Title Page

Title Page

Optimisation of image quality and patient dose in radiographs of paediatric extremities using

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direct digital radiography.

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A Jones BSc, Msc *, 2C Ansell BSc, 1C Jerrom BSc, MSc and 1ID Honey MPhys, MSc

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Guy’s and St. Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1

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Evelina London Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust,

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London SE1 7EH E
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Western Sydney Local Health District, Sydney, New South Wales NSW 2145, Australia
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Optimisation in paediatric extremity imaging using DDR

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 Abstract

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2 Objectives
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5 The purpose of this study was the evaluate effect of beam quality on the image quality (IQ) of
6 ankle radiographs of paediatric patients in the age range of 0-1 years whilst maintaining
7 constant effective dose.

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10 Methods
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12 Lateral ankle radiographs were taken of an infant foot phantom at a range of tube potentials
13 (40 – 64.5 kVp) with and without 0.1mm Copper filtration using a Trixell Pixium 4600

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detector. Effective dose to the patient was computed for the default exposure parameters using
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16 PCXMC v2.0 and fixed for other beam qualities by modulating the mAs. The contrast-to-

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17 noise ratio (CNR) was measured between the tibia and adjacent soft tissue. The IQ of the
18 phantom images was assessed by three radiologists and a reporting radiographer. Four IQ

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19 criteria were defined each with a scale of 1-3, giving a maximum score of 12. Finally, a
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service audit of clinical images at the default and optimum beam qualities was undertaken.
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23 Results
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The measured CNR for the 40 kVp/ no Copper image was 12.0 compared to 7.6 for the default
mode (55 kV 0.1 mm Copper). An improvement in the clinical IQ scores was also apparent at
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28 this lower beam quality.
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30 Conclusion
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33 Lowering tube potential and removing filtration improved the clinical IQ of paediatric ankle
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34 radiographs in this age range.

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36 Advances in knowledge
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39 There are currently no U.K guidelines on exposure protocols for paediatric imaging using
40 direct digital radiography. A lower beam quality will produce better IQ with no additional
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41 dose penalty for infant extremity imaging.

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 1. Introduction

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Long bones (arms and legs) and short bones (hands, wrists, feet and ankles) of the upper and
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6 lower extremities undergo endochondral ossification; a process by which hyaline cartilage is
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8 converted to bone. This process begins during early gestation and continues through puberty
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11 and into early adulthood until skeletal maturity (18-25) when all of the cartilage is replaced by

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13 bone. Therefore in comparison to adults, paediatric bones are more porous and have wider

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16 haversian canals in addition to containing a large amount of collagen and cartilage [1].

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18 Extremity imaging of patients during infancy poses a unique challenge due to the low intrinsic

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contrast during skeletal bone development. When considering optimisation of extremities in
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23 this age range, an understanding of the unossified cartilaginous skeleton is essential.
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28 Extremity imaging at Evelina London Children’s Hospital (ELCH) is undertaken through
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30 various routes of referral and clinical indicators including trauma and orthopaedic imaging
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33 (the identification of fractures or other bony injuries), genetics (ossification/growth of the
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35 bones), and oncology. Perhaps most significant in the context of this study is the referral of
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38 patients for skeletal survey imaging which incorporates both genetic and non-accidental
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40 injury (NAI) pathways. With an increased demand for NAI imaging within the establishment,
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Radiology Consultants who report all the imaging undertaken in ELCH, identified some ankle
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45 imaging of infant patients (0 – 1 years old) as undiagnostic with particular reference to
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47 reduced image contrast where it was felt a loss of clinical features caused subsequent
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50 difficulty in making confident clinical decisions. Occasionally repeat imaging was requested,
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52 with radiographers adjusting their individual imaging parameters in pursuit of an image
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55 providing clarity between the soft tissue and bone regions within the image.
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 Paediatric patients are more susceptible than adults to the damaging effects of ionising

1 radiations due to more rapid cell division and a longer life expectancy [2]. The lack of
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inherent contrast in paediatric extremity imaging is therefore also met by a requirement for
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6 optimisation of the imaging parameters to ensure the radiation dose to the patient is kept ‘as
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8 low as reasonable achievable’ (ALARA) [3]. Optimisation may also minimise the number of
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11 requests for repeat imaging, hence reducing the radiation dose and therefore risk to the

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13 paediatric patient. In the context of paediatric trauma [4], planar X-ray imaging is still

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16 considered to be the primary imaging investigation of choice due to its ready availability and

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18 cost effectiveness. Additionally, the Royal College of Radiologists indicate that for focal bone

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pain in paediatrics, plain film imaging is recommended as the first line of investigation in the
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23 evidence based guidelines ‘Making the best use of clinical radiology’ [5]; the standards upon
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which all referrals are subject to in terms of justification.
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30 In conventional screen-film radiography, a fixed detector dose is required to achieve the
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33 correct optical density and therefore produce a useable clinical image. European guidelines
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35 [6] published in 1996 have influenced the setting of exposure parameters across the range of
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different radiographic views. This guidance covers some of the most frequent anatomical
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40 projections including projections of the chest, skull, pelvis, full and segmental spine, abdomen
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42 and urinary tract. The general guidance recommends using a higher tube potential (kV) for all
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45 radiographic exposures of paediatrics. For older tube-generator systems, where the shortest
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47 exposure times are not possible, slight lowering of the tube potential and the use of additional
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50 filtration is recommended to achieve the required optical density. It states ‘The soft part of
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52 the radiation spectrum which is completely absorbed in the patient is useless for the
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production of the radiographic image and contributes unnecessarily to the patient dose’. There
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57 is evidence suggesting that a harder beam quality in screen-film radiology can result in a
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59 lower effective dose (ED) for projections including postero-anterior projections of the chest
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62 and anterior posterior projections of the abdomen [7]. However, a potential consequence of
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 this dose reduction is a negative effect on the image quality as a harder beam results in

