Evaluation of a flat CRT monitor for use in radiology.

Medical radiographs based on familiar projection techniques are planar images traditionally displayed by placing on a flat surface viewbox. Presenting these planar images in digital form on a traditional monitor with a curved surface may cause distortions, possibly affecting diagnoses. This would be true especially if physical linear dimensions of the anatomy are important. Reflections from ambient lights behind the observer also could be a problem with curved displays. The goal of this study was to compare physical and psychophysical performance of a flat-surface display monitor with a traditional curved-surface monitor. Two display monitors with different types of front glass-panel surfaces were evaluated. The first monitor had a traditional curved surface, and the other had a flat surface. Physical measurements included dynamic range, display function, veiling glare, and spatial uniformity. An observer performance study used low-contrast, square-wave patterns to determine just-noticeable differences. Ambient lights were turned off in one condition and on in the other. Physical measurements showed that the display functions were nearly identical, but uniformity, veiling glare, and signal-to-noise-ratio were better for the curved monitor. Observer performance was better overall with the curved monitor, but the degradation in performance between lights off and lights on was greater for the curved than flat monitor. The greater degradation with the lights on could be attributed to more reflections off the curved than the flat monitor. A flat-surface display monitor may be useful for viewing clinical radiographs.

Calibration of medium-resolution monochrome cathode ray tube displays for the purpose of board examinations.

This report discusses calibration and set-up procedures for medium-resolution monochrome cathode ray tubes (CRTs) taken in preparation of the oral portion of the board examination of the American Board of Radiology (ABR). The board examinations took place in more than 100 rooms of a hotel. There was one display-station (a computer and the associated CRT display) in each of the hotel rooms used for the examinations. The examinations covered the radiologic specialties cardiopulmonary, musculoskeletal, gastrointestinal, vascular, pediatric, and genitourinary. The software used for set-up and calibration was the VeriLUM 4.0 package from Image Smiths in Germantown, MD. The set-up included setting minimum luminance and maximum luminance, as well as positioning of the CRT in each examination room with respect to reflections of roomlights. The calibration for the grey scale rendition was done meeting the Digital Imaging and communication in Medicine (DICOM) 14 Standard Display Function. We describe these procedures, and present the calibration data in. tables and graphs, listing initial values of minimum luminance, maximum luminance, and grey scale rendition (DICOM 14 standard display function). Changes of these parameters over the duration of the examination were observed and recorded on 11 monitors in a particular room. These changes strongly suggest that all calibrated CRTs be monitored over the duration of the examination. In addition, other CRT performance data affecting image quality such as spatial resolution should be included in set-up and image quality-control procedures.

The influence of a perceptually linearized display on observer performance and visual search.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether perceptual linearization of the tone scale affects the detection and visual search behaviors of radiologists searching mammograms for masses and microcalcifications. A perceptually linearized display is designed to match the capabilities of the human visual system more closely than a nonlinearized display. MATERIALS AND METHODS: Six radiologists viewed 50 pairs of mammograms, once on a perceptually linearized cathode-ray tube (CRT) monitor and once on a non-linearized CRT monitor. Eye position also was recorded as the observers searched the images for masses and microcalcifications. RESULTS: Observer performance was significantly (P = .003) better with the perceptually linearized display. Dwell times associated with true-negative decisions were significantly longer with use of the nonlinearized display. The number of fixation clusters generated during search was also greater with use of the nonlinearized display for the lesion-free images. CONCLUSION: A perceptually linearized display yields better detection performance and a more efficient visual search. Perceptually linearized displays should be used for reading radiographs displayed on CRT monitors.

Characterization of monochrome CRT display systems in the field.

This article presents a review of image quality assessment methods for monochrome CRTs in the field as opposed to the laboratory. The review includes image quality programs at the University of Washington, the University of Texas at Houston, the University of Michigan, and the University of Arizona. CRT manufacturers and display-board suppliers also are concerned with image quality, particularly with respect to the life time of the CRT. The programs show that the need for image quality assessment for CRTs in the clinic is recognized. Although several experimental programs are in place, there is no universally accepted program. In fact, the clinical consequences of degraded monitor performance are not even well known and must be established. The existing programs mainly are based on the most comprehensive test pattern, the SMPTE pattern. The programs permit assessment of maximum luminance, display function, dynamic range, and contrast. They do not permit assessment of spatial resolution. There is no easy method to determine the spatial resolution in the field as precisely as desired simply because there are no visual aids (test patterns) to reliably determine loss of spatial resolution and signal-to-noise ratio using human observers. This report also presents initial and encouraging data obtained at the University of Arizona with a CCD camera. This CCD camera has the potential to be developed into an important tool for practical CRT evaluation for the clinic.

