouts. Both of these parameters vary for each modality that
produces digital images.

There are two major types of imagers still in use today:

• Wet (Chemical) Laser Imagers

• Dry Laser Imagers

Wet Imagers
Wet imagers use chemicals to process the film that has been exposed to the laser. The laser beam
produces an intensity of light that is proportional to the signal being received to regulate the optical
density recorded on the film. The laser emits a red light, so the film that is used must be red
sensitive. Conventional film has silver halide crystals suspended in an emulsion; the wet laser film is
not much different other than being red sensitive so that the laser may etch the image into the film.
Because this film is sensitive to red light, it must be placed in its film magazine and processed in total
darkness. This processing takes place in a bath of chemicals just like film used in the traditional
film/screen department.

Because wet imagers require chemicals, they must be placed in a well-ventilated area with proper
drainage and plumbing. Because of these requirements, fewer departments install this type of
imager. Wet imagers also take up much more space than the dry imagers, and the cost of chemicals,
disposal, and maintenance makes them a less popular choice than dry imagers.

Dry Imagers

Dry imagers use heat to process the latent image that is etched into the silver emulsion by the laser.
Just like conventional film, dry laser film also has silver within its emulsion, but instead of silver
halide crystals, the dry film has silver behenate. The film is exposed with a laser in a fashion similar to
the wet imager. The silver salts are then exposed to heat and turn to metallic silver to create the
image on the film.

Dry imagers have been found to have slightly worse quality than wet imagers, but the dry imagers
take up less space and require no special locations. The dry imager film quality tends to degrade over
time, and it is more sensitive to heat and humidity than conventional film, especially if the film is
stored in a warm environment. Moreover, because the chemicals that make the image are still on the
film after it is processed, the image can gain more density when stored in a high heat area. The major
advantage to the dry imager is that it only requires an outlet and a network connection to connect to
the departmental modalities.

Common Uses of Imagers

Even though the future of radiology is a filmless environment, there will always be a need for
producing a hardcopy film. The following paragraphs outline a few reasons why film can and will be
used in the “filmless” radiology department.

• Backup:

The ability to print just in case the PACS goes down is one of the most often heard explanations. In
most hospital networks, the modalities are set up to send not only to the PACS but also directly to a
laser imager. So if the PACS is down for some reason, the modality can still print directly to the
imager.

• Difficult PACS Locations:

When a PACS is installed, there are a few departments that are difficult to convert to PACS initially,
like surgery, orthopedics, and sometimes the emergency room. In surgery, space is at a premium, and
it may be difficult to place a PACS workstation in the surgical suite. In many instances, films are
printed for surgery and placed on a lightbox.

• Outside Physicians:
Many referring physicians prefer to see their patient’s images while reviewing the radiologist’s
report. When installing a PACS, one of the last pieces to be converted is outside physician access so,
with imagers, films can be printed and sent to the physicians as normal.

• Legal Cases:

For legal cases, films can be printed to be viewed in court. It may become more commonplace to
have computer access in the courtroom, and at that time images can be viewed digitally.

• Teaching Purposes:

Most hospitals train students at their institution. The printing of films for training purposes will
continue to be a need.

CD/DVD Burners

Early PACS advocates used cost savings to justify purchasing a PACS, but there remains a need for
hard copies. Film printing is a costly part of a PACS because laser film is expensive, more expensive
than conventional film. Most hospitals try to reduce the amount of printing done in the department.
One alternative to printing hard copies is to burn images to an optical disk.

CDs and DVDs are both thin injection-molded polycarbonate plastic disks. The disk is impressed from
a mold to form microscopic bumps that indicate either a 1 or 0 to the computer. Over the bumps is a
reflective layer of aluminum covered with a clear protective coat of acrylic. In a DVD, there are
multiple layers of the polycarbonate plastic. Aluminum is used behind the inner layers, and gold is
used behind the outer layers. The gold is semi-reflective so the laser can penetrate to the inner layers
of plastic. With a burner, the information is burned onto the disk starting in the center and spiraling
out to the edge of the disk. The laser will burn a tiny depression (pit) into the disk to represent the
data being saved. A burned disk will be a series of pits and lands, areas that were not burned by the
laser.

