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As the transition toward total digital image acquisition continues, radiology is transcending the current standard of two-dimensional (2-D) cross-sectional anatomic imaging to more complex models. Among these are three-dimensional (3-D) anatomic images, constructed either from a synthesis of traditional 2-D data sets, or directly from volumetrically acquired data. However, current trends are moving beyond mere anatomic imaging to include physiological data once mainly obtained via nuclear medicine. Recent magnetic resonance pulse sequences, in addition to Doppler and harmonic ultrasound methods, are providing insight into blood flow, oxygenation, and metabolite concentrations non-invasively. Through image registration techniques, these data (even from differing modalities) are being assembled into 2-D and 3-D "fusion" images that promise to revolutionize diagnosis. Furthermore, with improvements in miniaturization, reliability, speed, built-in intelligence, and ease of use, these new developments are finding their way into use by nonspecialists. For instance, a new hand-held ultrasound unit will likely become a common tool among emergency medical teams, military medical teams, and in NASA's manned space program. Portable computed tomography (CT) scanners are already being used in the operating room. The increasing sophistication of imaging instruments will bring about a complementary increase in ease of use for both scanning and data interpretation, bringing diagnostic imaging and therapeutic capabilities closer to the patient, rather than the converse.

The authors have investigated the application of the NASA Advanced Communications Technology Satellite (ACTS) to teleradiology and telemedicine using the Jet Propulsion Laboratory (JPL)-developed ACTS Mobile Terminal (AMT) uplink. In this experiment, bidirectional 128, 256, and 384 kbps satellite links were established between the ACTS/AMT, the ACTS in geosynchronous orbit, and the downlink terrestrial terminal at JPL. A terrestrial Integrated Digital Services Network (ISDN) link was established from JPL to the University of Washington Department of Radiology to complete the bidirectional connection. Ultrasound video imagery was compressed in real-time using video codecs adhering to the International Telecommunication Union-Telecommunication Standardization Sector (ITU-T) Recommendation H.261. A 16 kbps in-band audio channel was used throughout. A five-point Likert scale was used to evaluate the quality of the compressed ultrasound imagery at the three transmission bandwidths (128, 256, and 384 kbps). The central question involved determination of the bandwidth requirements to provide sufficient spatial and contrast resolution for the remote visualization of fine- and low-contrast objects. The 384 kbps bandwidth resulted in only slight tiling artifact and fuzziness owing to the quantizer step size; however, these motion artifacts were rapidly resolved in time at this bandwidth. These experiments have demonstrated that real-time compressed ultrasound video imagery can be transmitted over multiple ISDN line bandwidth links with sufficient temporal, contrast, and spatial resolution for clinical diagnosis of multiple disease and pathology states to provide subspecialty consultation and educational at a distance.

Over the past five years the University of Washington has created a clinical data repository. This repository combines in a distributed relational database information from multiple departmental databases (MIND). MINDscape provides a platform independent, web browser view of the MIND dataset that can easily be linked to other information resources on the network.

A limited flip angle gradient-echo 3D volume acquisition imaging protocol for mapping partial pressure of oxygen (pO2) in perfluorocarbon compounds (PFCs) at low field (0.14 T) is presented. The PO2 measurement method is based on the paramagnetic effect of dissolved molecular oxygen (O2) which reduces the PFC 19F T1. Specific objectives related to imaging of PFCs through use of the protocol include improved image signal-to-noise characteristics and elimination of 19F chemical shift artifacts. A parametric Wiener deconvolution filtering algorithm is used for suppression of 19F chemical shift artifacts. Application of the protocol is illustrated in a series of calculated PO2 maps of a gas equilibrated, multi-chamber phantom containing perfluorotributylamine (FC-43). The utility of the protocol is demonstrated in vivo through images of a commercially available perfluorocarbon based blood substitute emulsion containing FC-43 sequestered in the liver and spleen of a rat.

Microsporidia are obligate intracellular protozoal pathogens associated with chronic diarrhea in individuals infected with HIV. Direct detection methods for microsporidial spores in stool include chromotrope-based, fluorochrome, and immunofluorescent stains. The authors compared the ability to detect microsporidial spores in 168 stool specimens using two stains: a chromotrope-based modified trichrome stain and a fluorochrome stain, calcofluor white (Cellufluor, Polysciences, Warrington, PA). In addition to being faster and easier to perform, the calcofluor white stain was found to be more sensitive than the chromotrope-based stain, as 6 of 24 specimens positive by calcofluor white were negative by the chromotrope-based stain on initial smear evaluation. Repeat examination confirmed these six as being positive. To evaluate the specificity of the calcofluor white stain, 20 formalin-fixed stool specimens (5 positive and 15 negative for microsporidial spores) were evaluated in blinded fashion by two affiliated clinical laboratories using their own formulations of calcofluor white. A single discrepant result (falsely positive) was reported from one laboratory. The use of the calcofluor white stain is recommended as a simple and highly sensitive screening procedure for the detection of microsporidial spores in stool specimens.

