Professional Documents
Culture Documents
No 706
Radiation Dose
and Image Quality
in Diagnostic
Radiology
Hkan Geijer
Hkan Geijer
ISBN 91-7373-143-9
ISSN 0345-0082
Copyright Hkan Geijer (pp 1-76)
Printed in Sweden
Linkpings Tryckeri AB
Contents
1 ABSTRACT................................
................................
.........................7
2 SAMMANFATTNING................................
................................
...........8
3 PRELIMINARY REPORTS................................
................................
... 9
4 ORIGINAL PAPERS................................
................................
...........10
5 ABBREVIATIONS................................
................................
..............11
6 INTRODUCTION................................
................................
...............13
6.1 GENERAL INTRODUCTION....................................................................... 13
6.2 RADIATION DOSE ................................................................................. 14
6.3 IMAGE QUALITY ................................................................................... 14
6.4 THE CONCEPT OF OPTIMIZATION .............................................................. 16
6.5 SCOLIOSIS RADIOGRAPHY ...................................................................... 17
6.6 FLAT-PANEL DETECTOR ......................................................................... 18
6.7 CORONARY INTERVENTION ..................................................................... 18
7 AIMS ................................
................................
...............................
19
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Hkan Geijer
12 ACKNOWLEDGEMENTS................................
................................
. 67
13 REFERENCES................................
................................
...............68
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Abstract
1 Abstract
X-rays are known to cause malignancies, skin damage and other side effects
and they are thus potentially dangerous. Therefore, it is essential and in fact
mandatory to reduce the radiation dose in diagnostic radiology as far as possi-
ble. This is also known as the ALARA (As Low As Reasonably Achievable) prin-
ciple. However, the dose is linked to image quality and the image quality may
not be lowered so far that it jeopardizes the diagnostic outcome of a radio-
graphic procedure. The process of reaching this balance between dose and im-
age quality is called optimization. The aim of this thesis is to propose and
evaluate methods for optimizing the radiation dose image quality relationship
in diagnostic radiography with a focus on clinical usefulness. The work was
performed in three main parts.
Optimization of scoliosis radiography: In the first part, two recently devel-
oped methods for digital scoliosis radiography (digital exposure and pulsed
fluoroscopy) were evaluated and compared to the standard screen-film method.
Radiation dose was measured as Kerma area-product (KAP), Entrance surface
dose (ESD) and effective dose; image quality was assessed with a contrast-
detail phantom and through Visual grading analysis. Accuracy in angle meas-
urements was also evaluated. The radiation dose for digital exposure was
nearly twice as high as the screen-film method at a comparable image quality
while the dose for pulsed fluoroscopy was very low but with a considerably
lower image quality. The variability in angle measurements was sufficiently low
for all methods. Then, the digital exposure protocol was optimized to a consid-
erably lower dose with a slightly lower image quality compared to the baseline.
Flat-panel detector: In the second part, an amorphous-silicon direct digital
flat-panel detector was evaluated using a contrast-detail phantom, measuring
dose as entrance dose. The flat-panel detector yielded a superior image quality
at a lower dose than both storage phosphor plates and screen-film. Equivalent
image quality compared to storage phosphor plates was reached at about one
third of the dose.
Optimization of percutaneous coronary intervention (PCI): In the third part,
influence of various settings on radiation dose and image quality in coronary
catheterisation and PCI was investigated. Based on these findings, the dose
rate for fluoroscopy was reduced to one-third. The dose reduction was evalu-
ated in a clinical series of 154 PCI procedures before and 138 after the optimi-
zation. Through this optimization, the total KAP was significantly reduced to
two-thirds of the original value.
In summary, this thesis indicates the possibility of dose reduction in diag-
nostic radiology through optimization of the radiographic process.
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Hkan Geijer
2 Sammanfattning
Det r knt att rntgenstrlning kan orsaka cancersjukdomar, hudskador och
andra sidoeffekter. Drfr r det viktigt och ven freskrivet i lag att strlexpo-
neringen inom diagnostisk radiologi skall snkas s lngt som mjligt. Detta
kallas p engelska ALARA-principen (As Low As Reasonably Achievable). Strl-
dosen r kopplad till bildkvalitet och denna fr inte snkas s lngt att det
diagnostiska vrdet av en underskning ventyras. Processen att n en sdan
balans mellan dos och bildkvalitet kallas optimering. Syftet med denna av-
handling r att finna och utvrdera metoder fr att optimera frhllandet mel-
lan strldos och bildkvalitet inom diagnostisk radiologi med fokus p klinisk
anvndbarhet. Arbetet utfrdes i tre huvuddelar.
Optimering av skoliosrntgen: I frsta delen utvrderades tv nyligen ut-
vecklade metoder fr digital skoliosrntgen (digital exponering och pulsad
genomlysning). De jmfrdes ven med film-skrmsystem som var den tidigare
standardmetoden. Strldosen mttes som Kerma area-produkt (KAP), ytdos
(Entrance surface dose, ESD) och effektiv dos; bildkvaliteten vrderades med
ett kontrast-detaljfantom och genom visuell analys p kliniska bilder. Nog-
grannheten i vinkelmtningar vrderades ocks. Strldosen fr digital expone-
ring var nstan dubbelt s hg som fr film med jmfrbar bildkvalitet medan
pulsad genomlysning hade en mycket lg dos men betydligt smre bildkvalitet.
Variabiliteten i vinkelmtningar var tillrckligt lg i alla metoder. Drefter op-
timerades instllningarna fr digital exponering till en betydligt lgre strldos
med viss snkning av bildkvaliteten jmfrt med utgngslget.
Direktdigital detektor: I den andra delstudien utvrderades en direktdigital
detektor med ett kontrast-detaljfantom dr strldosen mttes som ingngsdos i
fantomet. Den direktdigitala detektorn gav bttre bildkvalitet vid lgre dos
jmfrt med bde bildplattor och film. Jmfrbar bildkvalitet med bildplattor
nddes vid ungefr en tredjedel av dosen.
