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This guideline has been prepared by the ACPSEM to provide a standardised quality assurance program to be used within General X-ray imaging environments. The guideline includes the responsibilities of various multidisciplinary team members within medical imaging facilities. It must be noted that the listed tests and testing frequencies are not intended to replace or become regulatory requirements. Implementing a quality assurance program as outlined in this position paper is there to ensure best practice for imaging facilities by providing a framework to establish and monitor correct equipment performance. The current document has been produced through an extensive review of current international practices and local experience within the Australasian healthcare environment. Due to the constant evolution of digital radiographic equipment, there is no current consensus in international quality assurance guidelines as they continue to be adapted and updated. This document describes the current state of the use of digital General X-ray equipment in the Australasian environment and provides recommendations of test procedures that may be best suited for the current medical imaging climate in Australasia. Due to the everchanging developments in the medical imaging environment and the ability of new technologies to perform more complex tasks it is believed that in the future this document will be further reviewed in the hopes of producing a more globally agreed upon standard quality assurance program. Any such adjustments that are deemed to be necessary to Version 1.0 of this document will be provided in electronic format on the ACPSEM website with a notification to all parties involved in the use of digital General X-ray equipment. This guideline does not provide detailed methodologies for all the quality control tests recommended as it is it is expected that the professionals implementing aspects of this quality assurance program have the working knowledge and access to appropriate resources to develop testing methodologies appropriate for their local imaging environment., (© 2024. The Author(s).)

Context.—: Flexible working at diverse or remote sites is a major advantage when reporting using digital pathology, but currently there is no method to validate the clinical diagnostic setting within digital microscopy., Objective.—: To develop a preliminary Point-of-Use Quality Assurance (POUQA) tool designed specifically to validate the diagnostic setting for digital microscopy., Design.—: We based the POUQA tool on the red, green, and blue (RGB) values of hematoxylin-eosin. The tool used 144 hematoxylin-eosin-colored, 5×5-cm patches with a superimposed random letter with subtly lighter RGB values from the background color, with differing levels of difficulty. We performed an initial evaluation across 3 phases within 2 pathology departments: 1 in the United Kingdom and 1 in Sweden., Results.—: In total, 53 experiments were conducted across all phases resulting in 7632 test images viewed in all. Results indicated that the display, the user's visual system, and the environment each independently impacted performance. Performance was improved with reduction in natural light and through use of medical-grade displays., Conclusions.—: The use of a POUQA tool for digital microscopy is essential to afford flexible working while ensuring patient safety. The color-contrast test provides a standardized method of comparing diagnostic settings for digital microscopy. With further planned development, the color-contrast test may be used to create a "Verified Login" for diagnostic setting validation.

The purpose of the current study was to provide useful data, which may help neurosurgeons to manage the patient dose and image quality in spinal surgery procedures, utilising a phantom and a test object. The kerma area product, cumulative dose (CD) and entrance surface dose (ESD) rate on the phantom and image intensifier were measured, for selectable fields of view (FOVs), fluoroscopy modes, two geometric magnifications and various phantom thicknesses. The images were subjectively evaluated regarding low-contrast detectability and high-contrast resolution. Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), high-contrast spatial resolution (HCSR) and figure of merit (FOM) values were also estimated. The ESD rates increased with increasing phantom thickness, when using electronic or geometric magnification, continuous or high-definition fluoroscopy (HDF). The observers' evaluation showed relatively slight changes in image quality when pulsed fluoroscopy was used. SNR, CNR and HCSR values decreased with increasing phantom thicknesses, while remained almost constant when using pulsed fluoroscopy. SNR and HCSR improved in HDF, while the CNR remained almost constant only for the FOVs 23 and 17 cm. By applying electronic magnification, this resulted in improved HCSR. FOM values decreased in HDF, with increasing phantom thickness and using electronic magnification. For the 'thinnest' patients, CD may overestimate skin dose by 25% than the actual values. Geometric magnification resulted in improved FOM, especially for low-dose fluoroscopy and FOV 23 cm. The knowledge of the increments in dose values, image quality and FOM indices concerning phantom thickness may help neurosurgeons to optimise spinal surgery procedures by selecting the appropriate operational parameters, which could contribute toward the establishment of a radiation protection culture., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The Nigerian Nuclear Regulatory Authority (NNRA) was established to regulate and control the use of radioactive and radiation emitting sources in Nigeria. Quality control (QC) on diagnostic radiology equipment form part of the fundamental requirements for the authorization of diagnostic radiology facilities in the Country., Method: Some quality control tests (output, exposure linearity and reproducibility) were measured on the x-ray machines in the facilities that took part in the study. Questionnaire was developed to evaluate the frequencies at which QC tests were conducted in the facilities and the challenges in setting up QC., Results: Results show great variation in the values of the QC parameters measured. Inadequate cooperation by facilities management, lack of QC equipment and insufficient staff form the major challenges in setting up QC in the facilities under study. The responses on the frequencies at which QC tests should be conducted did not correspond to the recommended standards; indicating that personnel were not familiar with QC implementation and may require further training on QC.