1 reduced inherent image contrast as less of the X-ray photons in the spectrum interact via
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photoelectric absorption [7, 8].
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8 The International Commission on Radiological Protection (ICRP) have identified the need for
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11 optimisation and development of consistent protocols in paediatric digital radiology with

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13 active participation of staff from a wide range of disciplines [9]. Direct digital radiography

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16 (DDR) is fundamentally different from screen-film radiography in that it has a different

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18 energy response, does not require a fixed detector dose, and images can be processed post

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exposure. Numerous studies have been completed comparing the clinical image quality of
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23 extremity radiographs between screen-film and computed radiography [10-12] and
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additionally looking at the possibility of dose reduction in skeletal imaging using amorphous
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28 silicon flat panel detectors [13, 14]. However, there is little published evidence to confirm that
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30 current protocols are optimised for a wide range of X-ray projections, including extremity
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33 imaging.
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38 There have been some optimisation studies completed in areas such as cardiac imaging using
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40 a flat panel detector [15] and paediatric chest, abdomen and pelvis radiography using
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Computed Radiography (CR) [16] but there is very little literature available on optimisation
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45 in paediatric extremity imaging. Work by Hess et al. [17] questions the use of filtration and
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47 suggests tube potentials as low as 40 kVp and the removal of any additional filtration can
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50 improve the image quality in extremity radiographs of very young patients whilst keeping a
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52 fixed ED. This is a phantom study that simulates a paediatric extremity using polymethyl
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55 methacrylate (PMMA) representing soft tissue and an aluminium strip representing bone. The
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57 study by Brosi et al. [16] also questions the benefit of additional copper filtration, particularly
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for radiographic projections that exclude any radiosensitive organs from the primary beam.
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62 The study concludes that a reduction in entrance surface dose (ESD) due to the copper
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 filtration is not accompanied by a reduction in the ED, which is a true measure of patient risk.

1 An extremity of an infant represents very little attenuation of the beam and the dominant
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radiosensitive tissue in these projections is the bone marrow according to the ICRP Report
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6 103 [2] tissue weighting factors. For such small structures as the infant extremity, the ratio of
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8 the ED to ESD is relatively constant across the tube potential range and actually decreases
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11 slightly at the lower tube voltages [17].

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15 Despite the possible benefits of DDR and the scope for optimisation in paediatric extremity
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18 imaging, it is likely that the current protocols originate from a combination of the European

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20 guidance [6], manufacturers advice and local input from experience with screen-film and
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23 possibly CR systems. Moore et al. [18] highlights that the anatomically programmed
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radiography presets on equipment provided by manufacturers may not be appropriate for
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28 paediatric exposures. Image optimisation in digital radiography requires collaboration
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30 between the range of professions associated with the clinical sites and additionally, the
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equipment manufacturers. Successful collaboration should result in high quality digital
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35 radiographs being consistently achieved, whilst ensuring automated anatomical programme
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37 presets are in keeping with the ALARA principle. The literature review completed as part of
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40 this study suggests clinical image quality of extremity radiographs could potentially be
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42 improved by lowering the beam quality without resulting in a dose penalty to the patient.
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47 Prior to this study, the local setup for a lateral ankle exposure of a patient in the 0-1 (infant)
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age range at ELCH was 55 kV and 0.1 mm Cu filtration. The aim of this paper is to assess the
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52 effects of altering kV and filtration, with the object of improving contrast and overall image
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54 quality, whilst keeping the ED fixed. The intention is to verify the results of Hess and Brosi
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57 using an anthropomorphic phantom, and audit of clinical images.
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 2. Materials and Method

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2.1. Imaging system and default conditions
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8 All tests were performed at ELCH which is equipped with a Siemens Axiom Aristos MX
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11 (Siemens Medical Solutions, Erlangen, Germany) over-couch X-ray system. The Trixell

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13 Pixium 4600 DDR detector that is used by this unit has a Caesium Iodide (CsI) phosphor

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16 coupled to an array of photodetectors with a pixel pitch of 0.143 mm.