Optimering av perkutan koronar intervention (PCI): I tredje delstudien un-
dersktes pverkan p strldos och bildkvalitet av olika instllningar vid
kranskrlsrntgen och PCI. Utifrn dessa fynd snktes dosraten fr genomlys-
ning till en tredjedel. Dossnkningen utvrderades i en serie bestende av 154
PCI-procedurer fre och 138 efter optimeringen. Genom denna optimering
snktes det totala KAP-vrdet signifikant till tv tredjedelar av ursprungsvr-
det.
Sammanfattningsvis pvisar denna avhandling mjligheterna till dossnk-
ning i diagnostisk radiologi genom optimering av den radiografiska processen.
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Preliminary reports
3 Preliminary reports
The following reports have been given:
Abstracts
1. Geijer H, Andersson T, Beckman K-W, Persliden J. En ny digital metod fr
scoliosrntgen - vrdering av strldoser. Hygiea Svenska Lkare-
sllskapets handlingar 1998;107(1):256-7. Swedish Medical Society,
Annual Meeting.
2. Geijer H, Andersson T, Beckman K-W, Persliden J. Strldosreducerande
tgrder vid angiografi. Hygiea Svenska Lkaresllskapets handlingar
1998;107(1):257. Swedish Medical Society, Annual Meeting.
3. Geijer H, Andersson T, Beckman K-W, Jonsson B, Persliden J. A new
digital method for scoliosis radiography - description and assessment of
radiation dose. Eur Radiol 1999;9 Suppl 1:S110. European Congress of
Radiology, Vienna, ECR 99.
4. Geijer H, Andersson T, Beckman K-W, Persliden J. Reduction of radiation
dose in angiography. Eur Radiol 1999;9 Suppl 1:S286. European
Congress of Radiology, Vienna, ECR 99.
5. Geijer H, Beckman K-W, Andersson T, Persliden J. Radiation dose and
image quality with a flat-panel amorphous silicon digital detector. Eur
Radiol 2001;11(2 Suppl 1):S280. European Congress of Radiology, Vienna,
ECR 2001.
6. Verdonck B, Nijlunsing R, Melman N, Geijer H. Image quality and X-ray
dose for translation reconstruction overview imaging of the spine, colon
and legs. In: Lemke HU, Vannier MW, Inamura K, Farman AG, Doi K,
editors. CARS 2001. Proceedings of Computed Assisted Radiology and
Surgery; 2001 June 27-30; Berlin, Germany. Amsterdam: Elsevier
Science; 2001. p. 500-5.
Posters
1. Geijer H, Beckman K-W, Jonsson B, Andersson T, Persliden J. Digital
scoliosis radiography: evaluation of a new method. Radiology
1999;213(P):500. Radiological Society of North America, Chicago, RSNA
99.
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Hkan Geijer
4 Original papers
This thesis is based on the following original papers, which will be cited in the
text by their Roman numerals:
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Abbreviations
5 Abbreviations
ALARA as low as reasonably achievable
ANOVA analysis of variance
AP anteroposterior
DQE detective quantum efficiency
ESD entrance surface dose
ICS image criteria score
IQF image quality figure
KAP kerma area-product
keV kiloelectron volt
kV kilovolt (tube voltage)
LAO left anterior oblique
mA milliampere (tube current)
mAs milliampere second (tube charge)
MTF modulation transfer function
PA posteroanterior
PACS picture archiving and communicating system
PCI percutaneous coronary intervention
RAO right anterior oblique
RIS radiological information system
ROC receiver operating characteristics
ROI region of interest
SD standard deviation
TLD thermoluminescent dosimetry
VGA visual grading analysis
EU European Union
ICRP International Commission on Radiological Protection
ICRU International Commission on Radiation Units and Measurements
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Hkan Geijer
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Introduction
6 Introduction
6.1 General introduction
All radiological procedures involving X-rays deliver a radiation exposure to the
patient. In procedures where staff are present in the examination room, such
as in interventional radiological procedures, also the staff receive a radiation
exposure.
Radiation has long been known to be harmful to humans. The radiation
exposure received in an X-ray examination is known to increase the risk of
malignancy as well as, above a certain dose, the probability of skin damage and
cataract. The number of procedures performed is rising, and there is a trend
towards more complicated procedures that at the same time subject patients
and staff to higher doses. Some examples of these complicated, high-dose pro-
cedures are the wide range of interventional procedures such as percutaneous
coronary intervention (PCI), ablation procedures in the heart and vascular
interventions in other parts of the body such as aortic stent-grafting. There are
also a rising number of computed tomography (CT) procedures performed with
a concomitant rise in the collective dose. The CT issue is not investigated in
this document.
In todays diagnostic radiology there is a growing concern on radiation ex-
posure. This can be seen in the recommendations from the International
Commission on Radiological Protection (ICRP) where the current international
recommendations, ICRP 60, (ICRP 1991a) lay out the principles of justification
and optimization of all radiation exposures in diagnostic radiology. Later
recommendations, ICRP 85, (ICRP 2000) deal with the risk of skin damage in
interventional radiology. In Europe, the European Union council directive
97/43/Euratom (The Council of the European Union 1997) imposes the im-
portance of the two basic principles of justification and optimization.
The principle of justification implies that the benefits to the patient and
society of a radiological procedure must outweigh the risks for the patient as-
sociated with the radiation exposure. The other principle, the principle of opti-
mization, is the main topic of this document. This principle is introduced in
chapter 6.4 and is covered in detail later.
The present document presents investigations of the dose reduction possi-
bilities in three different areas. In papers I and II a digital method for scoliosis
radiography is described, and the radiation exposure to the patient is reduced
by changing exposure parameters. In paper III the potential in exchanging the
whole detector system for a recently available flat-panel detector is investi-
gated. In papers IV and V the potential for dose reduction in interventional
radiology is investigated using coronary intervention as a model. Altogether,
the whole project is focused on finding clinically useful solutions for optimi-
zation, leading to substantial dose reductions.
The project was undertaken at rebro University Hospital in the Depart-
ment of Radiology, which has been fully digital for nearly five years.