The authors have examined the utility of using the rate of change of the human chorionic gonadotropin (hCG) level and progesterone concentration to distinguish ectopic from normal intrauterine pregnancies. Patients suspicious for ectopic pregnancy had three outcomes: normal intrauterine gestation (NIUG), ectopic pregnancy (ECT), and inevitable abortion (IAB). The rate of change of the hCG level and the progesterone concentration distinguish NIUG from ECT with good sensitivity and specificity at optimal cut-offs of 0.14 (rate of change of the logarithm of hCG) and 8 ng/mL (progesterone). As the biochemical parameters of the ECT and IAB groups overlap, stating that NIUG can be biochemically distinguished from ECT is misleading. Thus, the authors have grouped them together as pathologic pregnancies (PATH). The rate of change of the hCG level and the progesterone concentration distinguish NIUG from PATH with good sensitivity and specificity with the same optimal cut-offs of 0.14 (rate of change of the logarithm of hCG) and 8 ng/mL (progesterone).

Computers have greatly facilitated the processing and storage of radiologic information. Manufacturers of radiology information systems (RISs) are gradually incorporating options for interfacing their products with other computers (e.g., hospital information systems). However, a growing need exists to also interface RISs with digital radiologic equipment so that images (e.g., computed radiographs of the chest and skeleton) are automatically labeled with identification data. Such connectivity would eliminate redundant work by technologists, decrease errors in the labeling of images, and increase the consistency of patients' data within a radiology department. Unfortunately, the rapid advances in digital technology, combined with the lack of a well-defined standard for the transfer of demographic information between dissimilar systems, have delayed development of these interfaces. We have developed a widely applicable method to automatically transfer patients' demographic data from an RIS to a commercially available computed radiography system. A personal computer is configured with inexpensive programmable telecommunications software to create an interactive gateway, which eliminates the need for redundant data entry (compared with entering data once on the RIS and again on the stand-alone computed radiography system), and thus also decreases errors in the labeling of images.

Rationale and Objectives: Existing retrieval models for radiology film libraries have not incorporated the influence of previous retrievals. A Markov chain model for the retrieval rates from an analog film library is proposed as a means of considering this effect., Methods: A Markov chain model was developed for the retrieval rates of an analog film library. The Markov chain model required identification of the states of the Markov chain, the required one-step transition probabilities between states, and the initial state probabilities., Results and Conclusions: The results from the Markov chain model compared favorably with the 30-day measurements (25,775 retrievals), but a large enough sample to determine a statistical confidence level was not considered.

To develop a cost-effective method of sharing educational resources, a dial-up teleconferencing network was implemented between three radiologic sites for a 30-day period of evaluation. By means of standard dial-up telephone channels, compressed video and audio signals displayed radiologic images, slides, and text, allowing residents and faculty from the three sites to participate in sight and sound interactions. Each of the three sites used compressed video/audio coder-decoders (codecs) conforming to the Consultative Committee on International Telegraphy and Telephony H.261 standard. Four video cameras were used at each site, and the audio was run in full duplex mode. A multipoint video bridge was used to broadcast codec output signals to the input lines of the other codecs. Our evaluation found audio quality to be suboptimal, but capable of being improved; diagnostic image quality was adequate when a video zoom mode was used; the digital-archive mode of the codec proved advantageous; the H.261 codec permitted participation from all sites; and all conference lecturers were able to conduct their conferences as they were accustomed. Although audio quality and spatial resolution need to be improved, the results of this pilot study imply that dial-up compressed video conferencing has the potential to become a practical, cost-effective method of sharing educational resources by means of interactive radiologic multisite educational programs.

Rationale and Objectives: Digital image compression reduces the storage requirements and network traffic on picture archiving and communications systems. Full-frame bit-allocation (FFBA) is an irreversible image-compression method based on the discrete cosine transform that provides for high compression ratios with a high degree of image fidelity., Methods: One hundred twenty-two posteroanterior chest radiographs were obtained on patients in an ambulatory patient setting, including 30 cases of interstitial lung disease, 45 images containing combinations of lung nodules (N = 37) or mediastinal masses (N = 39), and 47 normal images containing none of the pathology for which we were testing. The images were digitized (nominal 2 K x 2 K x 12-bit resolution), printed on a 35 x 35-cm hard copy format, and compressed at an approximate compression ratio of 20:1. Observer performance tests were conducted with five radiologists using receiver operating characteristics analysis on digitized uncompressed and compressed hard copy images., Results: There were no significant differences between the two display conditions for the detectability of any of the thoracic abnormalities., Conclusions: Our preliminary results suggest that irreversible image compression at ratios of 20:1 may be acceptable for use in digital thoracic imaging.