The routine quality assurance (QA) procedure for a high-dose-rate (HDR) 192Ir radioactive source is an important task to provide appropriate brachytherapy. Traditionally, it has been difficult to obtain good quality images using the 192Ir source due to irradiation from the high-energy gamma rays. However, a direct-conversion flat-panel detector (d-FPD) has made it possible to confirm the localization and configuration of the 192Ir source. The purpose of the present study was to evaluate positional and temporal accuracy of the 192Ir source using a d-FPD system, and the usefulness of d-FPD as a QA tool. As a weekly verification of source positional accuracy test, we obtained 192Ir core imaging by single-shot radiography for three different positions (1300/1400/1500 mm) of a check ruler. To acquire images for measurement of the 192Ir source movement distance with varying interval steps (2.5/5.0/10.0 mm) and temporal accuracy, we used the high-speed image acquisition technique and digital subtraction. For accuracy of the 192Ir source dwell time, sequential images were obtained using various dwell times ranging from 0.5 to 30.0 sec, and the acquired number of image frames was assessed. Analysis of the data was performed using the measurement analysis function of the d-FPD system. Although there were slight weekly variations in source positional accuracy, the measured positional errors were less than 1.0 mm. For source temporal accuracy, the temporal errors were less than 1.0%, and the correlation between acquired frames and programmed time showed excellent linearity (R2 = 1). All 192Ir core images were acquired clearly without image halation, and the data were obtained quantitatively. All data were successfully stored in the picture archiving and communication system (PACS) for time-series analysis. The d-FPD is considered useful as the QA tool for the 192Ir source.

Given the adverse impact of image noise on the perception of important clinical details in digital mammography, routine quality control measurements should include an evaluation of noise. The European Guidelines, for example, employ a second-order polynomial fit of pixel variance as a function of detector air kerma (DAK) to decompose noise into quantum, electronic and fixed pattern (FP) components and assess the DAK range where quantum noise dominates. This work examines the robustness of the polynomial method against an explicit noise decomposition method. The two methods were applied to variance and noise power spectrum (NPS) data from six digital mammography units. Twenty homogeneously exposed images were acquired with PMMA blocks for target DAKs ranging from 6.25 to 1600 µGy. Both methods were explored for the effects of data weighting and squared fit coefficients during the curve fitting, the influence of the additional filter material (2 mm Al versus 40 mm PMMA) and noise de-trending. Finally, spatial stationarity of noise was assessed.Data weighting improved noise model fitting over large DAK ranges, especially at low detector exposures. The polynomial and explicit decompositions generally agreed for quantum and electronic noise but FP noise fraction was consistently underestimated by the polynomial method. Noise decomposition as a function of position in the image showed limited noise stationarity, especially for FP noise; thus the position of the region of interest (ROI) used for noise decomposition may influence fractional noise composition. The ROI area and position used in the Guidelines offer an acceptable estimation of noise components. While there are limitations to the polynomial model, when used with care and with appropriate data weighting, the method offers a simple and robust means of examining the detector noise components as a function of detector exposure.

As part of the physico-technical quality assurance of the German breast cancer screening program, the threshold contrast visibility and the average glandular dose of every digital mammography system have to fulfill the requirements of the "European guidelines for quality assurance in breast cancer screening and diagnosis" (4th Edition). To accomplish uniform measurements in all federal states of Germany, the physical board of the reference centers developed a special guideline in 2009. Due to recent changes in the guidelines and standards, a second version of the guideline was developed by the reference centers. This guideline describes the determination of the average glandular dose as well as the CDMAM image acquisition and the CDMAM image evaluation. The determination of the threshold contrast visibility can be performed visually or automatically. The determination of the average glandular dose is based on DIN 6868 - 162 and the threshold contrast visibility test is based on the German "Quality Assurance Guideline"., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To assess whether there are any significant differences in the film-reading histories of interval or screen-detected cancers, and whether this affects stage at diagnosis., Materials and Methods: The rates of screen-detected and interval cancers (overall and by radiological categorization) were observed from 268,067 women screened in the East Midlands Breast Screening Programme over 2004-2007 to assess whether there were differences in incidence based on previous film-reading history. Cancers detected at the subsequent screen and film-reading history were analysed to assess whether this affected stage at diagnosis. Analysis undertaken involved cancer detection rates, confidence intervals, and chi-square tests with Monte Carlo simulation., Results: Rates of interval cancers were similar in all groups where at least one reader had indicated recall to assessment (6.1-7.7/1000) and were significantly higher in comparison to women whose previous film-reading outcome was unanimous routine rescreen (2.9/1000; p < 0.001). Four point one percent of interval cancers with no previous recall outcomes were false negatives, which was significantly lower compared to the groups where at least one reader had indicated recall (10.9%; p = 0.005). Cancers detected at the subsequent screen demonstrated no significant difference in prognosis dependent on previous film-reading history (p = 0.503)., Conclusion: The prognosis of screen-detected cancers was similar and few cancers were false negatives regardless of film-reading history at the previous screen., (Copyright © 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: Quality assurance (QA) is essential in dental radiography. Digital radiography is becoming more common in dentistry, so it is important that appropriate QA tests are carried out on the digital equipment, including the viewing monitor. The aim of this article is to outline the tests that can be carried out in dental practice., Clinical Relevance: Quality assurance for digital equipment is important to ensure consistently high quality images are produced.