All PACS vendors offer the ability to burn images to a CD or DVD for the purpose of sharing the
images outside of the PACS. When a disk is burned with the patient’s images, a digital imaging and
communications in medicine (DICOM) viewer is also burned onto the disk. When the disk is put into
a drive, the software automatically launches and displays the images. The software is generally very
intuitive and easy to use and allows for minor image enhancements such as window/level
adjustments and simple measurements.

Common Uses of Burners

These disks can be used in most of the same applications as the printed film with the exception of
using them as a fail-safe mechanism and for those departments that are in difficult locations. Many
referring physicians prefer having the images on disk rather than film because it takes up less space,
can be added directly to the patient’s office chart, and the images can be manipulated.

Disks also are much cheaper to produce and send out to physicians. One sheet of dry laser film is
approximately $0.48, whereas a CD is approximately $0.28. The CD can hold multiple studies, and
multiple sheets of film would be needed to print an entire study. The CD will also be much cheaper
to mail than the film. Disks will become much more common outside of the radiology department as
the advantages are seen by those outside of the department.

Quality Aspects
When you think of quality, what is the first thing that comes to mind? Is it the service at a restaurant
or the backpack purchased at the beginning of the semester? Both of these deal with quality in some
way: one is people-centered, and the other is product-centered. Likewise, radiology has both a
people-centered quality and a product-centered quality.

The traditional department with film and chemistry has many quality procedures that must be
followed. Many of these same protocols are used in the digital department, but they have been
modified to be relevant to digital equipment and processes.

Terms of Quality

Quality has always been a part of health care, whether as a service or product. Health care
institutions pride themselves on providing the highest quality possible, and they put many measures
into place to ensure that the highest quality is provided to each patient. The ultimate focus in health
care is to improve patient care and provide high-quality service so that patients will want to return.

Most health care institutions are accredited by The Joint Commission (TJC), formerly known as the
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). This accreditation is
voluntary but necessary in many instances to obtain Medicaid certification, hold certain licenses,
obtain reimbursements from insurance companies, and receive malpractice insurance. Today TJC
uses a more all-encompassing term of Continuous Quality Improvement (CQI) or Total Quality
Management (TQM).

Quality Assurance

Quality assurance (QA) can be defined as a plan for the systematic observation and assessment of the
different aspects of a project, service, or facility to make certain that standards of quality are being
met. QA activities are focused around people and service.

In a radiology department, there are many processes involved in the day-to-day activities. Most QA
activities will produce quantitative data that can be analyzed. These data can be used to monitor the
processes and determine whether the process is working as it should and whether the standard of
quality has been met.

Quality Control

Quality control (QC) can be defined as a comprehensive set of activities designed to monitor and
maintain systems that produce a product. QC measures are taken to ensure that radiologic
procedures are performed safely, are appropriate for the patient, are performed efficiently, and
produce a high-quality image.

QC measures are required by law to maintain the license for the room or department. The data from
the various activities are kept by a designated individual within the department. Most QC activities
are part of a QA program, and the data are used to improve the quality of the processes and
department.

There are three major categories of QC tests that are used at various times:
QC Test Description

Acceptance Performed before newly installed or majorly repaired equipment can be accepted by the departme
Testing whether the equipment is performing as promised.

Routine Performed to ensure that the equipment is performing as expected. Can catch problems before the
Maintenance radiographically apparent.

When errors occur in equipment performance, corrective action must occur. Corrections will gener
Error Maintenance service personnel employed by the vendor.

Continuous Quality Improvement

Continuous quality improvement (CQI) tends to focus on the process rather than on the people or the
service. The belief is that if the process is good, health care workers will follow it, and service will be
good.

The CQI process does not replace QA/QC programs. The QA/QC programs focus on maintaining a
certain level of quality, not necessarily improving to a higher quality. CQI focuses on improving the
process or system within which the people function as team members rather than focusing on an
individual’s work.