The accurate prediction of image throughput is a critical issue in planning for and acquisition of any successful picture archiving and communication system (PACS). Simulation plays an important role in this effort. The PACS image management chain is decomposed into eight subsystems. These subsystems include network transfers over three different networks and five software programs and/or queueing structures. This decomposition is used to create a simulation model that was effectuated using commercially available block-oriented network simulation software. From the PACS database, the traffic generation patterns of the imaging modality devices are used to drive the simulation. The simulation models the image file flow through the PACS for a 24-hour period. The behavior of the simulated traffic generators agreed well with the values derived from the PACS database. The mean delay for the simulated PACS is found to be 225 +/- 59 seconds. The delay time was found to vary during the simulated 24-hour cycle in a consistent manner with observations. This simulation provides estimates on what a radiological department can expect from a PACS in terms of throughput, utilization, and delay. The block-oriented network simulator (BONeS, Comdisco Systems Inc, Foster City, CA) simulation model of the modeled PACS is highly accurate. The models for the imaging modality traffic sources are validated with a high degree of accuracy. The simulation model allows for the study of what happens to the delay time under various loads. In this simulation, the reformatting process was determined to be the bottleneck causing a large increase in delay time under heavy loads.

This paper describes the implementation of a large-scale picture archiving and communication system (PACS) in a clinical environment. The system consists of a PACS infrastructure, composed of a PACS controller, a database management system, communication networks, and optical disk archive. It connects to three MR units, four CT scanners, three computed radiography systems, and two laser film digitizers. Seven display stations are on line 24 h/day, 7 days/wk in genitourinary radiology (2K), pediatric radiology in-patient (1K and 2K) and outpatient (2K), neuroradiology (2K), pediatric ICU (1K), coronary care unit (1K), and one laser film printing station. The PACS is integrated with the hospital information system and the radiology information system. The system has been in operation since February 1992. We have integrated this PACS as a clinical component in daily radiology practice. It archives an average of 2.0-gigabyte image data per workday. A 3-mo system performance of various components are tabulated. The deployment of this large-scale PACS signifies a milestone in our PACS research and development effort. Radiologists, fellows, residents, and clinicians use it for case review, conferences, and occasionally for primary diagnosis. With this large-scale PACS in place, it will allow us to investigate the two critical issues raised when PACS research first started 10 yrs ago: system performance and cost effectiveness between a digital-based and a film-based system.

A teleradiology system acquires radiographic images from one location and transmits them to one or more distant sites where they are displayed and/or converted to hard-copy film recordings. The long-term goal of teleradiology research is to show that teleradiology systems can provide diagnostically equivalent results when compared with conventional radiographic film interpretation. If this hypothesis is proven, provision of the following radiology services will be improved: (1) providing for primary interpretation of radiological images for patients in underserved areas as well as in other medical facilities; (2) integration of radiological services for multihospital/clinic health care provider consortiums; (3) improving emergency service and intensive care unit coverage; (4) offering consulting-at-a-distance with subspecialty radiologists; and (5) providing radiologists in the community or in rural areas with immediate access to large academic centers for help in the interpretation of difficult and problematic cases. We are designing a high-speed, high-resolution teleradiology network that will communicate between our level 3 medical center and several outlying medical centers within the metropolitan area. Computed tomography (CT), magnetic resonance (MR), and screen-film examinations will be digitized to 2,000 x 2,000 or 4,000 x 4,000 pixels at the remote sites, transmitted to the central referral facility, and sent to a laser film printer, replicating the original film. This film may then be used for primary diagnosis, overreading/consultative purposes, or for emergency department preparation. Inherently digital modality data (eg, MR and CT) can be sent without digitization of the multiformat film if desired.

PACS (Picture Archiving and Communication Systems) database design requires careful understanding of the data and processing needs of radiologists, referring physicians, radiology staff, administrators, and researchers. Due to access requirements, the physical implementation for the management of small text data sets differs from the implementation strategy for large image data sets (centralized vs. distributed storage strategies). In this paper we discuss the database structure, storage architecture, file placement strategies, and administration considerations of the UCLA PACS.

This paper outlines the diverse Picture Archiving and Communication Systems (PACS) networking implementation strategies at the University of California at Los Angeles, the University of Florida, and the University of Kansas. At the University of California at Los Angeles, a very high-speed network has been integrated into a hierarchical networking strategy, resulting in an entirely customized network for the local transmission of images. The University of Florida has chosen to implement networks for local transmission of images using commercially available equipment. The University of Kansas, specializing in teleradiology applications, uses commercial telecommunication circuits to implement long distance referral services to small hospitals.