Background: The ongoing improvement of imaging quality nowadays focuses increasingly more on immediate quality evaluation of surgical measures., Methods: Rotational tomography (RT) has been experimentally proven to be an alternative imaging technique to computed tomography (CT) in terms of quality and postoperative localization of middle ear implants in temporal bones. Based on these results imaging parameters were determined in the form of a surgical check list in order to systematically check individual but important surgical reconstructive steps., Results: The positive benefit of RT concerning immediate and significant postoperative quality control was confirmed by a patient study. The surgical check list was successfully implemented under clinical framework requirements. Among these standardized parameters the determined angulation of inserted middle ear implants was given outstanding significance due to the predictive value concerning functional outcome., Conclusion: The RT procedure has been proven to be a reliable imaging tool for postoperative quality control following reconstructive middle ear surgery.

Transition from film-screen to digital radiography requires changes in radiographic technique and workflow processes to ensure that the minimum radiation exposure is used while maintaining diagnostic image quality. Checklists have been demonstrated to be useful tools for decreasing errors and improving safety in several areas, including commercial aviation and surgical procedures. The Image Gently campaign, through a competitive grant from the FDA, developed a checklist for technologists to use during the performance of digital radiography in pediatric patients. The checklist outlines the critical steps in digital radiography workflow, with an emphasis on steps that affect radiation exposure and image quality. The checklist and its accompanying implementation manual and practice quality improvement project are open source and downloadable at www.imagegently.org. The authors describe the process of developing and testing the checklist and offer suggestions for using the checklist to minimize radiation exposure to children during radiography., (Copyright © 2013 American College of Radiology. All rights reserved.)

Objective: The purpose of this article is to educate radiologists and technologists about the clinically relevant portion of the new digital radiography standards., Conclusion: Both the International Electrotechnical Commission (IEC standard 62494-1) and the American Association of Physicists in Medicine (AAPM Task Group 116) have developed similar standards for monitoring exposure in digital radiography to eliminate proprietary and confusing terminology. Radiologists and technologists will need to learn three new terms--exposure index, target exposure index, and deviation index--to understand the new standards.

Unlabelled: This is the last in a series of three articles on X-ray dose reduction and covers aspects of quality assurance. The first outlined radiation physics and protection and the second the legislation relating to radiation safety., Clinical Relevance: Quality assurance is an essential part of dental radiography and is required to produce images of a consistently high standard, necessary for accurate diagnosis.

Background: Reject analysis can be used as a quality indicator, and is an important tool in localizing areas where optimization is required. Reducing number of rejects is important yielding reduced patient exposure and increased cost-effectiveness., Purpose: To determine rejection rates and causes in direct digital radiography., Material and Methods: Data were collected during a three-month period in spring 2010 at two direct digital laboratories in Norway. All X-ray examinations, types, numbers, and reasons for rejections were obtained using automatic reject analysis software. Thirteen causes for rejection could be selected., Results: Out of the 27,284 acquired images, 3206 were rejected, yielding an overall rejection rate of 12%. Highest rejection rates were found for examination of knees, shoulders, and wrist. In all, 77% of the rejected images arose from positioning errors., Conclusion: An overall rejection rate of 12% indicates a need for optimizing radiographic practice in the department.

Purpose: For the non-subjective evaluation of physical-technical defects of digital mammography systems within the German breast screening program, an automatic rating system (RS) on the basis of the annual quality control (AQC) was developed. The aim was to design a modular algorithm which could also be adjusted for other test procedures., Materials and Methods: This algorithm enables the separate evaluation of different test parts of the AQC (PAS 1054 and EPQC). To take into account the value of different test positions (TP) in these two parts, a weighting scheme was used. This scheme relates to the scope of different TP as well as variability through different types of systems. For the creation of the final result, both scores of the different test parts must be merged together. The final result is divided into 4 categories., Evaluation: The evaluation of the RS was based on the AQC. Here, the tester of the system was asked to classify the system in one of the 4 categories on the basis of his expert knowledge. In 78 % of the cases, the results of the tester were reproduced by the automatic RS, in 17 % the RS was more stringent and in 5 % the tester was more stringent., Conclusion: The RS allows non-subjective physical-technical evaluation of mammography systems. It acts as a good guide for the tester but is not a replacement for experience. In addition, the RS makes the results of different institutions and testers more comparable. The modular algorithm of the RS is able to react to future changes in the different test parts and can be modified for other X-ray modalities., (Georg Thieme Verlag KG Stuttgart, New York.)

A method of objectively determining imaging performance for a mammography quality assurance programme for digital systems was developed. The method is based on the assessment of the visibility of a spherical microcalcification of 0.2 mm using a quasi-ideal observer model. It requires the assessment of the spatial resolution (modulation transfer function) and the noise power spectra of the systems. The contrast is measured using a 0.2-mm thick Al sheet and Polymethylmethacrylate (PMMA) blocks. The minimal image quality was defined as that giving a target contrast-to-noise ratio (CNR) of 5.4. Several evaluations of this objective method for evaluating image quality in mammography quality assurance programmes have been considered on computed radiography (CR) and digital radiography (DR) mammography systems. The measurement gives a threshold CNR necessary to reach the minimum standard image quality required with regards to the visibility of a 0.2-mm microcalcification. This method may replace the CDMAM image evaluation and simplify the threshold contrast visibility test used in mammography quality.