One of the most important concepts to understand with CQI is that all levels of people within the
organization must be involved in the process of improvement. Because CQI focuses not on
individuals and their mistakes but rather on the process, each team member is more apt to
participate in improving the organization.

PACS Equipment QC

When beginning a QC program, care must be taken to document all surrounding variables so that
each quality## Quality Control in PACS Environments

This study guide covers the essential quality control (QC) activities that should be monitored in a
Picture Archiving and Communication System (PACS) environment. It includes display quality,
processing speed, network transfer speed, and data integrity.

Documentation

• Documentation is crucial in QC activities. It must be up-to-date to validate performance

measures.

• Without proper documentation, proving the need for system repair or updates becomes
challenging.

QC Activities

The following QC activities should be monitored in a PACS environment:

• Display quality (monitor and film)

• Processing speed
 • Network transfer speed

• Data integrity of data recalled from the archive

It's crucial to follow the vendor’s list and timetable for these activities.

ACR Guidelines

According to the American College of Radiology (ACR) "Technical Standard for Digital Image Data
Management":

Any facility using a digital image data management system must have documented policies and
procedures for monitoring and evaluating the effective management, safety, and proper performance
of acquisition, digitization, compression, transmission, display, archiving, and retrieval functions of
the system. The quality control program should be designed to maximize the quality and accessibility
of diagnostic information.

The ACR recommends using a Society of Motion Pictures and Television Engineers (SMPTE) test
pattern to ensure measurement consistency. The American Association of Physicists in Medicine
(AAPM) Task Group 18 (TG18) test pattern is also widely accepted for QC tests.

• ACR suggests monthly QC tasks.

• AAPM suggests a more rigorous schedule:

• Acceptance and annual testing by a trained physicist.

• Daily and monthly/quarterly tests by a trained QC technologist or physicist.

If tests fail or produce out-of-range readings, corrective action and continuous monitoring are
necessary.

Monitor Quality

The monitor is a critical component in the digital imaging chain, directly affecting the image quality
presented to radiologists and referring physicians. Radiologist workstations use high-quality medical-
grade monitors.

• 2K or 3K for computed radiography (CR) or digital radiography (DR).

• 1K or 2K for cross-sectional images.

• Up to 4K for mammography.

Physician review and technologist QC workstations typically have high-quality commercial monitors
with a resolution of 1K.

Recommendations for display monitors come from the AAPM document, "Assessment for Display
Performance for Medical Imaging Systems."

Daily Monitor QC

• Turn on the monitor and allow it time to warm up.

• Ensure the monitor surface and airflow areas are dust-free.

• Retrieve a QC monitor test pattern (SMPTE or AAPM TG18-QC).

 • Evaluate overall image quality and appearance, noting nonuniformities or artifacts, especially
at black-to-white transitions. Verify continuous vertical and horizontal bars.

• Check for geometric distortion, ensuring borders and lines are clear and straight, and the
pattern is centered.

• Verify that all 16 luminance patches are visible. Measure luminance using a photometer and
compare to previous measurements. Ensure the 5% and 95% patches are visible. Evaluate
the appearance of low-contrast letters and targets with and without ambient lighting.

• Evaluate Cx patterns at the center and corners, ensuring all letters and numbers appear.

Monthly/Quarterly Monitor QC

• Turn on the monitor and allow it time to warm up.

• Ensure the monitor surface and airflow areas are dust-free.

• Retrieve a QC monitor test pattern.

• Check for geometric distortions using the TG18-QC test pattern, maximizing it to fill the
display area.

• Determine if there are reflections from other light sources.

• Measure luminescence from the center of the monitor for each TG18-LN test pattern using a
photometer, and record each reading. Measure ambient luminance with the monitor off.

• CRT monitor: luminance > 170 cd/m².

• LCD monitor: luminance > 100 cd/m².

• Contrast ratio: > 250 cd/m² difference between TG18-LN-01 and TG18-LN-18
readings.

• Using the TG18-CT pattern, ensure half-moon targets and low-contrast objects are
visible.

• Assess bit-depth resolution using the TG18-MP test pattern.

• Assess luminance uniformity visually using the TG18-UN10 and TG18-UN80 test patterns.