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Hkan Geijer
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Introduction
The second item above means that image quality must be quantified in
some way. This quantification can be done in several ways and might encom-
pass different parts of the imaging system or the entire system.
In digital radiographic systems, image quality is closely linked to radiation
exposure. Keeping other factors constant, image quality decreases with a lower
exposure because of the increased noise (quantum mottle) in the image.
Accordingly, image quality increases with an increased exposure. Digital X-ray
image quality is thus noise limited (Cowen 1991). In all attempts to reduce
dose, image quality is crucial. The dose reduction may not be pursued too far,
potentially jeopardizing the diagnostic outcome of the procedure. Conse-
quently, it is vital to follow the image quality while optimizing a radiographic
procedure. Unfortunately, methods for image quality assessment are less
straightforward than for dose measurement.
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Hkan Geijer
5. Images of real humans are the ultimate goal in finding objects for image
quality evaluation. They have the advantage of being the very same images
that are being used in clinical practice without any approximations. Dis-
advantages are the natural variability between patients and the increased
radiation dose if several settings are tested on one subject. The same
methods as for anthropomorphic phantoms, VGA, ICS and ROC, can be
used.
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Introduction
This does not automatically mean the lowest possible radiation dose. Therefore,
an effort by the users to reduce the radiation dose to a level that results in a
diagnostically acceptable image quality without excessive radiation exposure is
often beneficial.
An alternative way of optimizing a radiological procedure is to change the
whole detector system. New systems with higher detective efficiency might lead
to lower doses without sacrificing image quality. This aspect is investigated in
the study on the flat-panel detector.
In interventional radiology the operator can influence the dose by the
amount of fluoroscopy and other imaging that is used. Consequently, the
operator's effect on dose can also be optimized. Normally this is done through
education and training. This potential is investigated in the study on coronary
intervention.
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Hkan Geijer
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Aims
7 Aims
The overall aim of this thesis is to find ways to optimize the radiation dose -
image quality relationship in diagnostic radiology. All solutions are explicitly
meant to be useful in daily clinical practice. The methodology for optimization
is evaluated in various clinical situations:
In scoliosis radiography, where the patients are young and thus extra
sensitive to radiation, the optimization is performed through adjustment of
the equipment.
In the second main part, dealing with the flat-panel detector, the optimiza-
tion potential in exchanging a whole detector system is evaluated. Such an
exchange has implications for a wide range of radiographic procedures.
In coronary intervention, where there is a risk of both acute skin burns
and radiation-induced malignancy, the possibility of optimizing an inter-
ventional procedure is investigated.
A second aim is to find methods for dose measurement and image quality
assessment that are practical to use during the optimization process.
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Hkan Geijer
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Materials and Methods
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Hkan Geijer
In the study for paper V, a KAP meter built into the collimator housing of
the angiographic equipment was used (Diamentor, PTW, Freiburg, Germany).
KAP values, separated into fluoroscopy and acquisition doses, can be printed
together with other details of the examination. The instrument was calibrated
with a calibration traceable to a standard laboratory.
a b
Figure 2. The instrument that was used for measurement of KAP. (a) Electrometer. (b) Ionisation
chamber mounted on the collimator housing.
E = wT H T (1)
T
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Materials and Methods
Tissue or organ Tissue weighting Table 1. Tissues, organs and tissue weighting factors
factor, wT for calculation of effective dose.
a The remainder is comprised of the following addi-
Gonads 0.20
Bone marrow (red) 0.12 tional tissues and organs: adrenals, brain, upper
large intestine, small intestine, kidney, muscle, pan-
Colon 0.12
creas, spleen, thymus and uterus.
Lung 0.12
Stomach 0.12
Bladder 0.05
Breasts 0.05
Liver 0.05
Oesophagus 0.05
Thyroid 0.05
Skin 0.01
Bone surface 0.01
a
Remainder 0.05
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Hkan Geijer
M 1000
De = 2 (2)
H
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Materials and Methods
kD
e e ( ref )
KAPref = KAPmeas kDe ( meas) (3)
e
where KAPref = KAP for Reference Man size, KAPmeas = measured KAP, k =
equipment-specific constant, De(ref) = equivalent diameter of Reference Man
(22.9 cm), and De(meas) = equivalent diameter of the patient (Chapple et al 1995).
The equipment-specific constant has to be determined for each type of
equipment.
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Hkan Geijer
In all studies, part of the image quality assessment was done with a
CDRAD 2.0 contrast-detail phantom (Instrumentele Dienst, Nijmegen, the
Netherlands) (Thijssen et al 1989). The phantom consists of a 265 mm by 265
mm by 10 mm acrylic sheet with drilled holes of different depth and diameter.
In each column, the diameter of the drilled holes varies logarithmically from 8
to 0.3 mm. In each row, the depth varies logarithmically from 8 to 0.3 mm. A
radiograph of the CDRAD phantom is shown in Figure 4. In each square, ex-
cept in the top three rows, there is one hole in the middle and one hole ran-
domly located in one corner. The observer has to indicate in which corner the
hole is located, thus making a four-alternative forced choice (4-AFC) (Aufrichtig
1999). All detection results were corrected according to the user manual for the
CDRAD phantom. Each correctly detected target needs two or more correctly
detected nearest neighbours (out of four) to remain true, and each incorrectly
or not detected target is considered true if it has three or four correctly
detected nearest neighbours. In this way, small inconsistencies in the readings
are eliminated.
From the resulting data, a graph can be drawn of the just visible objects,
see Figure 12 on page 41 for an example. Furthermore, a numerical value, the
Image Quality Figure (IQF), can be calculated (Thijssen et al 1998). The IQF is
defined as
15
IQF = Ci Di ,th (4)
i =1
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Materials and Methods
Because the IQF is derived from the sum of the products of depth and
diameter for the just visible objects in the phantom, a lower IQF indicates bet-
ter image quality.
The phantom was normally placed between two 7.5 cm-thick acrylic sheets
to simulate the scattering conditions of the human body. Normally, three im-
ages were produced at each setting to reduce the effect of random photon
fluctuations. Also to reduce random variations, each image was read by several
observers. The IQF results for all observers were then averaged.