Influence of film and monitor display luminance on observer performance and visual search.

RATIONALE AND OBJECTIVES: The purpose of this study was to measure the influence of display luminance on detection performance and visual search behavior. The results of the study should be helpful in establishing minimally acceptable display conditions for viewing radiographs on cathode-ray tube (CRT) monitors. MATERIALS AND METHODS: Two groups of six radiologists each viewed 50 pairs of mammograms. One group viewed film images on a standard mammographic view box; the other viewed images on a high-resolution CRT monitor. Two luminance levels were studied for each display type. Observers reported on the presence or absence of masses or microcalcification clusters and on their confidence in that decision. Confidence data were analyzed by using alternative free-response receiver operating characteristic (AFROC) techniques. Eye position also was recorded as observers viewed the images. RESULTS: For both the film and monitor studies, detection performance (AFROC area under the curve) was not affected significantly by display luminance, but search behavior was. Total viewing and decision dwell times were shorter with the higher-luminance displays, especially for true-negative decisions. Significantly more fixation clusters were generated during the search of lesion-free than of lesion-containing images with the lower-luminance displays. CONCLUSION: Display luminance affects visual search performance with both film and monitor displays without affecting detection performance significantly. Higher-luminance displays yield more efficient search performance. The true-negative dwell times and number of clusters are suggestive that lower-luminance levels prolong the search and recognition of normal, lesion-free areas compared with lesion-containing areas.

A prospective evaluation of the diagnostic work-up before laparoscopic cholecystectomy.

BACKGROUND AND STUDY AIMS: A prerequisite for successful laparoscopic cholecystectomy is the exclusion of potential risks such as cholangiolithiasis or anatomical malformations. As there is no general agreement regarding the appropriate preoperative diagnostic work-up, a comparative study of different diagnostic methods was carried out. PATIENTS AND METHODS: In 180 consecutive patients admitted to a community hospital for cholecystectomy due to symptomatic cholecystolithiasis, a prospective comparison was carried out of the diagnostic accuracy of patient history, physical examination, laboratory tests, upper gastrointestinal endoscopy, intravenous cholangiography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Measurement of the diameter of the common bile duct was found to be a reliable method as a single noninvasive parameter for diagnosing cholangiolithiasis (sensitivity 100%, specificity 93%), with good predictive power (positive predictive value 0.7, negative predictive value 1.0). The best accuracy achieved noninvasively and without sonography was with a combination of positive patient history and gamma-glutamyl transferase findings (sensitivity 58%, specificity 84%, positive predictive value 0.37, negative predictive value 0.93). ERCP detected additional cholangiolithiasis in 19 of 139 patients (13.7%) and anatomical malformations in three patients. In all 19 patients, the bile ducts were cleared of stones endoscopically within 24 hours, prior to laparoscopic cholecystectomy. Among the 163 patients primarily assigned to laparoscopic cholecystectomy, the protocol diagnostic work-up, including ERCP, allocated three patients (1.8%) to open surgery. Conversion from laparoscopic cholecystectomy to open cholecystectomy occurred in a further two of 158 patients (1.3%). CONCLUSIONS: These results show that routine ultrasonography prior to laparoscopic cholecystectomy can be recommended in order to determine the diameter of the common bile duct. In patients with a ductal diameter of more than 6 mm, ERCP should be performed. Laparoscopic cholecystectomy can be carried out within 24 hours after ERCP and papillotomy.

Reduction of patient exposure in pediatric radiology.

RATIONALE AND OBJECTIVES: The authors determined whether presently used exposure levels in pediatric imaging can be reduced without loss of information or a decrease in diagnostic accuracy. MATERIALS AND METHODS: Multiple (stacked) image detectors and filters were used to obtain identical compute radiographic images at different exposure levels of neonates with either no active lung disease or hyaline membrane disease. Physical characteristics of the images were measured. A contrast-detail study and a receiver operating characteristic study were conducted to measure observer performance. RESULTS: Physical measurements and results of the contrast-detail study revealed that the dose-reduction images were essentially limited by x-ray quantum noise. Results of the receiver operating characteristic study indicated that diagnostic accuracy did not decrease significantly up to about 75% exposure reduction levels, although image quality rating data decreased with each exposure reduction. CONCLUSION: Decreasing exposure levels to about 75% of current levels may be acceptable in some clinical situations where dose is a concern, such as in pediatric imaging.

