When interpreting radiographs, practitioners often express apprehension about missing a lesion. Most significant errors are indeed false negative interpretations, but false positive and misclassifications also occur (1). Factors contributing to this decreased confidence are the inherent subjectivity of radiographic interpretation, but also the high number of sources of error that must be considered. Gaining an understanding of these errors is essential to minimizing their occurrence and improving diagnostic accuracy.

Radiographic images are black-and-white 2-dimensional representations of disease, and interpreting them has inherent subjectivity, which is often perceived as a source of error. In fact, a more appropriate term is variation (2). Variation occurs in 2 forms: interobserver and intraobserver. Interobserver variation occurs when different radiographic interpreters do not arrive at a consensus on the radiographic findings and/or diagnosis, but where neither opinion is wrong. Intraobserver variation occurs when the same interpreter does not arrive at the same findings/diagnosis for different cases presenting the same radiographic appearance of disease. Variation can occur regarding the detectability of a lesion (for example, cardiomegaly — present or not), as well as in grading the severity of a lesion (cardiomegaly — mild or moderate) (2). Diseases where inter- and intraobserver variation is high are generally considered more difficult to confidently pose a radiographic diagnosis (2). For example, high interobserver variability is associated with a lower degree of certainty as to the presence of a bronchial pattern in cats when this pattern is less severe (3). Variability is important to consider as it can modify diagnostic sensitivity and specificity depending on the observers performing the interpretation (4).

Conversely, a radiographic error implies that a mistake has been made (2). Errors can be grouped into several categories: technical, perception (search), and analysis (judgement/cognition/decision) (2,5,6).

Reducing error in radiographic interpretation.

COVID-19 is a new pulmonary disease which is driving stress to the hospitals due to the large number of cases worldwide. Imaging of lungs can play a key role in the monitoring of health status. Non-contrast chest computed tomography (CT) has been used for this purpose, mainly in China, with significant success. However, this approach cannot be massively used, mainly for both high risk and cost, also in some countries, this tool is not extensively available. Alternatively, chest X-ray, although less sensitive than CT-scan, can provide important information about the evolution of pulmonary involvement during the disease; this aspect is very important to verify the response of a patient to treatments. Here, we show how to improve the sensitivity of chest X-ray via a nonlinear post-processing tool, named PACE (Pipeline for Advanced Contrast Enhancement), combining properly Fast and Adaptive Bidimensional Empirical Mode Decomposition (FABEMD) and Contrast Limited Adaptive Histogram Equalization (CLAHE). The results show an enhancement of the image contrast as confirmed by three widely used metrics: (i) contrast improvement index, (ii) entropy, and (iii) measure of enhancement. This improvement gives rise to a detectability of more lung lesions as identified by two radiologists, who evaluated the images separately, and confirmed by CT-scans. The results show this method is a flexible and an effective approach for medical image enhancement and can be used as a post-processing tool for medical image understanding and analysis.

https://www.mdpi.com/2071-1050/12/20/8573/pdf

Pipeline for Advanced Contrast Enhancement (PACE) of Chest X-Ray in Evaluating COVID-19 Patients by Combining Bidimensional Empirical Mode Decomposition and Contrast Limited Adaptive Histogram Equalization (CLAHE)

EOS es una nova tecnologia d'imatge que fa servir un detector de radiacio gasos, una cambra d'ionitzacio de micro-reixeta, derivada del Micromegas desenvolupat per Georges Charpak (Premi Nobel 1992) per recerca en fisica d'altes energies al CERN (Ginebra, CH). Aquests detectors poden obtenir imatges mediques a baixa dosi, permetent col·limacions estrictes que eviten la radiacio difusa que degrada dosi i qualitat. El prototip EOS, fent servir feixos de raigs-X molt fins (500 µm), va ser pensat per fer radiografia a baixa dosi de l'esquelet en bipedestacio. Dissenyat amb dos tubs de raigs-X i dos detectors, realitza una adquisicio per escanejat lineal biplanar sincronica, de dues imatges (a 90o) del cos. Aquest metode biplanar permet l'extraccio automatica de punts de referencia anatomics que poden ser matematicament projectats com un model 3D de l'esquelet real del pacient. El programari EOS pot generar models 3D amb baixa dosi, entre 1/10 i 1/100, de les modalitats existents (radiografia computada (CR), radiografia digital (DR), o TC a baixa-dosi). L'objectiu principal de la recerca d'aquest prototip, la imatge de columna, va ser validat, i el seu subsequent re-disseny industrial ha acabat com un dispositiu medic certificat per a estudis de l'esquelet: EOS ('EOS Imaging, Paris, France)'. Preparant la fase experimental de EOS en columna, un segon objectiu va ser considerat: valorar l'aplicabilitat del prototip EOS a l'exploracio radiografica mes frequent: radiografia de torax. Si EOS fos validat, permetria aplicar-lo a un altre camp del radiodiagnostic. La radiografia del torax es una prova que pot comportar algunes dificultats en un dispositiu voluminos, d'escanejat lineal, biplanar, amb baixa dosi i baixa resolucio espacial, com son els detectors de micro-reixeta, a investigar. Material i metodes: Es va preparar un estudi prospectiu comparant exploracions repetides entre EOS i un equip radiografic estat-de-l'art (DR, detector pla de aSi-Csi), per valorar l'aplicabilitat clinica, problemes tecnics, dosi i qualitat d'imatge. Un grup de 40 adults, amb radiografia de torax programada al Hopital Univ. Erasme (Brussel·les, BE), van ser enrolats per a fer un estudi repetit amb EOS (amb 50% dosi de CR). Les imatges recollides van ser puntuades independentment per quatre radiolegs seguint els 'European quality criteria in diagnostic imaging', incorporant reptes com valorar estructures anatomiques fines. Es recolliren dades tecniques, estudis dosimetrics addicionals, comparatius amb CR, i mesura de dades de dosi i de rendiment del detector. Resultats: 37 dels 40 casos van ser analitzats. La radiografia va ser correcta amb EOS, amb 13,5% d'estudis repetits. La dosi de radiacio es superior amb EOS (0.22 mGy) que amb DR (0.05) pero menys que la DRL o dosi per CR. Artefactes de soroll i 'arrissat' redueixen la FTM (funcio de transferencia de la modulacio) mesurada a 1-1.5 pl/mm. La puntuacio en qualitat d'imatge entre EOS i DR va ser comparable, amb millor puntuacio per a EOS en via aeria, mediasti o en cobertura anatomica. Conclusio: EOS es una modalitat funcional que compleix les dosis de referencia. La dosi es mes alta que per DR i mes baixa que per CR, per supressio de la radiacio difusa. En qualitat d'imatge, EOS no mostra valoracions inferiors significants a la DR, fins i tot en estructures fines; pot atribuir-se a la resolucio mes gran de densitats i a l'absencia de difusa que compensen la seva inferior resolucio espacial. Caldra fer desenvolupaments addicionals per millorar el control de la dosi i per millorar resolucio, i caldra fer recerca dirigida a validar resultats en series amb patologies cliniques.