According to the European Guidelines for quality assured breast cancer screening and diagnosis, noise analysis is one of the measurements that needs to be performed as part of quality control procedures on digital mammography systems. However, the method recommended in the European Guidelines does not discriminate sufficiently between systems with and without additional noise besides quantum noise. This paper attempts to give an alternative and relatively simple method for noise analysis which can divide noise into electronic noise, structured noise and quantum noise. Quantum noise needs to be the dominant noise source in clinical images for optimal performance of a digital mammography system, and therefore the amount of electronic and structured noise should be minimal. For several digital mammography systems, the noise was separated into components based on the measured pixel value, standard deviation (SD) of the image and the detector entrance dose. The results showed that differences between systems exist. Our findings confirm that the proposed method is able to discriminate systems based on their noise performance and is able to detect possible quality problems. Therefore, we suggest to replace the current method for noise analysis as described in the European Guidelines by the alternative method described in this paper.

The existing practice of quality assurance (QA) in medical imaging is problematic because of the subjective manner in which it is performed, the lack of community and industry-wide QA standards, a paucity of supporting technology, and an overall lack of accountability. The solution for optimizing QA lies in the creation of objective and reproducible QA metrics, whose analysis can be automated through the creation of computerized QA software algorithms. The QA data derived from these computerized programs would in turn create the infrastructure for a comprehensive QA database, which can serve as a valuable resource for QA education and training, research, decision support, and technology innovation. The ability to objectively track and analyze QA practice across the wide spectrum of imaging providers creates a mechanism for the creation and refinement of objective QA standards and "best practice" guidelines.

Image guided radiation therapy solutions based on megavoltage computed tomography (MVCT) involve the extension of electronic portal imaging devices (EPIDs) from their traditional role of weekly localization imaging and planar dose mapping to volumetric imaging for 3D setup and dose verification. To sustain the potential advantages of MVCT, EPIDs are required to provide improved levels of portal image quality. Therefore, it is vital that the performance of EPIDs in clinical use is maintained at an optimal level through regular and rigorous quality assurance (QA). Traditionally, portal imaging QA has been carried out by imaging calibrated line-pair and contrast resolution phantoms and obtaining arbitrarily defined QA indices that are usually dependent on imaging conditions and merely indicate relative trends in imaging performance. They are not adequately sensitive to all aspects of image quality unlike fundamental imaging metrics such as the modulation transfer function (MTF), noise power spectrum (NPS), and detective quantum efficiency (DQE) that are widely used to characterize detector performance in radiographic imaging and would be ideal for QA purposes. However, due to the difficulty of performing conventional MTF measurements, they have not been used for routine clinical QA. The authors present a simple and quick QA methodology based on obtaining the MTF, NPS, and DQE of a megavoltage imager by imaging standard open fields and a bar-pattern QA phantom containing 2 mm thick tungsten line-pair bar resolution targets. Our bar-pattern based MTF measurement features a novel zero-frequency normalization scheme that eliminates normalization errors typically associated with traditional bar-pattern measurements at megavoltage x-ray energies. The bar-pattern QA phantom and open-field images are used in conjunction with an automated image analysis algorithm that quickly computes the MTF, NPS, and DQE of an EPID system. Our approach combines the fundamental advantages of linear systems metrics such as robustness, sensitivity across the full spatial frequency range of interest, and normalization to imaging conditions (magnification, system gain settings, and exposure), with the simplicity, ease, and speed of traditional phantom imaging. The algorithm was analyzed for accuracy and sensitivity by comparing with a commercial portal imaging QA method (PIPSPRO, Standard Imaging, Middleton, WI) on both first-generation lens-coupled and modern a-Si flat-panel based clinical EPID systems. The bar-pattern based QA measurements were found to be far more sensitive to even small levels of degradation in spatial resolution and noise. The bar-pattern based QA methodology offers a comprehensive image quality assessment tool suitable for both commissioning and routine EPID QA.

Purpose: German breast cancer screening is monitored by a large physical quality assurance program. This report refers to the first experiences of the Reference Center (RC) Muenster after three years of the technical quality control of digital and analog mammography units (MU). This paper also shows whether the presently used quality assurance (QA) method is able to ensure that the MUs in the screening program are functioning without any serious problems., Materials and Methods: RC Muenster supervises 95 units (May 2008). The daily, weekly and monthly quality assurance of these units is controlled by web-based QA software named "MammoConrol" and developed by RC Muenster. The annual QA for the units must be conducted in the form of an on-site inspection by medical physics experts of the RC and is scored by an objective ranking system. The results of these QA routines were evaluated and analyzed for this paper., Results: During the period from 3/1/2006 to 5/31/2008, 8 % of the analog systems and 1 % of the digital systems exhibited problems in the daily QA. For 9 % of the analog MUs and 17 % of the digital MUs, failures appeared in the monthly QA. In the annual control, 86.7 % of the analog units exhibited slight problems and 13.3 % had serious problems. With respect to the digital units, 12 % were without any defects, 58 % had slight problems, 27 % had serious failures and 3 % had to be reported to the responsible authorities and were temporarily shut down., Conclusion: The special quality control requirements for German breast cancer screening, including annual on-site checks of the units, have shown in the last three years that QA with a high monitoring standard can be ensured for a large number of decentralized MUs. The currently used QA method sufficiently ensures that the screening program is technically safe. Further studies must show whether the density and focus of the QA measures must be reconfigured.