Parallax effect: Since the smallest and deepest holes of the CDRAD phan-
tom are located at the lower right corner, the farthest away from the centre
beam, there is a potential for parallax effect since the divergent beam would
strike the holes at an angle (Neitzel et al 2000). This potential was investigated
in paper III by exposing images centred in different parts of the phantom.
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Hkan Geijer
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Materials and Methods
The main difference between digital exposure and fluoroscopy is that the
fluoroscopy protocol employs grid-controlled pulsed fluoroscopy with a much
lower dose request. The grid-control feature automatically modulates exposure
parameters during the pulse. Each fluoroscopic image is saved to memory.
All images are then transferred to a workstation (EasyVision, Philips Medi-
cal Systems) where they are reconstructed to an overview image with the aid of
pattern recognition (Verdonck et al 2001) (Figure 6).
For comparison purposes, a screen-film examination was also evaluated. It
was performed in PA projection with a large dedicated film cassette giving a
radiated field of about 25x70 cm.
Images acquired with the three methods are shown in Figure 7.
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Hkan Geijer
a b c
a b
Figure 8. Photograph (a) and radiographic image (b) of the phantom used for the angle meas-
urements. The phantom is composed of acrylic, with aluminium sheets simulating vertebrae.
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Materials and Methods
Image quality was evaluated both with the CDRAD contrast-detail phan-
tom, where one image of each setting was read by three independent observers,
and using Visual grading analysis (VGA) in clinical images. An image base was
formed from 30 screen-film images and 30 images acquired with the digital ex-
posure protocol. These images were all compared to a reference screen-film im-
age of good quality. This approach was chosen because it was not possible to
examine patients with both screen-film and a digital method. Ten patients were
after informed consent double examined with both the digital exposure and the
digital fluoroscopy protocol. This permitted direct comparison of image quality
within each patient, with the digital exposure image being the reference image
in each pair. In paper II, the image base consisted of 30 images acquired with
the digital exposure protocol (same as in paper I) and 30 images with the opti-
mized protocol. These were all compared to a digital exposure reference image.
In both papers, each image was evaluated separately and independently by
three experienced radiologists.
Different approaches were employed in papers I and II as to which parts of
the image should be evaluated. In paper I, three levels of the spine were evalu-
ated in each image; third thoracic vertebra (T3), tenth thoracic vertebra (T10),
and third lumbar vertebra (L3). When evaluating the results it was found that
the results for T10 and L3 were very similar. The image quality at level T3 was
much inferior for screen-film because of a much darker exposure, but the
comparison with film was not an issue in paper II. Therefore it was decided to
allow the use of the whole image for the VGA study in paper II: the observers
were allowed to choose which vertebra to compare as long as the same part
was evaluated in the reference image. The motivation for this was that the pur-
pose of the study was to evaluate image quality and not positioning errors or
differences due to malformations or different degree of scoliosis. No masking
was used.
In each level, image quality was evaluated as six different aspects; contrast
level, noise, sharpness, visualisation of vertebral end plates, subjective suit-
ability for judging skeletal abnormalities and subjective suitability for angle
measurements. Furthermore, the overall quality of the image was assessed.
Each aspect was independently scored on a five level scale as much worse,
worse, equal, better or much better compared with the reference image
quality.
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Hkan Geijer
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Materials and Methods
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Hkan Geijer
Influence on KAP rate, scattered radiation and in some cases ESD rate and the
rate of effective dose was evaluated for the following settings:
Various projections that are normally used in cardiac catheterisation and
PCI.
With or without protective screens between patient and operator.
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Materials and Methods
a b
Figure 10. Sample images from the PCI procedures with the Alderson phantom for calculation of
effective dose. (a) Before optimization. (b) After optimization. A collimation of about 7 mm at
each side has been introduced.
Calculation of effective dose in a simulated PCI procedure: The effective dose for
a standard PCI procedure before and after optimization was calculated from
absorbed dose measured in relevant organs in the Alderson phantom as
outlined in 8.1.4 and 8.1.5. TLDs were also placed in the entrance fields
dorsally to record ESD.
The median KAP for a standard PCI procedure was obtained from a series
of 220 PCI procedures in our institution. Of these, 74 procedures included a
coronary angiography as part of the procedure. Before optimization, all settings
were those set at installation of the equipment and the aim was to irradiate the
phantom to obtain the median KAP values for fluoroscopy and digital
acquisition from the clinical series (Table 7 on page 47). The KAP values were
divided equally in four different projections that are used in PCI. After
optimization of equipment settings, the phantom was irradiated again with the
new settings. This time, the aim was to irradiate with the same fluoroscopy
time and the same number of images in each projection as before optimization.
In order to simulate an effect of improved user behaviour, a slight collimation
of about 7 mm at each side was introduced. This amount of collimation was
chosen as a clinically reasonable collimation that could be used in virtually all
PCI procedures. Sample images are shown in Figure 10.
Conversion factors from KAP to effective dose were calculated for the two
situations before and after optimization. These factors were applied to the KAP
values from the clinical series to estimate the effective dose.
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Hkan Geijer
Scattered radiation to the operator was also measured in the same session.
In the session prior to optimization, no protective screens were used in order to
create a worst case scenario, which was in fact standard practice in our
institution until a few years ago. In the session after optimization, screens were
used just like in an ordinary PCI procedure in our institution.
Monte Carlo simulation: Effective dose for a typical PCI procedure was also
simulated with Monte Carlo methodology before and after optimization. ESD
was measured with TLDs using the Alderson phantom in the same session as
for measurement of absorbed dose. Each of the four projections was measured
separately and since entrance doses had to be separated in fractions for
fluoroscopy and digital acquisition in each projection as a basis for the Monte
Carlo calculation, these fractions were assumed to be proportional to the KAP
values for fluoroscopy and acquisition. Equivalent doses and effective dose
were calculated with the PCXMC computer program. All Monte Carlo
calculations were tailored to a male patient of the same size as the Alderson
phantom.
