Changes in nutritional status by recovery phase interventions would be a powerful determinant of cardiovascular prognosis in heart failure patients

Background

Adequate nutrition has been proposed for better cardiovascular prognosis as well as fitness, although the impact of the “changes” in nutrition and fitness at recovery phase on the future prognosis has been unclear.

Purpose

We aimed to examine whether the change in nutritional level as a result of dietary intervention combined with exercise would determine patients' cardiovascular prognosis.

Methods

This study involved 398 consecutive patients who participated in phase II comprehensive cardiac rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion periods of CCR. Individual dietary guidance was periodically performed with exercise. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided in two groups according to the baseline GNRI and the change in GNRI (ΔGNRI) by the median, respectively, to compare their prognosis between groups. Then they were classified into four categories according to the median values of the changes in GNRI (ΔGNRI) and PVO2 (ΔPVO2) during CCR: “Both improved”, “Only GNRI improved”, “Only PVO2 improved” and “Both NOT improved”, to compare MACCE-free rate between categories.

Results

The rate of MACCE showed significant difference between categories (14%, 18%, 19% and 36%, p<0.001), which was approximately 2 times higher in “Both NOT improved” than the others. Kaplan-Meier analysis showed that according to the level of ΔGNRI, “higher ΔGNRI group” showed significantly higher in MACCE-free survival rate than “lower ΔGNRI group” (log rank p=0.010), whereas there was no significant difference according to the baseline GNRI (see figure). According to the categories divided by ΔGNRI and ΔPVO2, MACCE-free rate was significantly lower in “Both NOT improved” (log rank p<0.001) compared to the other categories. Cox proportional hazard regression analysis revealed that “both NOT improved” was an independent predictor of MACCE (hazard ratio, 2.1, 95% confident interval, 1.344–3.175, p<0.001).

Conclusion

Changes in nutritional level would determine patients' cardiovascular prognosis rather than the baseline nutritional level. Non-responders who showed no improvement in nutritional or fitness by interventions may result in a poor cardiovascular outcome.

Funding Acknowledgement

Type of funding source: None

P2528Responsiveness to nutritional intervention would impact on future cardiovascular prognosis in poor fitness patients

Purpose

Nutritional improvement has been proposed for long-term cardiovascular prognosis as well as fitness recovery. We aimed to examine whether “responsiveness” to nutritional and exercise interventions would impact patients' cardiovascular prognosis even patients in low baseline fitness level.

Methods

We included 254 consecutive patients who participated in the phase II comprehensive cardiovascular rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion phases of CCR. Nutritional guidance was periodically performed individually during CCR. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided into “low fitness” and “normal fitness” groups based on the median of baseline PVO2. Each group was further classified into four categories according to the changes in VO2 and GNRI during CCR: “Both NOT improved”, “Only GNRI improved”, “Only PVO2 improved”, and “Both improved”.

Results

Cox proportional regression analysis showed that the category of “both NOT improved” was an independent predictor for cardiovascular risk among the baseline low fitness group (Hazard ratio: 4.5, p=0.007); whereas no significant difference among the normal fitness group. Kaplan-Meier analysis revealed that the event-free survival rate was significantly lower in the “both NOT improved” category (log rank p=0.002) among the baseline low fitness group (figure); whereas no significant difference among the normal fitness group.

GNRI/PVO2 improvement vs. prognosis

Conclusion

Responsiveness to nutritional and exercise intervention could be a predictive factor of cardiovascular prognosis even in low fitness patients.

Performance evaluation of radiologists with artificial neural network for differential diagnosis of intra-axial cerebral tumors on MR images

BACKGROUND AND PURPOSE

Previous studies have suggested that use of an artificial neural network (ANN) system is beneficial for radiological diagnosis. Our purposes in this study were to construct an ANN for the differential diagnosis of intra-axial cerebral tumors on MR images and to evaluate the effect of ANN outputs on radiologists' diagnostic performance.

MATERIALS AND METHODS

We collected MR images of 126 patients with intra-axial cerebral tumors (58 high-grade gliomas, 37 low-grade gliomas, 19 metastatic tumors, and 12 malignant lymphomas). We constructed a single 3-layer feed-forward ANN with a Levenberg-Marquardt algorithm. The ANN was designed to differentiate among 4 categories of tumors (high-grade gliomas, low-grade gliomas, metastases, and malignant lymphomas) with use of 2 clinical parameters and 13 radiologic findings in MR images. Subjective ratings for the 13 radiologic findings were provided independently by 2 attending radiologists. All 126 cases were used for training and testing of the ANN based on a leave-one-out-by-case method. In the observer test, MR images were viewed by 9 radiologists, first without and then with ANN outputs. Each radiologist's performance was evaluated through a receiver operating characteristic (ROC) analysis on a continuous rating scale.

RESULTS

The averaged area under the ROC curve for ANN alone was 0.949. The diagnostic performance of the 9 radiologists increased from 0.899 to 0.946 (P < .001) when they used ANN outputs.