• Assess angular response visually using the TG18-CT test pattern.

• Measure luminance at five positions (center and four corners) using a calibrated photometer
with the TG18-UNL10 and TG18-UNL80 test patterns. Readings should be within 30% of each
other.

• Examine displayed Cx patterns at the center and four corners using the TG18-QC pattern and
PACS software magnifying glass. Evaluate line pair patterns and grayscale step pattern.

• Determine resolution uniformity using the TG18-CX test pattern and magnifying glass.

Annual and acceptance testing should be performed by a qualified medical physicist.

Printer Image Quality

Ensuring consistent image quality is essential for printed images.

Wet Laser Imager

Daily/Weekly QC

• Monitor each film for artifacts and consistency with monitor quality.

• Print a test pattern from the PACS or printer.

• Observe the test pattern for artifacts, density changes, contrast, and resolution.

• Measure steps on the test pattern using a densitometer and create a characteristic curve.

• Monitor processing mechanism, noting temperature and chemical levels. Clean racks and
rollers.

• Complete preventative maintenance and maintain documentation.

Dry Laser Imager

Daily/Weekly QC

• Monitor each film for artifacts and consistency with monitor quality.

• Print a test pattern from the PACS or printer.

• Observe the test pattern for artifacts, density changes, contrast, and resolution.

• Measure steps on the test pattern using a densitometer and create a characteristic curve.

• Complete preventative maintenance and maintain documentation.

Speed

Workstation Processing Speed

• Determine a test study with several images and a patient with multiple studies.

• Open the test study and note the loading speed. Page through images and note loading
speed.

• Perform an image processing function (e.g., edge enhancement) and note the processing
speed.

• Open the patient’s next study and note the loading speed.

This procedure should be followed weekly initially, then monthly if no changes are seen. Repeat
weekly after software or equipment updates.

Image Transfer Speed

• Determine a test study or use saved test patterns. Perform the procedure on the same day
and time to reduce network traffic variables.

• Retrieve the study to the workstation and note the time taken.

• Have each modality send QC images to the archive and note the transfer time. Ensure the
same image set is used each time.
This procedure should be followed weekly initially, then monthly if no changes are seen. Repeat
weekly after software or equipment updates.

Data QC

Data Integrity

• Monitor whether all images from the modality make it to the PACS. Check daily initially, then
weekly if no missing images are found.

• Periodically retrieve images from the archive to ensure they match the initially sent images.
Check weekly.

After system acceptance, follow the procedure daily, then weekly/monthly if no changes are seen.
Repeat daily after software or equipment updates.

Compression Recall

• Save versions of the AAPM TG18-QC test pattern with different compression ratios (no
compression, lossless, lossy) on the archive.

• Recall all test patterns and compare the results to determine if there is any loss of
information.

PACS CQI

Continuous Quality Improvement (CQI) activities should be monitored in a radiology department.

CQI activities revolve around processes rather than people and systems.

Recognition of Undiagnostic Images

• Radiologists should document undiagnostic images forwarded to the PACS.

• Note the study, performing technologist, areas, and reasons for poor image quality.

• Follow up with the technologist. Perform QC tests and service protocols for equipment
malfunction or provide additional training for operator error.

System Up-Time

• Monitor and log system downtime, including the reason, duration, fix, and who fixed it.

• Use the log to prove the need for equipment replacement or additional service.

System Training

• Establish an ongoing training program for all staff levels, from radiologists to ancillary
personnel.

• Train new employees and retrain existing personnel after software updates.

• Include PACS skills in annual training and keep training records for each employee.

Key Terms
Term Definition

Continuous Quality Focuses on improving the process or system in which people function as members of
Improvement (CQI) than focus on the individual’s work.

Quality Control (QC) A comprehensive set of activities designed to monitor and maintain a system or piece

Total Quality Management

(TQM) Overall efficiency and effectiveness of imaging systems.

Preventative Maintenance (PM) Activities performed to prevent equipment failure and ensure optimal performance.