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Materials and Methods
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Hkan Geijer
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Results
9 Results
9.1 Scoliosis radiography
Table 2. Measured and calculated phantom dose values. The ESD was meas-
ured with TLDs and included backscatter. The KAP for the optimized protocol
is not directly comparable and is thus not shown in this table.
KAP = kerma area-product. ESD = entrance surface dose. NA = not applicable.
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Hkan Geijer
Optimization steps Tube Tube Dose Acquisition Scan Number KAP ESD Effective IQF
potential current request rate speed of images dose
-1
(kV) (mA) (s ) (cm/s) (Gy cm2) (mGy) (mSv)
Exposure, baseline 70 Falling load 50% 2 3.5 36 1.07a (100%) 0.90 (100%) 0.15 (100%) 52
1. Lowered dose request 70 Falling load 33% 2 3.5 36 0.67 (63%) 52
2. Increased pulse frequency 70 Falling load 33% 3 7.5 27 0.48 (45%)
and scan speed
3. Fixed mA 70 320 33% 2 3.5 36 0.45 (42%) 58
4. Higher kV 81 160 33% 3 7.5 27 0.25 (23%) 0.21 (23%) 0.047 (31%) 62
a
Fluoroscopy, baseline 56-72 Fluoroscopy Fluoroscopy 3 3.5 57 0.12 (100%) 0.11 (100%) 0.015 (100%) 82
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Increased scan speed 56-72 Fluoroscopy Fluoroscopy 3 7.5 30 0.06 (50%) 0.043 (39%) 0.0067 (45%)
Table 3. Settings that were evaluated during the optimization process together with the resulting dose and image quality values. The
dose values and number of images refer to runs with the Alderson dose measurement phantom. IQF values were measured with the
contrast-detail phantom. The relative dose values refer to changes with respect to the baseline.
a = The KAP value is different between papers I and II, probably because of different collimation. Within this table, the change in KAP
is valid.
KAP = kerma area-product. ESD = entrance surface dose. IQF = image quality figure.
Results
0.5
0.0
11 13 15 17 19 21 23 25 27 29 31
Phantom slice #
10
Figure 12. Contrast-detail curves
for the CDRAD phantom, mean
values for three observers. The
further down to the left the curve
lies, the better the image quality is.
= Digital fluoroscopy, IQF=88.
Diameter of target (mm)
0.1
0.3 0.4 0.5 0.6 0.8 1 1.3 1.6 2 2.5 3.2 4 5 6.3 8
Depth of target (mm)
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Hkan Geijer
70
Fluoroscopy
80 baseline
90
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Results
22.0
21.8 Figure 14. Mean phantom angle meas-
urements obtained by three observers with
Mean angles (degrees)
21.6
each protocol.
21.4
= Observer 1.
21.2
= Observer 2.
21.0
= Observer 3.
20.8
20.6
20.4
20.2
20.0
Film Digital Digital
exposure fluoroscopy
Table 4. Means and SDs of Cobb angle measurements obtained with differ-
ent protocols. Three observers measured each angle twice each. The im-
ages for screen-film and digital exposure were obtained in different
patients and should not be assumed to have the same mean angles. The
ten double examined patients (digital exposure + digital fluoroscopy) are
shown in the two bottom rows.
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Hkan Geijer
Table 5. Tube charge, entrance dose and image quality for the
evaluated systems. The flat-panel detector was evaluated at
three different system speed settings. All exposure and dose
values are means for three images while the IQF values are
means of twelve readings for each setting (four observers and
three images).
IQF = image quality figure.
40 Observer 1
45 Observer 2
50 Observer 3
55 Observer 4
60
65 I I I I I
FP FP FP Storage phosphor Film
800 600 400 plates
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Results
Table 6. Individual p-values for the ANOVA comparing the flat-panel detector to
other detectors. Significant results are shown in bold.
FP = flat-panel detector at different speed settings.
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Hkan Geijer
2.5
2.0
Relative dose rate
1.5
Calculated
effective
1.0 dose rate
KAP rate
0.5
Operator
dose rate
0.0
+angulation Start +filtration +collimation +screens
LAO caud
Combined actions
Figure 16. This graph shows the combined effect of filtration, collimation,
protective screens and angulation on the dose rates to both patient and opera-
tor.
The second column, "Start", shows the normalised dose rates for effec-
tive dose, KAP rate and operator dose rate for a neutral starting position
(PA projection, 18 cm image intensifier size and no additional filtration).
The next column to the right shows the effects of additional filtration (the
thinnest extra filter with 1.5 mm Al and 0.1 mm Cu).
In the fourth column, the X-ray field has been collimated 2 cm at each
side.
In the fifth column, screens have been inserted between the patient and
the operator.
If a rather heavy angulation and rotation is applied (LAO 45
degrees/caudal 35 degrees) as is shown in the first column, KAP and
operator dose rate instead rise considerably.
- 46 -
Results
Effective dose in a simulated PCI procedure: The effective dose for a stan-
dard PCI procedure before optimization was 13 mSv. After optimization, the
measured effective dose was 4.6 mSv, showing a reduction to 35% of the origi-
nal effective dose. Using Monte Carlo techniques, the calculated effective dose
was 8.1 mSv before and 3.5 mSv after optimization, a reduction to 43% of the
original value. KAP values, ESD and operator dose from these procedures are
shown in Table 7.
Table 7. Radiation dose with an Alderson phantom for a standardized PCI procedure before
and after optimization. The operator dose was measured in chest level at the normal location of
the operator in the room. The apparent inaccuracies in the sums are due to rounding effects.
KAP = kerma area-product. ESD = entrance surface dose.
- 47 -
Hkan Geijer
40
NC
45
LP
LP HP
12.5 NP
50
LP-R
LC
IQF
55
60
LC-R
65
LP12.5-R
70
0 20 40 60 80 100
KAP rate (mGy cm2/s)
Figure 17. Image quality (IQF) versus KAP rate for equipment settings in a cardiac catheterisa-
tion laboratory. The arrows show changes from the original low-dose settings LC and LP that
were evaluated during the optimization process. All settings starting with L use the thickest
extra filtration (1.5 mm Al + 0.4 mm Cu). All settings starting with N use the thinnest extra
filtration (1.5 mm Al + 0.1 mm Cu). The setting starting with H is without extra filtration. C
denotes continuous and P pulsed fluoroscopy.