CONCLUSIONS

The ANN can provide useful output as a second opinion to improve radiologists' diagnostic performance in the differential diagnosis of intra-axial cerebral tumors seen on MR imaging.

Characterization of a second gene (ZSOD22) of Na+/H+ antiporter from salt-tolerant yeast Zygosaccharomyces rouxii and functional expression of ZSOD2 and ZSOD22 in Saccharomyces cerevisiae

We reported in our previous paper on the characterization of the Na+/H(+)-antiporter gene (ZSOD2) closely related to the salt-tolerance of yeast Zygosaccharomyces rouxii. In the present paper, we have cloned a second gene (ZSOD22) of Na+/H+ antiporter from Z. rouxii. The deduced amino acid sequence of Zsod22p was highly homologous to that of Zsod2p, Sod2p from Schizosaccharomyces pombe, and Nhalp from Saccharomyces cerevisiae. The open reading frames (ORFs) from ZSOD2 or ZSOD22 were inserted into a yeast expression vector pYES2, and their constructs (pZSOD2 and pZSOD22) were used to transform the salt-sensitive S. cerevisiae. pZSOD2- or pZSOD22-harboring-recombinant S. cerevisiae cells showed increases in salt tolerance. However, the Z. rouxii disruptant of ZSOD22 did not show any phenotypes related to salt tolerance or osmotolerance, unlike that of ZSOD2. The transcriptional expression of ZSOD22 was not observed by Northern blot analysis even in Z. rouxii cells subjected to NaCl-shock. From these results we conclude that although Z. rouxii includes at least two copies of the Na+/H(+)-antiporter gene (ZSOD2 and ZSOD22), ZSOD2 encodes a functional product as an antiporter and ZSOD22 is poorly transcribed, if at all.

[Improvement of detectability of microcalcifications by magnification digital mammography]

Our aim in this study was to evaluate the potential utility of magnification mammography with a CR system by investigating the basic imaging parameters and detectability of microcalcifications in comparison with those of conventional screen-film systems. The basic imaging parameters were evaluated by measuring scatter fraction, modulation transfer function (MTF), Wiener spectrum, and incident dose for the various magnification factors. The detection of simulated microcalcifications in radiographs of a mammographic phantom and breast specimens were evaluated subjectively and quantitatively for screen-film and CR techniques with various magnification factors. The scatter fraction of digital magnification mammography decreased with increasing magnification factor. MTF of magnification digital mammography improved with increasing magnification factor. The detectability of microcalcifications with the CR system was significantly improved by magnification technique. From the above results, it is expected that the use of magnification mammography with a CR system will improve the detectability of microcalcification.

Three-dimensional FISP imaging in the evaluation of carotid cavernous fistula: comparison with contrast-enhanced CT and spin-echo MR

PURPOSE

The purpose of this study was to assess the value of three-dimensional fast imaging with steady-state precession (FISP) MR sequences relative to contrast-enhanced CT and spin-echo MR imaging in the diagnosis of carotid cavernous fistula (CCF).

METHODS

Seventeen patients with 19 angiographically proved CCFs had contrast-enhanced CT, spin-echo MR imaging, and 3-D FISP imaging. Three observers assessed these imaging studies as well as those of 43 control sides in a blinded manner for the presence or absence of CCF. Receiver operating characteristic analysis was used to assess the diagnostic utility of each imaging technique. In a nonblinded study, contrast-enhanced 3-D FISP images were also evaluated.

RESULTS

Higher diagnostic accuracy was obtained with 3-D FISP sequences, as the shunt flow within the cavernous sinus was well seen. Sensitivity of 3-D FISP images was 83% and specificity was 100% in the blinded study. In the receiver operating characteristic analysis, the diagnostic performance of observers was found to be better with the 3-D FISP images than with the spin-echo MR images. Although there were no significant difference between 3-D FISP and contrast-enhanced CT, higher diagnostic performance was obtained with 3-D FISP images. In three CCFs without anterior drainage, a diagnosis was made only from the 3-D FISP images. The contrast-enhanced 3-D FISP images were not helpful, since the cavernous sinuses enhanced.

CONCLUSION

Three-dimensional FISP imaging is superior to spin-echo MR imaging and contrast-enhanced CT in the diagnosis of CCF. Contrast-enhanced 3-D FISP images are not helpful for the evaluation of CCF.

Physical and clinical evaluation of a 2,048 x 2,048-matrix image intensifier TV digital imaging system in bone radiography

RATIONALE AND OBJECTIVES

To evaluate the potential utility of a 2,048 x 2,048-matrix image intensifier television digital radiography (DR) system versus a conventional screen-film (S-F) system for bone radiography.

METHODS

Basic imaging properties were evaluated including resolution properties, Wiener spectra, and detectabilities of low-contrast signals. DR images were obtained with the same exposure (iso-dose) or one-third the exposure (low-dose) used with the S-F system. The visibility of pathologic details of metastatic disease on bone radiographs of 27 patients was evaluated subjectively by six radiologists.