/pdf/assessment-of-a-micro-grid-ionization-chamber-eos-for-low-54norl3m79.pdf

Assessment of a micro-grid Ionization-chamber (EOS) for low-dose chest radiography

Image interpretation accuracy is critical to ensure optimal care, yet many diagnostic reports contain expressions of uncertainty often due to shortcomings in technical quality among other factors. While radiologists will usually attempt to interpret images and render a diagnosis even if the imaging quality is suboptimal, often the details related to any quality concerns are dictated into the report. Despite imaging exam quality being an import factor for accurate image interpretation, there is a significant knowledge gap in terms of understanding the nature and frequency of technical limitations mentioned in radiology reports. To address some of these limitations, in this research we developed algorithms to automatically detect a broad spectrum of acquisition-related quality concerns using a dataset containing 1,210,858 exams. There was some type of a quality concern mentioned in 2.4% of exams with motion being the most frequent.

Detecting Technical Image Quality in Radiology Reports.

Development of a multiple energy synchrotron biomedical imaging system

OBJECTIVE. The purpose of this article is to discuss flat-panel digital radiography (DR) artifacts to help physicists, radiologists, and radiologic technologists visually familiarize themselves with an expanded range of artifact appearance. CONCLUSION. Flat-panel DR is a growing area of general radiography. As a radiology community, we are still becoming familiar with these systems and learning about clinically relevant artifacts and how to avoid them. These artifacts highlight important limitations or potential complications in using flat-panel DR systems.

https://www.ajronline.org/doi/pdf/10.2214/AJR.11.7237

Artifacts in Digital Radiography

FLASH Mechanisms Track (Oral Presentations) MOUSE ABDOMEN RADIATION USING A 50 MEV PROTON BEAM: FLASH VS. CONVENTIONAL DOSE RATE

<h3>Purpose/Objective(s)</h3> The mechanisms underlying normal tissue toxicity sparing and survival benefits of ultra-high dose rate radiation (FLASH) are still unclear. We used a low-energy proton system (50 MeV) optimized for small animal radiobiological research to study the biological effects after FLASH and conventional dose rate (CONV) proton radiation to mouse abdomen. <h3>Materials/Methods</h3> We radiated the abdomen of 6–7-week-old female C57BL/6 mice using the plateau region of a continuous (unpulsed) cyclotron-generated 50 MeV preclinical proton beam, transmitting through the abdomen, with 1.5cm (for survival study) or 3cm (for EdU assay) width of beam via customized vertical and horizontal collimators. Mice survival and regenerated crypts in colon tissues using EdU assay were studied. Mice were stratified into 3 groups: 1) control/sham radiation (n=8 for survival, n=4 for EdU); 2) FLASH (20Gy at 48-93Gy/sec, n=22 for survival and n=13 for EdU); 3) CONV (20Gy at ∼1Gy/sec, n=19 for survival, n=11 for EdU). For survival study, mice were observed for survival post radiation. For EdU assay, the mice were injected with EdU 3-4 hours prior to euthanasia, and colon tissues were collected at 24 hours and 96 hours post-radiation for sectioning and then EdU staining. <h3>Results</h3> FLASH and CONV groups showed different survival: FLASH (13 days post radiation, 36.4% survival); CONV (15.6% survival, P = 0.04). FLASH group had more EdU staining than the CONV group, though both FLASH and CONV groups showed reduced EdU staining compared to the control group. <h3>Conclusion</h3> Preliminary results of mouse abdomen FLASH and CONV proton radiation from a 50 MeV beam suggest FLASH proton radiation leads to better survival and less normal tissue damage than CONV radiation. 

FLASH vs. Conventional Dose Rate Proton Radiation in Mouse Abdomen

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Artifacts in Digital Radiography

FLASH Mechanisms Track (Oral Presentations) MOUSE ABDOMEN RADIATION USING A 50 MEV PROTON BEAM: FLASH VS. CONVENTIONAL DOSE RATE

FLASH vs. Conventional Dose Rate Proton Radiation in Mouse Abdomen