Summary

QC Activity Frequency Performed By

Daily Monitor QC Daily Trained Technologist

Monthly/Quarterly Monitor QC Monthly/Quarterly Trained Technologist

Printer Image Quality Daily/Weekly Trained Technologist

Speed Assessment Weekly/Monthly Trained Technologist

Data QC Daily/Weekly/Monthly Trained Technologist

Acceptance & Annual Testing Annually Qualified Medical Ph

Recognition of Undiagnostic Images As Needed Radiologist

System Up-Time Monitoring Continuously PACS Administrator/

System Training Ongoing (New Employees, Software Updates) Super Users/PACS A

Chapter Review Questions

1. What are the differences between quality control and quality assurance activities?

2. What is the definition of continuous quality improvement, and what are its uses in the
radiology department?
 3. What are the quality control activities that should be performed on the computer monitors
in the radiology department, and how often should these activities be performed?

4. What are the quality control activities that should be performed on the laser imagers in the
radiology department, and how often should these activities be performed?

5. How would system speed and data integrity be measured as part of the QC program?

6. Describe several quality assurance activities used in a digital radiology department.

Quality Control in CR and DR Systems

This section covers the essentials of quality control (QC) in computed radiography (CR) and digital
radiography (DR) systems, focusing on the responsibilities of technologists, service personnel, and
radiation physicists.

Technologist Responsibilities

Radiologic technologists are the first line of defense in QC. Their duties include preventing,
recognizing, and reporting QC issues. Key areas include:

• Image Analysis:

• Placement, accuracy, location, and orientation.

• Collimation and shielding.

• Patient artifacts.

• Imaging equipment handling/processing artifacts.

• Image sharpness, magnification, and distortion.

• Positioning (film size, alignment, central ray placement, angles, rotation, anatomy
inclusion).

• Exposure:

• kVp appropriateness.

• Scale of contrast.

• Density (too dark/light).

• Exposure index appropriateness.

• mAs selection appropriateness.

• Equipment:

• Reader and histogram errors.

• Reject Reasons:

• mAs and kVp errors (easier to identify in DR).

• Positioning errors.

• Side/position marker errors.

It's highly recommended departments implement procedures to standardize exposure practices, not
for punishment, but for standardization. Accepting responsibility for one’s work is part of being a
professional.

Clean Imaging Plates

• Inspection:

• Remove imaging plates (IPs) from cassettes and visually inspect for dirt, hair, lint,
scratches, or cracks weekly, especially in high-throughput or "dirty" case areas.

• Cleaning:

• Use lint-free cotton gloves.

• Wipe debris gently with a lint-free cloth (photographic lens cloth).

• Use a camel hair brush carefully.

• If needed, use manufacturer-recommended cleaning solutions, following material

safety data sheet (MSDS) guidelines.

• Replace IPs if artifacts can’t be removed.

• Disposal:

• Imaging plates contain barium, requiring disposal according to state and EPA
regulations by a licensed company with an EPA identification number. Standard trash
disposal is unacceptable.

Artifact Identification

• Monthly QC:

• Identify recurring artifacts from debris on IPs, cassettes, laser lenses, and reader
mirrors.

• Reporting:

• Report major artifacts immediately.

• Address smaller artifacts to prevent long-term issues.

• Problem Reporting Procedures:

• Establish a mechanism to identify recurring quality trends (e.g., noisy or light

images). This can help service personnel identify issues based on location and
frequency and whether the system needs recalibration.

Service Personnel Responsibilities

Service personnel ensure equipment is properly maintained through preventative maintenance (PM),
typically semiannually.

• X-Ray Generator, Tube, and Reader:

• Tests for accuracy and reproducibility, ensuring code value at each pixel reflects the
x-ray exposure.
 • Reproducibility should be $ \pm 2% $ within established exposure parameters.
Kodak recommends 20 exposures per test at 80 kVp.

• Measure densities within low contrast bands and exclude them during recalibration.

• Address high contrast white spots (dust on screen) and sharply defined white streaks
(dust on light-collection optics).

• Phosphor Accuracy Testing:

• Use a special standardized cassette to test response uniformity and artifacts after
exposure.