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The system has paediatric anatomical presets for age ranges 0-1, 1-5, 6-10, and 15 years. The
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23 default exposure conditions for a lateral ankle radiograph of a patient in the 0-1 age range as
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set by the manufacturer, with local agreement, were 55 kV, 0.1 mm Cu and 1.4 mAs. These
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28 default settings required a fixed focus to detector distance (FDD) of 100 cm, with the beam
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30 collimated to the limb. The phantom was positioned and imaged to replicate a true lateral
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33 ankle including the distal third of the tibia and fibula with inclusion of the base of the fifth
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35 metatarsal as indicated in the radiograph in Figure 1. The detector was situated under the
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38 table and the anti-scatter grid was removed. The dose to the patient from this exposure can be
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40 defined in numerous ways; the incident air kerma, the ESD (which is the dose to the skin
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including backscatter) and the ED. The ED is the most appropriate dose for quantification of
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45 stochastic risk and it can be computed for a known entrance air Kerma from Monte Carlo
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47 simulation software such as PCXMC v.2.0 [19]; this uses the tissue weighting factors
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50 described in ICRP Report 103 [2]. Selection of the paediatric ‘phantom age’ was available on
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52 the software and in the case of this study; a 1 year old phantom age was selected. The
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55 phantom used in the software does not have extremities and therefore the X-ray field was
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57 positioned to cover the distal end of the lower leg.
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62 2.2. Study phantom
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 1 PCXMC v.2.0 was used to calculate the ED for a fixed entrance air Kerma at each Beam
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Quality. The tube output was measured at each beam quality using an Unfors Xi solid state
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11 The anatomical foot phantom used in the study was manufactured using water equivalent

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13 (WT1) material (St. Bartholomew’s Hospital, London) [20]. Paediatric skeletal structures

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16 including the tibia and fibula, tarsals and phalanges were set into this material to create an

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18 accurate representation of a true paediatric foot. The size of the phantom is consistent with

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that of an infant of an age between 0 and 1 years. The phantom was exposed to six different
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23 preset tube potentials in the range 40 – 64.5 kV, with and without the presence of a 0.1 mm
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Cu filter. The standard measurement geometry discussed in section 2.1 was used for all
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28 exposures. In order to maintain the fixed ED across a range of beam qualities, the mAs had to
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30 be modulated for both the variance in computed ED on PCXMC and the variance in the
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33 measured tube output.
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38 2.4. Phantom image quality assessment
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2.4.1. Image quality quantification
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47 Variation of the beam quality can have a direct influence on both the image contrast and
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50 image sharpness. In order to define an appropriate parameter to quantify the image quality,
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57 Patient movement has to be considered as a possible cause of image sharpness degradation,
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particularly in the imaging of paediatric patients. The default tube current on the Siemens
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62 Axiom Aristos system for an infant lateral ankle exposure was 220 mA. The exposure time
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 for the range of mAs settings in this study therefore varies between 2.3 and 16.4 ms. These

1 short exposure times should not result in blurring due to motion, particularly if local
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immobilisation protocol is correctly followed.
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8 In the case of lateral images of the ankle, the radiologists reported low image contrast which
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13 tissue. The lack of clarity left the clinicians diffident in making clinical decisions, leading to

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16 lateral ankle images being deemed suboptimal and requiring a repeat X-ray for clinical

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18 decision making purposes.

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23 It was decided that the contrast-to-noise ratio (CNR) was the most appropriate measure to
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assess the effect of changes in beam quality on image quality [8]. This approach to
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28 quantitative image quality assessment has been successfully adopted in other comparable
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30 optimisation studies [15, 17, 21]. The CNR relates to the contrast/signal difference between
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33 the structure of interest and the background and can be measured using pixel values in an
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35 image that contains a particular contrast detail of interest.
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40 2.4.2. Contrast-to-noise ratio measurements
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45 The images of the phantom at each beam quality were minimally processed by setting
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47 processing ‘gain’ values to zero, selecting a linear ‘look-up-table’ and removing the Siemens
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50 ‘Diamond View’ multi-resolution spatial filter processing software. However, the

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52 ‘amplification’ was set to the default amplification value for the default beam quality (55 kV
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55 0.1 mm Cu). These settings were necessary to ensure that the signal transfer properties of the
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57 system remained consistent. The images were sent to GE Centricity Enterprise Web PACS
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(GE Medical Systems Information Technologies, 2006) for region of interest (ROI) analysis
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 1 The CNR for the purpose of this investigation was defined as shown in equation (1), where S
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is the signal in regions 1 and 2 and σ1 is the standard deviation (noise) in region 1.
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8 CNR = (S1 – S2)/σ1 (1)
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13 S1 and S2 were defined as a rectangular ROI placed in the central lower region of the tibia and

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16 an identical sized ROI in the soft tissue located in a position posterior to the tibia. The

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18 positioning of the ROI’s is demonstrated in Figure 1. The average number of pixels in the

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traced ROI’s for the 12 images was 1979 (σ = 5).The reproducibility of the pixel values in the
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23 regions was checked for the default exposure. The ROI was moved into position 5 times in
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each case and the mean measured signal in ROI’s 1 and 2 and noise in ROI 1 recorded. Using
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28 these measurements the CNR for the default settings was calculated as 7.6 (σ = 0.7). The
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30 measured CNR values (CNRm) were corrected for the ratio between the calculated mAs
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33 (mAs1) values and set mAs (mAs2). This was required as the set mAs could only be adjusted
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35 to discreet preset values. For a quantum noise limited system, the CNR is proportional to the
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38 square root of the dose. A corrected CNR, CNRcor was calculated using the relationship
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40 described by equation (2)
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45 CNRcor = CNRm x √(mAs1/mAs2) (2)
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50 In order for equation 2 to be valid, a quantum noise limited system is required [8]. The Trixell
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52 Pixium 4600 DDR detector is assumed to be quantum noise limited over the range of receptor
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55 doses used in this study. A comparative technical report [22] states that the detective quantum
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57 efficiency (DQE) of this Trixell detector varies by a maximum of 10% over the frequency
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range 0.5 – 4 cycles mm-1 between doses of 1.1 μGy and 11.4 μGy. Quantum noise is
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 and measure a maximum peak DQE deviation of 15% between doses ranging from 0.91 μGy

1 and 9.31 μGy.