Both reducing the pulse frequency from 25 to 12.5 pulses per second (LP LP12.5), and
reducing the image intensifier dose request to half (LP LP -R), reduced the KAP rate to
about half but decreased image quality slightly.
When both these measures were combined (LP12.5-R), image quality was heavily af-
fected.
When the dose request in continuous fluoroscopy was reduced by 65% (LC LC -R) the
KAP rate was reduced accordingly but image quality also suffered.
The net change implemented during the optimization was from setting NP to LP-R.
- 48 -
Results
40
NCcoll
NC
45
LP
NClight
50
IQF
55
LPthick
60
65
70
0 20 40 60 80 100
2
KAP rate (mGy cm /s)
Figure 18. Image quality (IQF) versus KAP rate for changes due to patient and operator
factors in a cardiac catheterisation laboratory. The arrows show changes from the original
settings that were evaluated during the optimization process. LP = pulsed fluoroscopy with
extra filtration 1.5 mm Al + 0.4 mm Cu. NC = continuous fluoroscopy with extra filtration 1.5
mm Al + 0.1 mm Cu.
Collimation: 2 cm collimation at each side reduced the KAP rate to less than half
without any substantial change in image quality (NC NCcoll).
Ambient lighting: Increased lighting in the room (NC NClight) reduced the image
quality slightly.
Object thickness: When the acrylic thickness was increased from 15 to 20 cm (LP
LPthick), image quality was considerably reduced while the KAP rate increased.
- 49 -
Hkan Geijer
Period Fluoroscopy Digital Total KAP Calculated Fluoroscopy Procedure Number of Number of
Statistic KAP acquisition effective time Time procedures stents per
KAP dose with including procedure
conversion stent
factors placement
2
(Gy cm ) (Gy cm 2) (Gy cm 2) (mSv) (min) (min)
PCI only
Before (n=94)
Mean 55.9 23.3 79.2 13.5 50.0 84 (89%) 1.28
Median 39.9 19.2 61.8 11 9.8 42.5
Third quartile 92.9 17.1
After (n=59)
Mean 33.8 22.4 56.2 16.4 48.2 53 (90%) 1.54
Median 16.5 20.1 41.3 6.8 12.1 44.0
Third quartile 66.5 20.5
Combined proce-
dures
Before (n=60)
Mean 71.7 44.4 116 15.3 62.6 52 (87%) 1.12
Median 57.5 38.7 97.1 18 12.8 57.0
Third quartile 146 19.4
After (n=79)
Mean 36.2 42.5 78.7 14.9 53.0 74 (94%) 1.37
Median 24.2 35.0 61.4 10 12.9 48.0
Third quartile 99.8 19.4
All patients
Before (n=154)
Mean 62.0 31.5 93.6 14.2 55.0 136 (88%) 1.21
Median 46.0 24.8 72.6 13 11.2 48.5
Geometric mean 47.5 25.4 75.7 11.4
Third quartile 121 18.4
After (n=138)
Mean 35.2 33.9 69.1 15.6 51.0 127 (92%) 1.44
Median 22.3 28.2 55.4 9.2 12.6 47.0
Geometric mean 22.0 28.3 54.6 12.0
Third quartile 82.6 19.6
Ratio after to
before optimiza- 0.45 0.99 0.67 1.03
a
tion
95% confidence
0.36-0.55 0.86-1.13 0.57-0.78 0.87-1.22
interval
Table 8. Dose and clinical data before and after optimization of settings for coronary inter-
vention.
KAP = kerma area-product.
a The ratio after to before optimization was corrected for the imbalance in number of com-
bined procedures. A ratio of 1 indicates no change during the optimization. A ratio of 0.67
indicates a reduction to 67% of the original value.
- 50 -
Results
The multivariate analysis showed that the total KAP increased with a mean
factor 1.42 (95% confidence interval 1.22-1.64) for a combined procedure
compared to PCI only. The total KAP increased with a factor 1.14 (95%
confidence interval 1.09-1.19) for each cm increase of the equivalent diameter.
There were three complications (1.9%) noted before optimization: one
balloon rupture during stent implantation, one air embolisation in the right
coronary artery and one dissection in an obtuse marginal that was stented. All
these patients recovered uneventfully. After optimisation, there were six
complications among the 138 patients (4.3%); two puncture site
pseudoaneurysms that were treated with ultrasound-guided compression, one
large dissection that was stented with five stents, still open without restenosis
at angiography two months later, and one abrupt closure which ended with a
myocardial infarct. There was also one case of diminished flow after balloon
dilatation where the patient recovered uneventfully, and finally an old
occlusion that couldnt be opened during infarct-PCI.
Altogether there were twelve operators included in the study; six cardiolo-
gists and six radiologists. Of these, three cardiologists and three radiologists
performed cases both before and after the optimization. These six performed
127 out of 154 procedures (82%) before and 95 out of 138 procedures (69%)
after optimization. Cardiologists and radiologists performed about equal
amounts of procedures. KAP values for these six operators are shown in Figure
19 and in greater detail in Figure 20.
- 51 -
Hkan Geijer
A (26/14)
100 B (23/5)
C (20/32)
80
D (16/20)
60 E (40/19)
F (2/5)
40
20
0
Before After
Figure 20. Box-and-whisker plots of the total KAP before and after optimization for the six
operators who participated in both parts of the study. The number of procedures for each period
is shown over the bars.
- 52 -
Discussion
10 Discussion
The results of this project indicate that it is possible to reduce radiation dose
further, even in a modern digital radiology department. In scoliosis radiography
it was possible to reduce the effective dose to one tenth using pulsed fluoro-
scopy instead of digital exposure. By optimizing the digital exposure protocol
the effective dose was reduced to about one third. By exchanging storage
phosphor plates or film for a flat-panel detector it was possible to both reduce
dose and improve image quality. In coronary intervention, finally, the
fluoroscopy dose rate could be reduced so much that the total KAP was
reduced to about two-thirds.