With the introduction of criteria for clinical audit by the Irish Dental Council, and the statutory requirement on dentists to introduce this into their practice, this article will introduce the basic concepts of quality standards in intra-oral radiography and the subsequent application of these standards in an image quality audit cycle. Subjective image quality analysis is not a new concept, but its application can prove beneficial to both patient and dental practitioner. The ALARA (as low as reasonably achievable) principle is fundamental in radiation protection, and therefore the prevention of repeat exposures demonstrates one facet of this that the dental practitioner can employ within daily practice.

Some of the findings of a review of the relationship between physical measurements and clinical image quality have been summarised. Mixed results were found: some studies had no relationship at presently typical dose levels, whereas others had a clear correlation between them. It is concluded that the various image quality evaluation tasks in an X-ray department are best done by different methods. Presently, exact physical measurements cannot supersede subjective evaluation in judging the acceptability of clinical images, whereas they are indispensable in specification and testing of technical performance.

Computed radiography (CR) and digital radiography (DR) are replacing traditional film screen radiography as hospitals move towards digital imaging and picture archiving and communication systems (PACS). Both IPEM and KCARE have recently published quality assurance and acceptance testing guidelines for DR. In this paper, the performance of a range of CR and DR systems is compared. Six different manufacturers are included. Particular attention is paid to the performance of the systems under automatic exposure control (AEC). The patient is simulated using a range of thicknesses of tissue equivalent material. Image quality assessment was based on detector assessment protocols and includes pixel value measures as well as subjective assessment using Leeds Test Objects. The protocols for detector assessment cover a broad range of tests and in general detectors (whether DR or CR) performed satisfactorily. The chief limitation in performing these tests was that not all systems provided ready access to pixel values. Subjective tests include the use of the Leeds TO20. As part of this work, suggested reference values are provided to calculate the TO20 image quality factor. One consequence of moving from film screen to digital technologies is that the dynamic range of digital detectors is much wider, and increased exposures are no longer evident from changes in image quality. As such, AEC is a key parameter for CR and DR. Dose was measured using a standard phantom as a basic means of comparing systems. In order to assess the AEC performance, exit doses were also measured while varying phantom thickness. Signal-to-noise ratios (SNRs) were calculated on a number of systems where pixel values were available. SNR was affected by the selection of acquisition protocol. Comparisons between different technologies and collation of data will help refine acceptance thresholds and contribute to optimising dose and image quality.

In order to quantify the clinical quality of full-field digital mammography, a set of image quality parameters is developed. The set consisted of 12 image quality criteria and 8 physical characteristics of the image. The first set interrogates the visibility of anatomical structures and typical characteristics of a digital image, such as noise and saturation of dark and white areas. The second set of criteria evaluates contrast, sharpness and confidence with the representation of masses, microcalcifications and the image. The use of these criteria is reported in a retrospective study, in which the impact of dose on the radiological quality of digital mammograms is evaluated. Fifty patients acquired in a low-dose mode were retrieved and compared with 50 patients acquired in a dose mode that was set 41% higher. The dose affects, more than expected, contrast and sharpness of the image, whereas the visibility of the anatomical structures remains unchanged. With these parameters, quantification of the image quality is possible; however, because of subjectivity of the parameters, only intra-observer comparison and evaluation of the individual parameters rather than the overall results are advised. Together with physical tests of image quality, critical radiological evaluation of the quality should be included in the acceptance process of digital mammography.

Application of a quality control (QC) programme is very important when optimisation of image quality and reduction of patient exposure is desired. QC surveys of diagnostics imaging equipment in Republic of Srpska (entity of Bosnia and Herzegovina) has been systematically performed since 2001. The presented results are mostly related to the QC test results of X-ray tubes and generators for diagnostic radiology units in 92 radiology departments. In addition, results include workplace monitoring and usage of personal protective devices for staff and patients. Presented results showed the improvements in the implementation of the QC programme within the period 2001--2005. Also, more attention is given to appropriate maintenance of imaging equipment, which was one of the main problems in the past. Implementation of a QC programme is a continuous and complex process. To achieve good performance of imaging equipment, additional tests are to be introduced, along with image quality assessment and patient dosimetry. Training is very important in order to achieve these goals.

Mammographic phantom images are usually used to study the quality of images obtained by determined mammographic equipment. The digital image treatment techniques allow carrying out an automatic analysis of the phantom image. Nowadays, the digital radiographic equipments are replacing the traditional film-screen equipments and it is necessary to update the parameters to guarantee the quality of the process. In this work we apply some techniques of digital image processing to compute a specific image quality indexes for mammographic phantoms, namely CIRS SP01 and CDMAM 3.4. to study the evolution of this parameter with different varying conditions of the mammographic equipment. The indexes are calculated from a scoring system based on a designed algorithm which analyses the phantom image by means of an automatic detection of the test objects in each phantom.