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6 The receptor doses in this investigation were indicated by placing the Unfors Xi detector
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8 under the foot phantom so that the tibia and fibula crossed the detector element
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11 perpendicularly. The default receptor dose was measured as 7.0 μGy and all receptor doses

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13 across the kV range used in this investigation were within 20 % of this value. The corrections

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16 made to the mAs are small, with the maximum correction being 12.9 % for the 64.5 kV and

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18 no added Cu exposure (0.50 to 0.44 mAs). The effect on the CNR correction of any slight

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deviation from quantum noise limited behaviour of the detector can be seen to be very small.
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2.4.2. Subjective clinical image quality assessment of phantom images
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30 Exposures were made of the anthropomorphic phantom at each beam quality in an identical
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33 manner to that discussed for CNR evaluation. However, no changes were made to the
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35 automated default clinical pre-processing and display settings and the images were transferred
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38 directly to PACS. This was necessary in order to simulate the exact process that occurs for
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40 true clinical images. All of the images were also sent with the DiamondView algorithm ‘11 –
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Extremities’ (DV11) turned on and therefore there were twenty four images in total. This
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45 particular algorithm is occasionally selected by the radiographers hence it’s inclusion in this
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47 study. The images were randomised in order and were interpreted independently with
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50 observers blinded to the variation in beam quality. A subjective assessment of clinical image
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52 quality was completed by four trained observers; in this case three consultant radiologists and
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55 one reporting radiographer. Guidelines for assessing basic aspects of quality have been laid
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57 out by the European Commission [6] for a range of projections and paediatric age ranges.
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However, extremity imaging has not been covered. The ideal set of parameters to describe
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62 image quality should measure the effectiveness with which an image can be used for its
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 intended purpose [24]. The general scoring framework set out in this study follows the CEC

1 guidelines although the image quality criteria have been set on the specific diagnostic
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requirements of paediatric extremity imaging, as defined by the clinicians at ELCH. As
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6 discussed previously, the primary issue with the image quality of the radiographs using the
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8 default parameters is the difficulty in differentiating between the cortexes of the tibia and
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11 surrounding soft tissue. Therefore, the visibility of the cortexes and the trabecullar pattern,

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13 which is required to identify any unexpected disruption, is essential.

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18 The image sharpness (X1), image noise (X2) and the perceived visibility of the cortex and

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trabecullar pattern (X3) were all assessed as unacceptable, suboptimum or optimum and given
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23 a corresponding image quality score of 1, 2 or 3 for each assessment respectively. Finally, the
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overall clinical acceptability (X4) was determined as not acceptable, probably acceptable or
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28 fully acceptable and also given an integer image quality score of 1, 2 or 3. Each of these
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30 image quality indices relates to overall exposure and contributes to the radiographic
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33 assessment of the image. All indices were equally weighted, assuming that they are of equal
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35 significance clinically. The mean score was taken for each criterion across the four observers
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38 and these mean scores summed to give a total score for each. The summing of all four mean
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40 criterion scores provides a possible total mean image quality score range of 4 – 12 with a
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maximum score of 12 representing all criteria being determined to be imaged optimally by all
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45 scorers.
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54 Once an optimum beam quality was established, the final step was to perform a service audit
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57 to verify that the improvement was evident on clinical images. Post-mortem patients were
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59 selected that had both ankles imaged as part of a skeletal survey. The mean age of the subjects
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62 at the time of imaging was 6.2 months with an age range of 1 to 15 months. 10 images were
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 acquired on post-mortem patients using the new optimised technique and compared to 10

1 images previously acquired using the old technique on a different group of patients. No
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additional imaging was performed on any individual. Five observers were asked to score the
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6 images in an identical manner to that described in section 2.4.2. In this verification, the
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8 observers consisted of four consultant radiologists and one reporting radiographer. Once
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11 again, the order of the images was randomised and all images were anonymised. Observers

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13 were blinded to the variation in beam quality.

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 3. Results

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3.1. Dosimetry
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8 The ED resulting from an exposure under the default conditions (55kV, 1.4mAs) in this study
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11 is 0.06 µSv; calculated using PCXMC. Radiation dosimetry of the paediatric extremity has

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13 also been previously attempted by assessing the energy imparted to a homogeneous slab of

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16 water and the value scaled for the difference in mass between an adult and child [25]. The

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18 upper limit on the effective dose for an ankle exposure of a 1 year old patient was calculated

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to be 0.31 µSv, this is in agreement with the ED measured from this study when accounting
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23 for change in exposure factors to 58kV and 6 mAs.
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28 This dose is low in comparison to other radiographic projections as would be expected for an
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30 infant extremity exposure; however, the primary purpose of this work was to investigate the
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33 possibility of improving image quality, specifically image contrast.
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38 3.2. CNR measurements
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The CNRcor is shown in Figure 2 across the range of tube potentials and with and without 0.1
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45 mm Cu filtration. The highest CNRcor (11.98 (σ = 0.87)) was measured on the image taken at
U

46
47 the lowest tube potential (40 kV) without the Cu filtration. The CNRcor at this beam quality is
48
49
JR