The three most difficult problems in making picture archiving and communication systems (PACS) a clinical reality in radiology are image archiving, very high-resolution display stations, and high-speed networking. This article considers high-speed image transmission through a high-capacity network. Our laboratory has tested several commercially available high-speed networks over the past year. Only one of these networks (UltraNet) has adequate throughput and capacity potential necessary for our PACS. The focus of this experiment is to determine the throughput and capacity characteristics of this star topology networking scheme as they relate to the operation of a PACS in the clinical environment. A large-scale test was done to gauge network performance for three networking configurations modeling those in a PACS: duplex, parallel, and relay. Ten computers used in our PACS (Sun 3 and 4 computers) were connected with UltraNet. For point-to-point throughput (half-duplex model), the network delivers up to 3.1 megabytes/sec for Sun 3 computers and 6.8 megabytes/sec for the Sun Sparcserver 490. As regards capacity considerations (parallel model), five parallel image transfer processes generated a maximum of 13.9 megabytes/sec through the network. Only a slight degradation in individual process throughput was observed (1.4%). With regard to shared access to high-contention resources on the PACS network (e.g., archive servers), this network demonstrated equal sharing of server networking capacity between the various client computers. With the encouraging results of this experiment, we believe that the UltraNet network will be sufficient for the image communication requirements of our PACS. We are proceeding with the implementation of UltraNet as the high-speed backbone of our extended PACS network.

We have integrated a commercially available microprogrammable state machine (Tecmag PULSkit) for use as a magnetic resonance pulse programmer. Providing the capability for active research environment imaging protocols, it features timing resolution of 100 nsec, ten 16-bit loop counters, and individually addressable look-up tables. This integration involved hardware and software integration with a VAX 11/750 at several levels. Hardware: Each of the three gradient channels employs three digital-to-analog converters (DACs). An 8-bit, 4-quadrant, multiplying DAC generates the gradient waveform shape. A 12-bit DAC generates the multiplying DAC scaling voltage, controlling gradient amplitude and sign. A third 12-bit DAC produces a gradient offset (shim) voltage. An eddy current compensation network is present for each gradient channel. Software: The software design philosophy was to create a flexible interface (interactive window environment), while not constraining complex manipulation of the hardware (direct use of the pulse-sequence compiler primitives and microprogramming). The software levels include (a) pulse-sequence microprogramming, (b) pulse-sequence compiler, (c) interactive parameter specification, and (d) canned pulse-sequence microcode library.

This paper focuses on analysis and development of a single-exposure dual-energy digital radiographic method using computed radiography (Fuji FCR-101 storage phosphor system). A detector sandwich consisting of storage phosphor imaging plates and an interdetector filter is used. The goal of this process is to provide a simple dual-energy method using typical plane-projection radiographic equipment and techniques. This approach exploits the transparency of the storage phosphor plates, using radiographic information that would be otherwise lost, to provide energy selective information essentially as a by-product of the radiographic examination. In order to effectively make use of the large dynamic range of the storage phosphor imaging plates (10,000:1), a computed radiography image reading mode of fixed analog-to-digital converter gain and variable photomultiplier sensitivity provides image data which can be related to relative incident exposure for export to the decomposition algorithm. Scatter rejection requirements necessitated crossed 12:1 grids for a field size of 36 x 36 cm. Optimal technique parameters obtained from computer simulation through minimization of the aluminum and Plexiglas equivalent image uncertainty under conditions of constant absorbed does resulted as: 100 kVp using a 0.15-mm-thick tin (Sn) interdetector filter for the lung field. This yields a surface exposure of 23 mR and a surface absorbed dose of 0.26 mGy for a 23-cm-thick chest. Clinical application in evaluation of the solitary pulmonary nodule is discussed, along with an image set demonstrating this application.

This study presents preliminary results of single kVp dual-energy computed radiography using laser stimulable luminescent phosphor image plate detectors. The single kVp technique makes use of four of these plates in a single cassette, each plate acting as an X-ray filter to the next so that the energy separation required for the dual-energy basis decomposition is achieved. An analysis to determine the best operating technique for the chest is performed using computer stimulation, and was found to be 85 kVp and 14 mAs. This technique yields the same entrance exposure value as is used clinically, so that the information for the decomposition is obtained without additional dose to the patient. The iso-transmission line technique was used as the decomposition algorithm. A humanoid chest phantom was used to demonstrate the quality of the resulting calibration material equivalent images.

Implementation of a Picture Archiving and Communication System (PACS) is a system integration task and requires the knowledge of multidisciplinary fields. This paper reviews current PACS development with emphasis on radiological images. The following topics are covered: methods of image acquisition, image compression, storage, display, communication, and image database structure. Methods of implementation of PACS in a clinical environment as well as current operational PACS in hospitals are reviewed. A survey of private industry participating in PACS research and development are also given.