Image quality control for digital mammographic systems: initial experience and outlook.

This report presents (1) a broad topical review and a tutorial of the possibilities for image quality control (IQC) with digital systems, and (2) results and initial experience for IQC with two commercial digital imaging systems, but with limited discussion on any particular method. Digital imaging systems used for mammographically guided digital stereotactic breast biopsy were evaluated extensively at the University of Arizona. Measurements were made of linearity, sensitivity, signal-to-noise ratio, and square-wave modulation. Images of phantoms such as the American College of Radiology Accreditation Phantom and the contrast detail mammography Phantom were evaluated as well as images of the x-ray source's focal spot. The evaluation also included the cathode ray tubes for the imaging systems. The data collected show that digital imaging systems have an important advantage over film-screen systems because they provide a digital signal as output that can be used for quantitative analysis. As a result, IQC can become a much more quantitative discipline than presently practiced, providing more information on the imaging systems under evaluation, and providing better control over their properties during actual operation.

Observer performance comparison of digital radiograph systems for stereotactic breast needle biopsy.

RATIONALE AND OBJECTIVES: Two digital radiograph systems for stereotactic mammography, one using a lens to couple a Lanex Regular screen to a back-illuminated charge-coupled device (CCD) and one using a fiber-optic taper to couple a Min-R Regular-type screen to a front-illuminated CCD, were evaluated with respect to observer performance. METHODS: A contrast-detail phantom was imaged in a variety of equivalent exposure conditions on both systems. Six observers viewed images on a video monitor and recorded which objects were detected. RESULTS: Performance (percent correct detections) with the lens-coupled system using the Lanex Regular screen was significantly higher than with the fiber-optic-coupled system using the Min-R Regular-type screen. CONCLUSION: Differences in absorption efficiencies of phosphors used, as well as differences in design of the two cameras, can explain differences in observer detection performance.

Adaptive image contrast enhancement based on human visual properties.

Existing methods for image contrast enhancement focus mainly on the properties of the image to be processed while excluding any consideration of the observer characteristics. In several applications, particularly in the medical imaging area, effective contrast enhancement for diagnostic purposes can be achieved by including certain basic human visual properties. Here the authors present a novel adaptive algorithm that tailors the required amount of contrast enhancement based on the local contrast of the image and the observer's Just-Noticeable-Difference (JND). This algorithm always produces adequate contrast in the output image, and results in almost no ringing artifacts even around sharp transition regions, which is often seen in images processed by conventional contrast enhancement techniques. By separating smooth and detail areas of an image and considering the dependence of noise visibility on the spatial activity of the image, the algorithm treats them differently and thus avoids excessive enhancement of noise, which is another common problem for many existing contrast enhancement techniques. The present JND-Guided Adaptive Contrast Enhancement (JGACE) technique is very general and can be applied to a variety of images. In particular, it offers considerable benefits in digital radiography applications where the objective is to increase the diagnostic utility of images. A detailed performance evaluation together with a comparison with the existing techniques is given to demonstrate the strong features of JGACE.

Performance characteristics and image fidelity of gray-scale monitors.

Gray-scale monitors are an essential element of electronic radiology, and their ability to provide images that are perceived to be identical to those available on conventional or laser-printed film is crucial to success of electronic radiology. Image fidelity is measured in physical characteristics (luminance, dynamic range, distortion, resolution, and noise) and with psychophysical techniques, including receiver operator characteristics analysis with clinical images and testing with contrast-detail patterns to determine threshold contrast. Currently, laser-printed images facilitate greater information transfer than does a gray-scale monitor because of their higher absolute luminance (500 ft-L vs 60 ft-L), greater perceived dynamic range, and better spatial resolution. In the near future, the developments of gray-scale monitors with 150-200 ft-L luminance, a display standard based on just noticeable differences, and algorithms to improve similarities between gray-scale display images and laser-printed images will help increase the acceptability of monitors as a means to make primary diagnoses.