50 48 % higher than the CNRcor measured from the image using the default 55 kV and 0.1 mm
51
52 Cu setup.
53
B

54
55
56
57
58
59
60
61
62
63
64 14
65
 3.3. Clinical image quality of phantom images

1
2
3
4
The clinical image qualities of the radiographs of the phantom were assessed using the
5
6 criterion set out in section 2.4.2. The mean total image quality scores of all four observers are
7

FS
8 shown in Figures 3.a and 3.b, where 3.b demonstrates the effect of the DV11 pre-processing
9
10
11 algorithm. The correlation between the mean scores of each of the 4 image quality indices

O
12
13 was assessed by calculating the Spearman’s rank correlation coefficient as displayed in Table

O
14
15
16 1. The coefficient of variation (CoV) across the mean scores of each image quality index and

R
17
18 the total image quality are displayed in Table 2. The variation across the 4 observers in the

P
19
20
21
mean total image quality score was also assessed using the CoV and these results are
22

D
23 displayed in Table 3. The mean CoV of the mean image quality scores was 17.4 % (0 – 35.5
24
25
26
%).
E
T
27
28
C

29
30 The results clearly indicate that the highest overall image quality score was given to the
31
E

32
33 exposure made using 40 kV and no additional filtration. Therefore, the subjective image
R

34
35 quality assessment is in agreement with the quantitative assessment of the CNR. The
R

36
37
38 inclusion of DV11 does not suggest an improvement in IQ at the lower tube potentials.
O

39
40 However, at tube potentials of > 55 kV, it could have a positive effect on the clinical image
C

41
42
43
quality.
N

44
45
U

46
47 3.4. Verification of optimum beam quality using patient images
48
49
JR

50
51
52 The clinical image quality of ten images obtained using the default beam quality (55 kV, 0.1
53
B

54
55 mm Cu, 1.4 mAs) and ten images obtained using the trial beam quality (40 kV, no Cu, 2.5
56
57 mAs) was assessed using the methodology discussed in section 2.4.2. The default tube
58
59
60
current was 220 mA resulting in exposure times of 6.4 ms and 11.4 ms for the default and trial
61
62 beam qualities respectively. The mean image quality scores of each criterion (X1-X4) and the
63
64 15
65
 total mean image quality scores across the five observers are displayed in Table 4. The mean

1 and standard deviation of the mean total image quality scores for the ten images acquired
2
3
4
using the default beam quality and ten images acquired using the trial beam quality were 7.9
5
6 (σ = 0.8) and 11.6 (σ = 0.3) respectively. The variation across the 5 observers in the mean
7

FS
8 total image quality score was assessed using the CoV and these results are also displayed in
9
10
11 Table 4.

O
12
13

O
14
15
16

R
17
18

P
19
20
21
22

D
23
24
25
26
E
T
27
28
C

29
30
31
E

32
33
R

34
35
R

36
37
38
O

39
40
C

41
42
43
N

44
45
U

46
47
48
49
JR

50
51
52
53
B

54
55
56
57
58
59
60
61
62
63
64 16
65
 4. Discussion

1
2 4.1. Optimum setup
3
4
5
6
7 The pre-existing local settings for infant extremity (ankle) exposures originate from a

FS
8
9
10 combination of the European guidance, input from manufacturers and local optimisation
11

O
12 strategies. The existing European guidance [6] for paediatric radiology is based on screen-
13

O
14
film detector systems and recommends the use of additional filtration for the majority of
15
16

R
17 projections covered. It also provides a recommended range of tube potentials for each of these
18

P
19 planar exposures, none of which fall below 60 kV. Although extremity imaging is not
20
21
22 specifically mentioned in these guidelines, the results of this study are contradictory to the

D
23
24 general advice and suggest improvements can be made to the image quality through changing
25
26
E
the current local protocol. There is an opportunity to exploit the improved CNR and clinical
T
27
28
C

29 image quality at 40kV with no added copper filtration. Locally this has been used to achieve a
30
31
E

32
required image quality improvement, but equally could have been used to reduce patient dose.
33
R

34 The image quality improvements are likely to be seen in a range of extremity radiographic
35
R

36 projections of infants and could possibly be extended to different paediatric age ranges.
37
38
O

39 However, further optimisation studies will be required for verification.

40
C

41
42
43
N

44 Lowering the average energy of the spectrum leads to a larger proportion of the photons
45
U

46 interacting via photoelectric absorption. This results in an improvement in the inherent

47
48
49 contrast in the image [8] and therefore an increase in the measured CNR. However, lowering
JR

50
51 the mean energy of the spectrum leads to more absorption in the patient and less photon
52
53
fluence at the detector. The use of additional copper filtration can be utilised to harden the
B

54
55
56 beam and reduce patient dose. Huda et al. [26] suggest that the main indication for the use of
57
58 additional copper filtration in paediatric radiology is to reduce the skin dose during complex
59
60
61 interventional procedures. However, deterministic effects such as skin erythema are not a
62
63
64 17
65
 realistic concern in paediatric planar imaging and the key patient risk is actually the stochastic

1 process of carcinogenesis.
2
3
4
5
6 In certain paediatric planar radiographic projections that include superficial radiosensitive
7

FS
8 tissue such as the breast tissue, the ED can be reduced when adding copper filtration and
9
10
11 increasing the beam quality. However, Brosi et al. [16] report that a reduction in ESD is not