Quantitative image quality results in the form of the modulation transfer function (MTF), normalized noise power spectrum (NNPS) and detective quantum efficiency (DQE) are presented for nine full field digital mammography (FFDM) systems. These parameters are routinely measured as part of the quality assurance (QA) programme for the seven FFDM units covered by our centre. Just one additional image is required compared to the standard FFDM protocol; this is the image of an edge, from which the MTF is calculated. A variance image is formed from one of the flood images used to measure the detector response and this provides useful information on the condition of the detector with respect to artefacts. Finally, the NNPS is calculated from the flood image acquired at a target detector air kerma (DAK) of 100 microGy. DQE is then estimated from these data; however, no correction is currently made for effects of detector cover transmission on DQE. The coefficient of variation (cov) of the 50% point of the MTF for five successive MTF results was 1%, while the cov for the 50% MTF point for an a-Se system over a period of 17 months was approximately 3%. For four a-Se based systems, the cov for the NNPS at 1 mm(-1) for a target DAK of 100 microGy was approximately 4%; the same result was found for four CsI based FFDM units. With regard to the stability of NNPS over time, the cov for four NNPS results acquired over a period of 12 months was also approximately 4%. The effect of acquisition geometry on NNPS was also assessed for a CsI based system. NNPS data acquired with the antiscatter grid in place showed increased noise at low spatial frequency; this effect was more severe as DAK increased. DQE results for the three detector types (a-Se, CsI and CR) are presented as a function of DAK. Some reduction in DQE was found for both the a-Se and CsI based systems at a target DAK of 12.5 microGy when compared to DQE data acquired at 100 microGy. For the CsI based systems, DQE at 1 mm(-1) fell from 0.49 at 100 microGy to 0.38 at 12.5 microGy. For the a-Se units, there was a slightly greater reduction in average DQE at 1 mm(-1), from 0.53 at 100 microGy to 0.31 at 12.5 microGy. Somewhat different behaviour was seen for the CR unit; DQE (at 1 mm(-1)) increased from 0.40 at 100 microGy to 0.49 at 12.5 microGy; however, DQE fell to 0.30 at 420 microGy. DQE stability over time was assessed using the cov of DQE at 1 mm(-1) and a target DAK of 100 microGy; the cov for data acquired over a period of 17 months for an a-Se system was approximately 7%. For comparison with conventional testing methods, the cov was calculated for contrast-detail (cd) data acquired over the same period of time for this unit. The cov for the threshold contrast results (averaged for disc diameters between 0.1 mm and 2 mm) was 6%, indicating similar stability.

This article on digital radiography image acquisition is the first of two articles written as part of an intersociety effort to establish image quality standards for digital and computed radiography. The topic of the other paper is digital radiography image processing and display. The articles were developed collaboratively by the ACR, the American Association of Physicists in Medicine, and the Society for Imaging Informatics in Medicine. Increasingly, medical imaging and patient information are being managed using digital data during acquisition, transmission, storage, display, interpretation, and consultation. Data management during each of these operations has a direct impact on the quality of patient care. These articles describe what is known to improve image quality for digital and computed radiography and make recommendations on optimal acquisition, processing, and display. The practice of digital radiography is a rapidly evolving technology that will require the timely revision of any guidelines and standards. This document provides a basis for the technologies available today in clinical practice and may be useful in guiding the future clinical practice of digital radiography.

This article on digital radiography image processing and display is the second of two articles written as part of an intersociety effort to establish image quality standards for digital and computed radiography. The topic of the other paper is digital radiography image acquisition. The articles were developed collaboratively by the ACR, the American Association of Physicists in Medicine, and the Society for Imaging Informatics in Medicine. Increasingly, medical imaging and patient information are being managed using digital data during acquisition, transmission, storage, display, interpretation, and consultation. The management of data during each of these operations may have an impact on the quality of patient care. These articles describe what is known to improve image quality for digital and computed radiography and to make recommendations on optimal acquisition, processing, and display. The practice of digital radiography is a rapidly evolving technology that will require timely revision of any guidelines and standards.

Dosimetry using an imaging plate (IP) of computed radiography (CR) systems was developed for quality control of output of the x-ray equipment. Sensitivity index, or the S number, of the CR systems was used for estimating exposure dose under the routine condition: exposure dose from 1.0 to 1.0 x 10(2) microC kg(-1), tube voltages from 50 to 120 kV, and added filtration from 0 to 4.0 mm Al. The IP was calibrated by using a 6 cc ionization chamber having traceability to the National Standard Ionization Chamber. The uncertainty concerning the fading effect was suppressed less than 1.9% by reading the latent image 4 min+/-5 s after irradiation at the room temperature 25.9+/-1.0 degrees C. The S number decreased linearly on the logarithmic graph regardless of the beam quality as exposure dose increased. The relationship between the exposure dose (E) and the S number was fitted by the equation E=a' X S(-b). The coefficient a' decreased when the added filtration and the tube voltage were increased. The coefficient b was 0.977+/-0.007 in all beam qualities. The dosimetry using the IP and the equation can estimate the exposure dose in a range from 9.0 x 10(-2) to 5.0 microC kg(-1) within an uncertainty of +/-5% required by the Japanese Industry Standard. This dose range partially included the doses under routine condition. The doses between 1.0 and 1.0 x 10(2) microC kg(-1) under the routine condition can be shifted to the 5% region by using an absorber. The IP dosimetry is applicable to the quality control of the CR systems.