Use of storage phosphor imaging plates in portal imaging and high-energy radiography: the intensifying effect of metallic screens on the sensitivity.

The sensitivity of storage phosphor imaging plates (SPIP) at megavolt photon energies (60Co, 6-, 10-, and 18-MV radiotherapy beams) is studied both experimentally and by Monte Carlo radiation transport calculations. In addition, the same techniques are used to investigate the intensifying effect of metal screens on the sensitivity of the SPIP. The results provide evidence that the sensitivity of the SPIPs is proportional to the absorbed energy in the phosphor layer per cGy. The spectral sensitivity is calculated for photon energies between 10 keV and 20 MeV for various SPIP-screen combinations.

Computer-simulated lung nodules in digital chest radiographs for detection studies.

Computer simulations of lung nodules overcome many shortcomings of creating radiographs using anthropomorphic nodule phantoms for lung nodule detection studies, but these algorithms can be cumbersome and involved. A simple, fast, and flexible computer program to simulate lung nodules in digital chest radiographs for detection studies is reported. To verify the realism of the simulated nodules, a psychophysical study and a statistical study were conducted. In the psychophysical study, six radiologists and four nonradiologists were asked to distinguish between 17 real lung nodules and 17 computer-simulated lung nodules shown in eight radiographs. The results show that the computer-simulated lung nodules are indistinguishable visually from real lung nodules. Using parameters from the Rose model of vision, results show that the simulated and real nodules are the same statistically. Thus, besides visual validity, statistical analysis in confirming the validity of the simulated lung nodules is included.

Performance tests and quality control of cathode ray tube displays.

Spatial resolution, noise, characteristic curve, and absolute luminance are the essential parameters that describe physical image quality of a display. This paper presents simple procedures for assessing the performance of a cathode ray tube (CRT) in terms of these parameters as well as easy set up techniques. The procedures can be used in the environment where the CRT is used. The procedures are based on a digital representation of the Society of Motion Pictures and Television Engineers pattern plus a few simple other digital patterns. Additionally, measurement techniques are discussed for estimating brightness uniformity, veiling glare, and distortion. Apart from the absolute luminance, all performance features can be assessed with an uncalibrated photodetector and the eyes of a human observer. The measurement techniques especially enable the user to perform comparisons of different display systems.

Intraoperative arteriography: comparison of conventional screen-film with photostimulable imaging plate radiographs.

This prospective study compared images obtained with a photostimulable imaging plate with matched images obtained with a conventional screen-film combination in 26 patients undergoing intraoperative arteriography. Diagnostic accuracy of the two techniques was assessed objectively, and image quality was assessed subjectively. In 16 patients (62%), the radiation exposure was reduced by 50% for the imaging plate technique by decreasing the mAs level generally used for the screen-film combination. Because of the dynamic range of the imaging plate system, no repeat examinations were necessary, while 12% of the screen-film studies had to be repeated because of over- or under-penetration. Imaging plate studies required 6% more time for processing than screen-film studies. Receiver-operating-characteristic analysis indicated no difference in diagnostic accuracy between the two imaging techniques. Subjective evaluation also revealed no difference in observer preference for imaging plate or screen-film studies. The imaging plate technique is an excellent alternative to screen-film studies in the operating room.

Finite-length line-spread function.

In this paper we derive a formula for calculating the point-spread function (PSF) of a rotationally symmetric imaging system from measurements along a line through the image of an arbitrary separable input object. An important special case of this formula is when the input object is a finite-length slit. The set of measurements in this case is called the finite-length line-spread function (FLSF). The FLSF differs from the infinite-length line-spread function (LSF) only in the assumed finite length of the line that is input into the system. This difference between the FLSF and the LSF becomes important for imaging systems for which the PSF is large in extent and in which the isoplanatic patch is relatively small. The usual LSF-to-PSF conversion formulas cannot be applied accurately to such systems.

The digital radiology department of the future.

The boom in microelectronics, including cost-effectiveness, has now allowed us to consider the use of these objects to store digital images. There remains much research, development, and clinical evaluation to be done in receptor technology. Further improvements in image processing, optical laser disk storage, and optical transmission and further commercial development of display technology must take place. All of these developments are occurring simultaneously. Within 5 to 10 years, radiology departments will most likely be totally electronic, probably cost-effective, and, it is hoped, more diagnostically accurate.