O
12
13 accompanied by a reduction in ED when including additional copper filtration into the beam

O
14
15
16 in DDR of the pelvis and abdomen. The beam hardening reduces the dose to superficial

R
17
18 organs but leads to an increased dose to more deep lying structures. An extremity of an infant

P
19
20
21
patient (0 – 1 year old) represents very little attenuation of the beam and the main tissue
22

D
23 structure of interest in computing the effective dose is the bone marrow. For lateral exposures
24
25
26
E
of an infant ankle, the ratio of the ED per unit air kerma at 55 kV with 0.1 mm Cu (default) to
T
27
28 40 kV with no added copper (optimum) is 1.9 i.e. the lower energy spectrum results in a lower
C

29
30 bone marrow dose and therefore lowers the ED. The mAs can therefore be increased for the
31
E

32
33 lowest beam quality, whilst keeping the ED fixed. The result is an improvement in the
R

34
35 contrast and consequently the CNR.
R

36
37
38
O

39
40 The phantom image quality scores displayed in Figure 3 are in agreement with the
C

41
42
43
quantitative image quality assessment. All three radiologists and the reporting radiographer
N

44
45 involved in the image quality assessment each independently scored the image at 40 kVp, no
U

46
47 Cu with a maximum of 12 out of 12 and therefore selected it as the optimum spectrum. The
48
49
JR

50 strongest positive correlation across the scores of the 12 images without the inclusion of
51
52 DV11 was between sharpness and overall acceptability (R2 = 0.959); closely followed by
53
B

54
55 cortex/trabecullar pattern with overall acceptability (R2 = 0.947). The improved contrast and
56
57 therefore visibility of the cortex/trabecullar pattern at the lower energy spectrum is also likely
58
59
60
to improve the perceived image sharpness, hence the strong positive correlation (R2 = 0.896)
61
62 between these indices. An improvement in the contrast and sharpness as the beam quality is
63
64 18
65
 reduced, therefore directly translates to an increase in likelihood that the overall acceptability

1 is determined as fully acceptable. The mean overall acceptability score over all images had
2
3
4
the highest coefficient of variation (41.6 %) out of all 4 image quality indices and therefore is
5
6 likely to have a dominant affect on the overall score. The images that achieved an overall
7

FS
8 acceptability score of 2 or 3 (i.e. probably acceptable or fully acceptable) were all at a tube
9
10
11 potential ≤ 50 kVp.

O
12
13

O
14
15
16 The inclusion of DV11 does not result in an improved mean image quality score at the

R
17
18 optimum beam quality setting determined by this study. However, in 5 out of 6 images

P
19
20
21 exposed using a tube potential greater than 55 kVp, the inclusion of DV11 led to an improved
22

D
23 mean image quality score. The specifics of how DV11 changes the images are not freely
24
25
26
E
available, but this study indicates it is likely that the improvements are only seen at higher
T
27
28 tube potentials. It is recognised that the effect of image processing has not been fully
C

29
30 investigated in this study. Further work is required to fully evaluate image processing settings
31
E

32
33 and investigate the effect they might have on the conclusions of this study.
R

34
35
R

36
37
38 The same pattern of correlation between the 3 indices discussed previously (X1, X3 and X4)
O

39
40 was also evident in the DV11 images. However, the correlation was not as strong which is
C

41
42
43
indicated by a maximum R2 value of 0.824 between resolution and overall acceptability.
N

44
45 There is no evidence to suggest that DV11 inclusion leads to an improved image quality in
U

46
47 extremity imaging of infant patients. The results of this study indicate that for a lowered beam
48
49
JR

50 quality (40 kV and no Cu), removal of DV11 is favourable. The benefits of DV11 and other
51
52 post processing tools should be investigated to ensure that they are suitable to the
53
B

54
55 requirements of the specific investigation.
56
57
58
59
60
The maximum CoV between the observers total image quality score was 35.5 % (see Table
61
62 3), which occurred in the scoring of the 64.5 kVp, 0.1 mm Cu and DV11 image. The observers
63
64 19
65
 in this case scored the image total image quality as 4, 5, 7 and 9 (mean 6.25). A CoV of 0 %

1 was measured for the 40kVp, no Cu image which achieved 12 out of 12 by all observers. The
2
3
4
CoV is generally lower for the lower kVp exposures and also for those without DV11. There is
5
6 an improved image quality in these exposures due to a significant improvement in the
7

FS
8 sharpness of the cortical bone which provides differentiation between cortex and soft tissue
9
10
11 and the presence of a defined trabecullar pattern not previously demonstrated. This

O
12
13 improvement enables a more confident approach to reporting in the identification or exclusion

O
14
15
16 of pathology and fracture, hence the associated decrease in the score variation.