• Image Processing:

• Test parameters to ensure anatomic image analysis and histogram production

function correctly.

• Disable automatic functions and process images manually to evaluate processing

errors. Discard test images.

• Image Display:

• Verify correct positioning and image processing selections, subsampling images.

These images are only for image display issues, not system performance.

• Screen Erasure:

• Test erasure function yearly to avoid interference from previous exposures or

extraneous light.

• Spatial Frequency Response Testing:

• Use line-pair testing phantoms to determine resolution patterns. Phantoms should

encase objects at least 0.05 mm thick with patterns at least 10 mm long.

Radiation Physicist Responsibilities

Schedules vary; physicists may handle multiple facilities or be dedicated to one. Responsibilities
include:

• Semiannual/Annual QC:

• Review departmental images to reestablish baseline values, check exposure indicator

accuracy, determine exposure trends, analyze repeat rates, review QC records, and
analyze service history.

• Standard Tests:

• Filtration, collimation, focal-spot size, kVp calibration, exposure timer accuracy,

exposure linearity, exposure reproducibility, and protective apparel.

• AAPM Report 74:

• Follow AAPM Report 74 for daily, weekly, monthly, semiannual, and annual tests and
reports for photostimulable phosphor systems.
 Summary

Role Responsibilities

First line of defense; prevent, recognize, and report QC issues; image analysis, exposure assessment
Technologist checks.

Service Equipment maintenance through preventative maintenance (PM); tests for accuracy, reproducibility
Personnel correction.

Radiation Semiannual/annual QC reviews, standard tests (filtration, collimation, etc.), and adherence to AAPM
Physicist photostimulable phosphor systems.

Radiology Study Guide

Network Topologies and Components

• Network: A system for devices to communicate.

• LAN (Local Area Network):

• Geographic Classification: Limited to a local area.

• WAN (Wide Area Network):

• Geographic Classification: Spans a broad area.

• Communication Medium: Means through which devices connect.

• Coaxial Cable: A type of cable used for transmitting signals.

• Fiberoptic Cable: A cable that transmits data as light.

• Twisted-Pair Wire: A type of cable with wires twisted together.

• Wireless Connections: Communication without physical cables.

• Network Bridge: Connects two networks.

• Network Hub: A central point that connects devices in a network, but is not very efficient in
its routing.

• Network Router: Routes data between networks.

• Network Switch: More efficiently directs traffic than a hub.

• NIC (Network Interface Card): Connects a device to the network.

• TCP (Transmission Control Protocol): A standard of communication.

• IP (Internet Protocol): Part of the internet protocol suite.

• TCP/IP: A common suite of protocols for communication.

• Network Protocol: Standard set of rules for data exchange.

 • Common Network Topologies:

• Bus Topology:

All devices connected along a single cable.

• Ring Topology:

Devices connected in a circular path.

• Star Topology:

All devices connect to a central hub.

• Mesh Topology:

Devices are interconnected with many redundant paths.

Digital Imaging and Radiography

• Digital Imaging: A method of capturing images electronically.

• CR (Computed Radiography):

• A digital radiography method using a cassette.

• DR (Digital Radiography):

• A form of radiography where digital X-ray sensors are used instead of traditional
photographic film.

• Direct Capture: DR image acquired directly by detector.

• Indirect Capture: DR image converted to light then captured.

• Conventional Radiography: Traditional film-based X-ray imaging.

Comparison of CR, DR, and Conventional Radiography: | Feature | Conventional Radiography | CR |

DR | | :----------------------- | :----------------------- | :------------------------- | :------------------------- | | Image
Capture | Film | Imaging Plate | Digital Detector | | Processing | Chemical | Digital | Digital | |
Speed | Slower | Faster than Conventional | Fastest | | Post-processing Options| Limited | Extensive
| Extensive |

CR Equipment Components

• Cassette:

• Houses the imaging plate.

• Imaging Plate:

• Acquires and stores the latent image.

• Construction:

• Protective Layer: Protects the plate.

• Phosphor Layer: Contains photostimulable phosphor.

• Reflective Layer: Reflects light toward the reader.