This Discussion begins with specific parts for the three main studies on
scoliosis radiography, flat-panel detector and coronary intervention. Then, the
statistical methods are covered followed by discussions on radiation dose and
image quality. Finally, the subject of optimization methods is discussed.
- 53 -
Hkan Geijer
- 54 -
Discussion
2000; Floyd Jr et al 2001; Chotas and Ravin 2001) and Sterling (Piraino et al
1998) flat-panel detectors have been evaluated with similar results.
This beneficial balance between dose and image quality is largely due to
the higher DQE which has been reported at 0.6 to 0.75 (Chaussat et al 1998;
Bury et al 2000; Antonuk et al 2000; Granfors and Aufrichtig 2000; Spahn et al
2000; Floyd Jr et al 2001). This is about twice that of storage phosphor plates
at DQE = 0.3 (Kengyelics et al 1998) and at least twice that of screen-film
systems (Neitzel et al 2000). For the General Electric type of flat-panel detector,
the exposure needed for equal image quality with a contrast-detail phantom
has been predicted to be only 30% of the screen-film exposure (Aufrichtig
1999).
The Cesium Iodide (CsI) scintillator is a very important part of the flat-
panel detector (Chaussat et al 1998) and it is definitely contributing to the high
DQE. It has a geometric configuration of small channels acting as light guides,
thus preventing geometric light spread even at a large thickness. The X-ray
absorption is superior to selenium at energies higher than about 35 keV, and
the emitted light has a wavelength that matches the spectral sensitivity of the
amorphous silicon photodiode. Other reasons for the high DQE are the small
pixel size and the low electronic noise of the signal readout chain (Spahn et al
2000).
The high DQE of the flat-panel detector is valid only for higher
(radiographic) doses such as those used in this study (Siewerdsen et al 1998;
Antonuk et al 2000). For lower doses such as in fluoroscopy, the DQE falls
rapidly due to electronic noise in the detector (Chotas et al 1999; Maolinbay et
al 2000). The role of the flat-panel detector in fluoroscopic imaging is evolving
rapidly, but it has not been evaluated in this project.
This study points to an important way of reducing radiation dose by
exchanging the detector system. The recently available flat-panel detector
should enable important dose reductions in high-dose procedures such as
lumbar spine radiography and intravenous urography, and it is one of the most
important new devices that has been introduced in diagnostic radiography
recent years. However, it should be noted that it is not enough just to install a
new detector. Even using an efficient flat-panel detector, an optimization to the
lowest dose with acceptable image quality should still be done.
- 55 -
Hkan Geijer
2000; Widmark et al 2001), the mean KAP values in the clinical part of this
study are comparable; before optimization they are in the higher range, and
after optimization they are in the lower range.
There was a very large range in total KAP with a fiftyfold difference between
the lowest and the highest total KAP. This reflects the widely varying clinical
conditions, from a quick single-vessel PCI with direct stenting and only one
balloon inflation to a complex multi-vessel case, perhaps with dissection and
other complications.
There was also a large difference in KAP between operators. This difference
between operators has been noticed before (Clark et al 2000). Especially in
complicated cases, there can be a large difference in dose depending on
whether the operator is a high-dose or low-dose operator.
There has been a recent discussion on diagnostic reference levels for
different radiological procedures in the EU (Commission of the European
Communities 1996; The Council of the European Union 1997). If a sample
from an institution exceeds the reference dose level, an investigation should be
started and correction measures taken. Provisional quality criteria for coronary
angiography and reference levels for diagnostic and interventional procedures
have been proposed (Padovani et al 1998; Widmark et al 2001). The proposed
reference KAP levels for PCI are 120 Gy cm2 with a fluoroscopy time of 24 min
by Padovani et al and 90 Gy cm2 by Widmark et al. Our results for PCI are well
below these figures, even before optimization. However, the concept of reference
levels is difficult to adopt to interventional radiology because of the extreme
variability of procedures (Marshall et al 2000). Still, coronary angiography and
PCI are fairly standardized for being invasive procedures.
Analogously, one might conceive the concept of reference levels for
individual operators. If an individual operator repeatedly exceeds the reference
level, an investigation should start. Often, the solution would probably be
education and intensified training to make the operator aware of the problem
and show him or her ways to reduce the dose.
The dose issue in interventional radiology has gained increased attention
recent years with reports such as ICRP 85 (ICRP 2000) and papers describing
the risks of skin injuries (Koenig et al 2001a-b). The ESD reported in this study
for a standardized PCI procedure, 1.2 Gy before and 0.53 Gy after, is well below
the risk of skin erythema, which starts at about 2 Gy. The reports above only
deal with the deterministic risks, but the stochastic risk for induction of
malignancy must not be forgotten, although many PCI patients are so old and
at high risk from their underlying disease that they run a small risk of
developing a radiation-induced malignancy. However, another extremely
important reason to keep doses low is the occupational aspect. Operators and
staff receive significant doses while performing these procedures, so there is a
double gain in reducing dose. This ought to make operators more willing to
adopt dose-saving techniques, but that is not always the reality. All changes
that reduce the patient dose are also beneficial for the operator (Marshall and
Faulkner 1992). Most dose reductions impair image quality more or less, but
some actually increase image quality.
- 56 -
Discussion
- 57 -
Hkan Geijer
Putte et al 2000). Once displayed, it should then be easy to transmit the dose
data automatically to the radiological information system (RIS) where it can be
used for follow-up. Unfortunately ESD is very difficult to measure accurately in
a clinical situation with varying projections (Va et al 2001).
When performing simulated PCI procedures on an Alderson phantom,
there was a reduction of the fluoroscopy KAP value to 25% and the digital
acquisition KAP value to 66%, resulting in a reduction of the total KAP value to
39% of the value before optimization. The change in digital acquisition KAP can
probably be attributed to increased collimation (about 7 mm on each side, see
Figure 10 on page 35) since no other parameters were changed in the
acquisition settings. This together with the fact that the acquisition KAP wasnt
reduced in the clinical study shows that the clinical dose can probably be
reduced further through increased use of collimation in PCI.