R
17
18

P
19
20
21
4.2. Verification
22

D
23
24
25
26
E
The results of the clinical image quality comparison clearly indicate that the image quality at
T
27
28 the proposed beam quality is superior to those taken using the default beam quality.
C

29
30
31
E

32
33 The probability these results would have been attained if there was no difference in the
R

34
35 images is < 0.1% as indicated by a two tailed non-parametric Mann-Whitney U-Test
R

36
37
38 performed on the two sets of results. None of the ten mean total image quality scores of the
O

39
40 images obtained using the default protocol exceed the ten scores of the images obtained using
C

41
42
43
the optimised setup. These results display clearly that there is a significant improvement in
N

44
45 the clinical image quality of the radiographs taken using the lower beam quality and therefore
U

46
47 verify the comparable results obtained from the quantitative and qualitative analysis of the
48
49
JR

50 phantom images.
51
52
53
B

54
55 The mean coefficient of variation in the mean total image quality scores amongst the five
56
57 observers was measured as 13.9 % for the default parameters and 6.0 % for the optimised
58
59
60
setup (see Table 4). This demonstrates the improved confidence in reporting the images using
61
62 the new optimised parameters. Three of the ten images were scored as a perfect 12 out of 12
63
64 20
65
 by all 5 observers. Reducing the beam quality and improving the inherent contrast not only

1 improves the subjective image quality scores, but also reduces the variance in the observer’s
2
3
4
individual assessments.
5
6
7

FS
8 In this study quantitative CNR measurements have been combined with qualitative clinical
9
10
11 image quality assessments. It is widely accepted that true optimisation is best achieved using

O
12
13 task based measures of image quality [27-29]. There are a wide variety of examples of studies

O
14
15
16 in the literature utilising similar qualitative clinical image quality assessment methodologies

R
17
18 to that outlined in this paper [30-32], and it is considered to be likely that the conclusions of

P
19
20
21
this paper correlate with the results that would have been seen had a task based approach been
22

D
23 possible.
24
25
26
E
T
27
28 It is important to recognise that this study does not include a physical measure of resolution.
C

29
30 Qualitative scores of sharpness show the proposed new technique does not have a deleterious
31
E

32
33 effect on perceived sharpness. It should be noted that the new proposed technique could
R

34
35 theoretically degrade sharpness as a result of reduced detector MTF or increased patient
R

36
37
38 motion.
O

39
40
C

41
42
43
The detector resolution is reported to deteriorate slightly when lowering the tube potential
N

44
45 [22]. In this technical report by Lawinski et al., the modulation transfer function at the
U

46
47 Nyquist frequency of a Trixel Pixium detector is reduced from 9.7 % to 8.6 % when lowering
48
49
JR

50 the tube potential from 120 kVp to 70 kVp. Although measurements were not reported at tube
51
52 potentials less than 70 kVp, theoretically some reduction in MTF between the hardest and
53
B

54
55 softest beams investigated in this study is expected. At lower energies X-ray photons will tend
56
57 to interact closer to the surface of the phosphor in the detector. Consequently, the light
58
59
60
emitted has further to travel to the photodetector array, resulting in more spread and hence
61
62 poorer resolution properties. It should be noted that this study was initiated to address
63
64 21
65
 concerns raised by radiologists relating to image contrast, rather than resolution, therefore it

1 was believed that a small degradation in image sharpness would be tolerable. This is
2
3
4
supported by the qualitative assessment of image sharpness of the post mortem images,
5
6 although clearly this does not include any motion artefact effect.
7

FS
8
9
10
11 Patient movement needs to be taken into consideration if the results of this study are to be

O
12
13 implemented clinically. Movement during exposure can have a negative effect on the

O
14
15
16 sharpness of the final radiograph, as mentioned previously in section 2.4.1. The exposure

R
17
18 times for the default and optimised beam qualities are reported in section 3.4 as 6.4 ms and

P
19
20
21
11.4 ms respectively. European guidance [6] does not specifically address paediatric
22

D
23 extremity imaging; however it does recommend exposure times less than 10ms for AP pelvis,
24
25
26
E
and less than 20ms for a lateral skull. In order to eliminate the possible increased motion blur
T
27
28 as a result of increased exposure time one option would be to operate at 45 kV with no copper
C

29
30 filtration, allowing the exposure time to be reduced to 6.4 ms (1.4 mAs), and maintaining
31
E

32
33 most of the CNR improvement. A second option would be to sacrifice some of the CNR
R

34
35 improvement by reducing the mAs. Locally, it is considered that an exposure duration of 11.4
R

36
37
38 ms is acceptable, and this protocol has been implemented without reports of motion blur.
O

39
40
C

41
42
43
N

44
45
U

46
47
48
49
JR

50
51
52
53
B

54
55
56
57
58
59
60
61
62
63
64 22
65
 Conclusions

1
2
3
4
The image quality of extremity radiographs of paediatric patients using DDR can be
5
6 significantly improved by reducing the tube potential to 40 kV and removing any additional
7

FS
8 copper filtration. Results demonstrate that for fixed effective dose, the softer beam leads to a
9
10
11 greatly improved CNR between the tibia and surrounding soft tissue, in lateral projections of

O
12
13 a phantom infant foot. These findings have been implemented at ELCH and verified with

O
14
15
16 clinical image quality audit.

R
17
18

P
19
20
21
22

D
23
24
25
26
E
T
27
28
C

29
30
31
E

32
33
R

34
35
R

36
37
38
O

39
40
C

41
42
43
N

44
45
U

46
47
48
49
JR

50
51
52
53
B

54
55
56
57
58
59
60
61
62
63
64 23
65
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1
2
3
4
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11 International Commission on Radiological Protection. ICRP Report 103. Elsevier,

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 1 30 Dougeni ED, Delis HB, Karatza AA, Karogeropoulou CP, Skiadopoulos SG,
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Mantagos SP et al. Dose and image quality optimization in neonatal radiography. Br J
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6 Radiol 2007; 80:807-815.
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8 31 Sandborg M, Tingberg A, Ullman G, Dance DR, Alm Carlsson G. Comparison of
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11 clinical and physical measures of image quality in chest and pelvis computed

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13 radiography at different tube voltages. Med Phys 2006; 33(11):4169-4175.