 • Conductive Layer: Reduces static.

• Color Layer: Absorbs stimulating light.

• Backing Layer: Provides support.

CR Image Acquisition

• Exposure:

• Process of exposing the imaging plate to radiation.

• Collimation: Limiting the X-ray beam size.

• Equipment Selection: Choosing appropriate equipment.

• Part Selection: Selecting the correct body part.

• Side/Position Markers: Indicating patient orientation.

• Technical Factors:

• kVp (Kilovoltage Peak): Affects beam penetration.

• mAs (Milliamperage Seconds): Affects the number of X-ray photons.

Image Artifacts and Errors

• Imaging Plate Artifacts:

• Arise from the imaging plate itself.

• Plate Reader Artifacts:

• Result from issues in the plate reader.

• Operator Errors:

• Mistakes made by the person operating the equipment.

Image Processing and Manipulation

• Digital Radiographic Image Processing and Manipulation: Techniques to enhance and adjust
images.

• Automatic Rescaling: Adjusting image brightness and contrast.

• Contrast Manipulation: Adjusting the range of gray values.

• Edge Enhancement: Accentuates the edges of structures.

• Spatial Frequency Filtering: Modifying the image based on spatial frequency content.

• High-Pass Filtering: Sharpens image.

• Low-Pass Filtering: Smooths image.

• Image Annotation: Adding text or markers to the image.

• Image Orientation: Adjusting the image's orientation.

 • Image Stitching: Combining multiple images into one.

• Magnification: Enlarging the image.

Basic Image Manipulation Functions:

• Background Removal or Shuttering

• Image Annotation

• Image Orientation

• Image Stitching

• Magnification

• Window and Level Adjustments

PACS (Picture Archiving and Communication System)

• PACS: System for storing, retrieving, and viewing medical images.

• Display Workstations:

• Computers used to view and manipulate images.

• Image Acquisition:

• Process of capturing images and entering them into PACS.

• Image Management:

• Functions for organizing and managing images.

• Image Storage:

• Short-Term Storage: Temporary storage for quick access.

• Long-Term Storage: Permanent storage for archival purposes.

• Magnetic Disk Storage: Using hard drives.

• Magnetic Tape: Archiving on magnetic tape.

• Optical Disk: Using CDs, DVDs, etc.

Quality Control and Maintenance

• QC (Quality Control): Ensuring consistent image quality.

• CQI (Continuous Quality Improvement): Ongoing efforts to improve quality.

• Equipment QC: Regular checks of equipment performance.

QC Tests:

• Acceptance Tests

• Error Maintenance

• Routine Maintenance
 • System Training: Educating users on the system.

Image Storage Mediums

• CD (Compact Disc): Optical storage medium.

• DVD (Digital Versatile Disc): Higher-capacity optical storage.

• MOD (Magneto-Optical Disk): Rewritable optical storage.

• UDO (Ultra Density Optical) Disk: High-capacity optical storage.

• DAS (Direct Attached Storage): Storage directly connected to a server.

• NAS (Network Attached Storage): Storage accessible over a network.

• SAN (Storage Area Network): High-speed network for storage devices.

Display Monitors

• Classification Measurements: Dot pitch, aspect ratio, and refresh rate.

• Types:

• CRT (Cathode Ray Tube)

• LCD (Liquid Crystal Display)

• Plasma Displays

Exposure Indicators

• EI (Exposure Index): Numerical value indicating radiation exposure.

• lgM (Logarithm of Median Exposure): Logarithmic measure of exposure.

• S (Sensitivity Number): Another form of exposure indicator.

RIS and HIS Integration

• RIS (Radiology Information System): Manages radiology-specific data.

• HIS (Hospital Information System): Manages all hospital-related data.

DICOM Standard

• DICOM (Digital Imaging and Communications in Medicine): Standard for handling, storing,
printing, and transmitting information in medical imaging.

• SCP (Service Class Provider): Provides a service.

• SCU (Service Class User): Uses a service.

• SOP (Service-Object Pairs): Combination of a service and an object.

• UIDs (Unique Identifiers): Unique identifiers for objects in DICOM.