- 58 -
Discussion
- 59 -
Hkan Geijer
The thickness of the patient influences KAP and ESD profoundly, and it is
thus vital to record patient height and weight in a patient survey. When re-
ducing the sample size to eg. ten to 20 patients as has been advocated by the
EU (Commission of the European Communities 1996), even one or two individ-
ual patients may influence the mean value considerably. To minimise this ef-
fect, it is often recommended that only patients within certain weight limits
such as 60 to 80 kg are included in the study. A drawback of this concept is
that about half of the subjects will be excluded, which decreases the statistical
power of the study. An alternative approach is to use the information about
patient size (Lindskoug 1992). It has been shown that there is a linear
relationship between the logarithm of entrance dose and equivalent diameter
(Martin et al 1994; Mooney and Thomas 1998). It should thus be possible to
measure doses on all patients and then apply a correction factor for patient
size (Chapple et al 1995).
- 60 -
Discussion
Mean (SD)
0 Observer 1 FP = flat-panel detector at
5 Observer 2 different speed settings.
Observer 3
10 Observer 4
15
20
25 I I I I I
FP FP FP Storage phosphor Film
800 600 400 plates
- 61 -
Hkan Geijer
- 62 -
Discussion
- 63 -
Hkan Geijer
Removing the grid might also reduce the dose considerably (Martin et al
1999a). This must be balanced with the increased scatter that might occur. It
has a role predominantly in paediatric radiology but can also be used in eg.
chest radiography (Fung and Gilboy 2001).
User habits play a major role in determining the dose from a procedure:
Reduced field size through collimation is very effective in reducing KAP
and effective dose, both in general radiography and in angiography (paper
IV). The use of collimation also increases image quality.
Compression also has the double benefit of reducing dose and increasing
image quality, and this should be used whenever feasible (paper IV).
Ultra-low dose fluoroscopy can often be used as long as the user is able to
increase dose and image quality when needed (papers IV and V). This is
most effective in procedures with high fluoroscopy doses such as inter-
ventional radiology.
Angulation can influence particularly the operator dose in interventional
radiology (paper IV).
Protective screens are very efficient in protecting the operator from scat-
tered radiation (papers IV and V).
Pulsed fluoroscopy is a way to reduce dose in fluoroscopy (den Boer et al
1994; Harrison et al 1998; Wagner et al 2000; Boland et al 2000) (papers
IV and V). Pulsed fluoroscopy should not automatically be regarded as
synonymous with low-dose fluoroscopy since at high frame rates the dose
rate might exceed that of continuous fluoroscopy (Wagner et al 2000).
Ambient lighting should be reduced to get the optimal image quality in
monitor reading (Klein et al 1994; Mertelmeier 1999; Ricke et al 2000) (pa-
per IV). In interventional radiology there is always a balance between
reduced lighting to increase visibility of small objects in the monitor image
and the need of seeing small objects in the room such as balloon catheters
and guidewires that are down to a fraction of a mm in diameter.
- 64 -
Discussion
Using methods such as the one outlined above, it should be possible to reduce
the radiation exposure to patients and staff in a large amount of procedures.
Still, a constant vigilance on image quality is essential during the optimization.
- 65 -
Hkan Geijer
11 Conclusions
The following conclusions can be drawn from this project:
The scanning method for scoliosis radiography has acceptable image qual-
ity and accuracy in angle measurements in its baseline protocol, but a
high effective dose, about twice that for film. The baseline protocol could
be optimized to a much lower dose with slightly inferior image quality. A
low-dose alternative is to use pulsed fluoroscopy, which delivers one tenth
of the original effective dose.
An amorphous-silicon direct digital flat-panel detector yielded a superior
image quality at a lower dose than both storage phosphor plates and film.
Equivalent image quality to storage phosphor plates was reached at about
one third of the entrance dose.
In percutaneous coronary intervention (PCI), the dose is depending on a
multitude of parameters. By optimizing the fluoroscopy dose rate in PCI, it
was possible to reduce the total KAP for a PCI procedure to two-thirds.
This was assessed in a clinical series of 154 PCI procedures before and
138 after the optimization.
- 66 -
Acknowledgements
12 Acknowledgements
I wish to express my sincere gratitude to:
My tutor Jan Persliden, always happy and smiling, always ready to sup-
port me during the dark moments. Jan has guided me into the often in-
comprehensible jungle of medical physics.
My assistant tutor Torbjrn Andersson, always positive this project is
proceeding too fast!.
My co-worker K-W Beckman who has struggled with dose measurements
and Monte Carlo calculations and tried to make sense of the strange re-
sults.
Biomedical engineer Roland Eriksson for help with equipment set-up
and especially for asking those annoying questions like have you thought
of... or why didnt you
Berith Jonsson, RN and Robert Larson, RN for measuring assistance and
loving care of the TLD chips.
Co-author Bert Verdonck at Philips in the Netherlands for help and friend-
ship.
Robert Popek, MD for all the midnight hours doing image quality evalua-
tions.
Lars Norn, MD for help and a sensible approach to image quality.
All radiologists, cardiologists and radiographers at the section for thoracic
radiology for putting up with the rotten fluoroscopic image quality we got
at the end.
Radiographer Lena Evaldsson with colleagues at the section for skeletal
radiology for excellent imaging.
Anders Magnusson, Lennart Bodin, Frida Hgberg and Leif Norn for
statistical assistance.
All the nice and helpful people I have encountered at Philips Medical Sys-
tems in Sweden and the Netherlands.
SYLMAD (Svenska Yngre Lkare Mot Allt Digitalt) for intellectual support,
just like in the best paper I have ever contributed to (Geijer et al 1997).
My brother Mats, MD for countless hours of discussions on digital radiol-
ogy; on the phone, in Vienna, in Ume and elsewhere. He is probably an
even more fervent digital-basher than I am
My neighbours at the dairy farm for giving me ample opportunities to do
something really different for a change.
My wife Mia and my daughter Mrta-Sofie, simply for being there.
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Hkan Geijer
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