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16 32 Almen A, Tingberg A, Mattsson S, Besjakov J, Kheddache S, Lanhede B et al. The

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22

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C

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E

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35
R

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O

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C

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N

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45
U

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JR

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B

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64 27
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 List of Figure Legends

1
2 Figure 1. Default lateral exposure of infant phantom with an indication of ROI bone (1) and ROIsoft (2) used to
3 calculate the CNR.
4
5
6 Figure 2. CNRcor measurements at a range of beam qualities for the default fixed ED of 0.06µSv. The empty
7

FS
circles and solid diamonds indicate 0.1 mm of added copper and no added copper respectively.
8
9
10
11 Figure 3. Phantom image quality assessment: Total IQ score for a) the range of potentials with and without 0.1

O
12 mm Cu and b) the range of tube potentials with and without 0.1 mm Cu but with the inclusion of DV11. The
13 empty circles and sold diamonds indicate 0.1 mm of added copper and no added copper respectively.

O
14
15
16 Table 1. Spearman’s correlation coefficients between the mean scores of each image quality index of the

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17 phantom images. The coefficients are displayed separately for the correlation in indices overall images taken at
18 all beam qualities with and without DV11, images without DV11 and images with DV11.

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21 Table 2. Coefficient of variation between the mean scores of the four image quality indices and the mean total
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image quality score of the phantom images. Results are displayed separately for all 24 images, 12 images
23 without DV11 and 12 images with DV11.
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27 Table 3. Coefficient of variation in the mean total image quality scores of the phantom images across the 4
28 observers at each beam quality. Results are displayed separately for all beam qualities with and without the
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29 inclusion of DV11.
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32 Table 4. Mean post mortem image quality scores across five observers for ten images taken using the default
33 beam quality and ten images using the trial beam quality. The coefficient of variation in the mean total image
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34 quality score across the 5 observers is displayed for each image.

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Figure 1
Click here to download high resolution image

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Figure 2

14.0

12.0

10.0

8.0
CNRcor

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4.0

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35 45 55 65
Tube Potential (kV)

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Figure 3

14.0

12.0

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Mean Total IQ Score

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Tube Potential (kVp)

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Table 1

Image
Image Rank of
Quality R2
Group Correlation
Indices
X1 X2 0.478 6
X1 X3 0.842 3
All X1 X4 0.918 1
Images X2 X3 0.491 5

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X2 X4 0.561 4
X3 X4 0.855 2
X1 X2 0.765 6

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X1 X3 0.896 3
Without X1 X4 0.959 1
DV11 X2 X3 0.784 5

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X2 X4 0.811 4
X3 X4 0.947 2

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X1 X2 0.568 5
X1 X3 0.777 2

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With X1 X4 0.824 1
DV11 X2 X3 0.431 6

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X2 X4 0.705 4
X3 X4 0.767 3
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Table 2

Image Coefficient of Variation

Quality All Without With
Index images DV11 DV11
X1 0.214 0.258 0.158
X2 0.126 0.142 0.100
X3 0.156 0.173 0.139

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X4 0.314 0.416 0.196
Total 0.185 0.229 0.138

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Table 3

Coefficient of variation
No Copper With Copper
kVp
No No
DV11 DV11 DV11 DV11
40 0.000 0.133 0.087 0.163
45 0.133 0.182 0.140 0.201
50 0.140 0.270 0.077 0.182

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55 0.278 0.167 0.118 0.240
60 0.228 0.240 0.153 0.204
64.5 0.077 0.346 0.074 0.355

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Table 4

Total Coefficient
Image Exposure
X1 X2 X3 X4 image of
number parameters
quality Variation
1 1.4 2.0 1.8 1.0 6.2 0.135
2 1.6 2.0 1.8 1.2 6.6 0.173
3 2.0 2.0 2.2 1.8 8.0 0.234

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4 55 kVp, 2.0 2.2 2.0 2.2 8.4 0.274
5 0.1 mm 2.0 2.2 2.2 2.0 8.4 0.136
6 Cu, 1.4 2.0 2.2 2.4 2.2 8.8 0.095
7 mAs 2.0 2.0 2.2 1.6 7.8 0.107

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8 2.0 2.0 2.2 1.6 7.8 0.107
9 2.0 2.2 2.0 2.2 8.4 0.065

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10 2.0 2.2 2.0 2.2 8.4 0.065
1 2.8 3.0 3.0 2.8 11.6 0.077

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2 2.6 3.0 3.0 2.6 11.2 0.098
3 3.0 3.0 3.0 3.0 12.0 0.000

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4 3.0 3.0 3.0 3.0 12.0 0.000
5 40 kVp, 3.0 2.8 3.0 3.0 11.8 0.038
no Cu, 2.5
6 3.0 3.0 3.0 3.0 12.0 0.000

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mAs
7 2.6 3.0 2.8 2.8 11.2 0.116
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2.8
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3.0
2.8
3.0
2.8
2.8
11.4
11.6
E0.118
0.077
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10 2.8 3.0 3.0 2.8 11.6 0.077
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