This Technical Paper describes Acceptance Testing and Commissioning of the Kodak DirectView CR-850 digital radiography system installed at the Royal Adelaide Hospital. The first of its type installed in Australia, the system is a "dry" image processor, for which no chemicals are required to develop images. Rather, latent radiographic images are stored on photostimulable phosphor screens, which are scanned and displayed by a reader unit. The image can be digitally processed and enhanced before it is forwarded to a storage device, printer or workstation display, thereby alleviating the need to re-expose patients to achieve satisfactory quality images. The phosphor screens are automatically erased, ready for re-use. Results are reported of tests carried out using the optional "Total Quality Tool" quality assurance package installed with the system. This package includes analysis and reporting software which provides for simple testing and reporting of many important characteristics of the system, such as field uniformity, aspect ratio, line and pixel positions, image and system noise, exposure response, scan linearity, modulation transfer function (MTF) and image artefacts. Acceptance Tests were performed for kV and MV exposures. Resolution for MV exposures was at least 0.8 l/mm, and measured phantom dimensions were within 1.05% of expected magnification. Reproducibility between cassettes was within 1.6%. The mean pixel values on the central axis were close to linear for MV exposures from 3 to 10 MU and reached saturation level at around 20 MU for 6 MV and around 30 MV for 23 MV beams. Noise levels were below 0.2 %.

The use of imaging phantoms is a common method of evaluating image quality in the clinical setting. These evaluations rely on a subjective decision by a human observer with respect to the faintest detectable signal(s) in the image. Because of the variable and subjective nature of the human-observer scores, the evaluations manifest a lack of precision and a potential for bias. The advent of digital imaging systems with their inherent digital data provides the opportunity to use techniques that do not rely on human-observer decisions and thresholds. Using the digital data, signal-detection theory (SDT) provides the basis for more objective and quantitative evaluations which are independent of a human-observer decision threshold. In a SDT framework, the evaluation of imaging phantoms represents a "signal-known-exactly/background-known-exactly" ("SKE/ BKE") detection task. In this study, we compute the performance of prewhitening and nonprewhitening model observers in terms of the observer signal-to-noise ratio (SNR) for these "SK E/BKE" tasks. We apply the evaluation methods to a number of imaging systems. For example, we use data from a laboratory implementation of digital radiography and from a full-field digital mammography system in a clinical setting. In addition, we make a comparison of our methods to human-observer scoring of a set of digital images of the CDMAM phantom available from the internet (EUREF-European Reference Organization). In the latter case, we show a significant increase in the precision of the quantitative methods versus the variability in the scores from human observers on the same set of images. As regards bias, the performance of a model observer estimated from a finite data set is known to be biased. In this study, we minimize the bias and estimate the variance of the observer SNR using statistical resampling techniques, namely, "bootstrapping" and "shuffling" of the data sets. Our methods provide objective and quantitative evaluation of imaging systems with increased precision and reduced bias.

The systematic monitoring of image quality and radiation dose is an ultimate solution to ensuring the continuously high quality of mammography examination. At present several protocols exist around the world, and different test objects are used for quality control (QC) of the physical and technical aspects of screen-film mammography. This situation may lead to differences in radiation image quality and dose reported. This article reviews the global QC perspective for the physical and technical aspects of screen-film mammography with regard to image quality and radiation dose. It points out issues that must be resolved in terms of radiation dose and that also affect the comparison.

Due to German regulations, acceptance and consistency tests have to be obtained by 12.31.2005 for all equipment used for computed radiography according to special standards published in DIN 6868. This article familiarizes all users with the most important aspects of these standards. In addition, explanatory and background information for establishing these regulations are provided.

The modulation transfer function (MTF) is well established as a metric to characterize the resolution performance of a digital radiographic system. Implemented by various laboratories, the edge technique is currently the most widespread approach to measure the MTF. However, there can be differences in the results attributed to differences in the analysis technique employed. The objective of this study was to determine whether comparable results can be obtained from different algorithms processing identical images representative of those of current digital radiographic systems. Five laboratories participated in a round-robin evaluation of six different algorithms including one prescribed in the International Electrotechnical Commission (IEC) 62220-1 standard. The algorithms were applied to two synthetic and 12 real edge images from different digital radiographic systems including CR, and direct- and indirect-conversion detector systems. The results were analysed in terms of variability as well as accuracy of the resulting presampled MTFs. The results indicated that differences between the individual MTFs and the mean MTF were largely below 0.02. In the case of the two simulated edge images, all algorithms yielded similar results within 0.01 of the expected true MTF. The findings indicated that all algorithms tested in this round-robin evaluation, including the IEC-prescribed algorithm, were suitable for accurate MTF determination from edge images, provided the images are not excessively noisy. The agreement of the MTF results was judged sufficient for the measurement of the MTF necessary for the determination of the DQE.

Digital imaging in mammography is becoming more and more accepted using both computed (CR) and direct radiography (DR). These techniques will soon be used in screening programs. Therefore, quality assurance for this technique is indispensable. The relevance of the current regulations, such as EPOC and the German QS-RL was investigated. For the investigation, a breast phantom and appropriate software were developed. Both were tested using digital mammography systems from six manufactures. Quality assurance parameters (such as contrast to noise ratio and contrast resolution) were calculated from these data sets. The results should be considered in future standards for mammography (IEC respectively DIN). In addition, this type of test procedure is time saving and enables a reduction in test devices, i. e. in costs.

U.S. Food and Drug Administration (FDA) regulations require that medical physicists and technologists adhere to the procedures, testing frequencies, and performance criteria outlined in the quality control (QC) manuals provided by the manufacturers of full-field digital mammography (FFDM) systems. As a result of this requirement, QC for digital equipment has become both complicated and inconsistent. The objective of this study was to compare the current QC protocols for the tests to be performed by medical physicists for three commercially available FFDM systems (the Senographe 2000D, the SenoScan, and the Selenia). Although not yet approved by the FDA, the 5000 MA was also included because of its unique design and extensive use in a major ongoing clinical research trial involving the other three FFDM systems. It was found that currently, a high degree of discord exists between the FFDM QC protocols of the early commercial systems, with wide variation in opinion with respect to the minimum performance criteria and testing intervals and with respect to which tests are necessary and what quantities should be measured. Additionally, very few digital detector-specific tests are currently in place. Although technological differences between the early FFDM systems prohibit a strictly uniform set of QC procedures and performance guidelines, a much greater degree of consensus among manufacturers is desirable as FFDM continues to gain clinical presence during the next few years.

Breast imaging centers in the United States are currently transitioning from traditional screen-film mammography to full-field digital mammography. Quality control for full-field digital mammography is more difficult, time consuming, and expensive than for traditional screen-film mammography. Full-field digital mammography quality control is more precise than screen-film mammography quality control at identifying noncompliant components. As per U.S. Food and Drug Administration requirements, each manufacturer of full-field digital mammography equipment designs and establishes its own quality control process.

The factors influencing the spatial resolution of digital detectors are discussed and demonstrated on simulated bar pattern images. Lead bar patterns are often used in quality control procedures to test the spatial resolution of image detectors. In digital imaging systems the pixelization of the detector interferes with the periodic bar pattern and makes it difficult to determine the resolution limit. Bar pattern images seem to have only limited value for characterizing the imaging performance of digital detector systems.

In our institution, an individualized dosimetric quality assurance protocol for intensity modulated radiotherapy (IMRT) is being implemented. This protocol includes dosimetric measurements with a fluoroscopic electronic portal imaging device (EPID) for all IMRT fields while the patient is being irradiated. For some of the first patients enrolled in this protocol, significant beam attenuation by (carbon fiber) components of the treatment couch was observed. To study this beam attenuation in two-dimensional, EPID images were also acquired in absence of the patient, both with and without treatment couch and immobilization devices, as positioned during treatment. For treatments of head and neck cancer patients with a 6 MV photon beam, attenuation of up to 15% was detected. These findings led to the development of new tools and procedures for planning and treatment delivery to avoid underdosages in the tumor.

With the recent approval of the National Electrical Manufacturers Association (NEMA) standard for "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," comprehensive cardiac image assurance control programs are now possible. This standard was developed by a joint NEMA/Society for Cardiac Angiography and Interventions (SCA&I) working group of imaging manufacturers and cardiology society professionals over the past 4 years. This article details a cardiac catheterization laboratory image quality assurance and control program that includes the new standard along with current regulatory requirements for cardiac imaging. Because of the recent proliferation of digital imaging equipment, quality assurance for cardiac imaging fluoroscopy and digital imaging are critical. Included are the previous works recommended by the American College of Cardiology (ACC) and American Heart Association (AHA), Society for Cardiac Angiographers and Interventions (SCA&I), and authors of previous image quality subjects.

The purpose of this study was to develop and test a computer imaging method for assessing longitudinal processor variability. A technique called adaptive histogram equalization was used to test deviation in automatic processing when a test film is compared with a time-temperature processed standard at two different kVp's and film speeds. In a 14-day study we found that the density ranges for the standard film did not change, while the density range of the automatically processed films changed by a factor of two. These results suggest that if automatic processing is to be used for films taken as part of a longitudinal study-for example, subtraction-then processor variation can potentially lead to incorrect inference of bone gain or loss.

This paper discusses the technical aspects of mammographic image quality and the factors that affect it. Emphasis is placed on the role of the service professional and the challenges he or she faces as a result of implementation of the Mammography Quality Standards Act of 1992 (MQSA). The passage of the MQSA represented the first attempt to legislate diagnostic image quality. Such legislation will only succeed, however, if all members of the mammographic imaging team fully understand the factors that affect image quality, the role that each member plays in assuring image quality, and the mandates of the MQSA.

The implementation of a Quality Assurance (QA) programme in orthodontic radiography is designed to improve the quality of the resultant radiographs and to reduce the number of repeat exposures. This is particularly desirable in orthodontic practice where the majority of patients are young and therefore more at risk from the detrimental effects of X-rays. A programme is described and QA tests are given that may be applied in the surgery. Particular emphasis is placed on QA measures for extraoral radiography, since this is frequently undertaken in the treatment of the orthodontic patient.

The reported poor diagnostic quality of 30-50% of all radiographs made in dental practices suggests the need for standardized quality measures and appropriate image improvement procedures. We propose a new method to evaluate the quality of digital/digitized radiographs using feature vectors. This method assures the separation of over- and under-exposed radiographs from well exposed ones as clusters of "good image quality" and "poor image quality" in the resulting feature space. Automatic image improvement is accomplished by adaptive, piece-wise linear grayvalue transformation with regard to the image quality being measured. In particular, our method automatically detects grayvalue intervals which are likely to represent relevant diagnostic information as well as grayvalue intervals which are irrelevant for diagnostic purposes. Based on those intervals, a piece-wise linear grayvalue mapping function is calculated. These procedures may be used both on whole images and for the interactive improvement of suspected pathological regions of interest. Actual image quality is indicated by the simultaneous display of the defined cluster of "good image quality" and the position of the image within the feature space for visual control.