RESULTS

Resolution properties of the DR system were slightly superior to those of the S-F system at low-frequency range, but the S-F system showed considerably higher resolution properties at the high-frequency range. The noise levels for iso-dose DR were slightly greater than those for S-F imaging at low spatial frequency; however, low-dose digital radiographs showed higher noise levels. Visibility of details of diagnostic features on bone radiographs was similar with both systems, but the low-dose digital radiographs were slightly inferior.

CONCLUSION

High-resolution image intensifier television DR systems may be clinically useful for bone radiography.

Basic imaging properties of a new screen-film system for chest radiography

To evaluate the potential clinical usefulness of a new screen-film system (advanced screen-film system; AD system) for chest radiography, its fundamental imaging properties compared with a conventional screen-film system (HR-4/HR-S) were investigated. The basic imaging properties were evaluated by measuring characteristic (H&D) curves, relative speeds, MTFs (modulation transfer functions), WS (Wiener spectra), and x-ray attenuations of screens. The detail visibilities and pathological details of various diseases in chest radiographs of patients were evaluated subjectively. The film gradient of the AD system was slightly lower at low radiographic density, and higher at high density, as compared with a conventional screen-film system. The screen speed of the AD system was 212% greater than that of the conventional system, and the film speed was 53% that of the conventional film. As the result, the total speed of the AD system was slightly higher compared with the conventional system. The spatial resolution of the AD system was comparable to or slightly lower than that of the conventional system. The noise level of the AD system was considerably lower than that of the conventional system at low (D = 0.5) and middle (D = 1.0) radiographic density levels. However, it was high at high radiographic density (D = 1.8). The radiographic densities in the underpenetrated areas with the AD system were greater than those of the conventional system when the lung densities are matched comparable. Improvement in noise level with the AD system at low and middle density levels may be useful for detection of various diseases in chest radiographs.

Dynamic MR imaging of the temporomandibular joint in patients with arthrosis: relationship between contrast enhancement of the posterior disk attachment and joint pain

OBJECTIVE

The purpose of this study was to determine the relationship between joint pain, disk position, and the degree of contrast enhancement of the posterior disk attachment in patients with temporomandibular joint arthrosis using dynamic contrast-enhanced MR imaging.

SUBJECTS AND METHODS

T1- and T2-weighted spin-echo and spoiled gradient-recalled acquisition in the steady state MR imaging was performed in 36 healthy volunteers and 105 patients who were asymptomatic or who had joint pain, muscular pain, or both. On T1-weighted images, the position of the disk was classified as normal and anteriorly displaced. Next, on sagittal spoiled gradient-recalled acquisition in the steady state MR images, signal intensity from teh posterior disk attachment was measured. Time-intensity curves of the signal-intensity ratio versus the time after contrast administration were obtained in each case. Diagnostic accuracy of enhancement among the clinical symptoms was assessed using receiver operating characteristic curves. Imaging findings of contrast enhancement were correlated with pain and disk position.

RESULTS

In quantitative measurement, a rapid enhancement pattern was seen most frequently in patients with joint-pain, whereas relatively gradual enhancement was seen in the healthy subjects and in patients who were asymptomatic or who had muscular pain. The mean peak-signal-intensity ratio of the group with joint pain was significantly higher than that of the other groups (p < .001). In the group with joint pain, anterior disk displacement without reduction was strongly associated with the mean signal-intensity ratio (p < .01). With regard to receiver operating characteristic analysis, the group with joint pain showed significantly greater accuracy than did the other groups (p < .001).

CONCLUSION

Our results suggest that prominent contrast enhancement of the posterior disk attachment on spoiled gradient-recalled acquisition in the steady state MR images may help differentiate intraarticular from extraarticular causes of pain in and around the temporomandibular joint. In the group with joint pain, anterior disk displacement without reduction was closely associated with prominent enhancement.

Hemifacial spasm: three-dimensional MR images in the evaluation of neurovascular compression

PURPOSE

To assess the diagnostic accuracy of three-dimensional (3D) magnetic resonance (MR) images in the preoperative evaluation of hemifacial spasm.

MATERIALS AND METHODS

In 27 patients with surgically confirmed hemifacial spasm, the axial source images from 3D time-of-flight MR angiography were evaluated for 27 symptomatic sides and 26 asymptomatic sides by three observers in a blinded manner for neurovascular compression and identification of compressive vessels.

RESULTS

Sensitivity was 95% and specificity was 77%. Vascular compression on the symptomatic sides could be identified retrospectively in all 27 patients. On the asymptomatic sides, vascular compression could be excluded retrospectively in all but one patient. In the blinded study, as the mean value of three observers, the vertebral artery and posterior inferior cerebellar artery could be identified correctly in seven and 7.7 of seven and nine patients, respectively, whereas the compressive anterior inferior cerebellar artery was identified correctly in 7.7 of 16 patients.

CONCLUSION

Three-dimensional MR images have a high diagnostic accuracy and are useful in the preoperative evaluation of hemifacial spasm.

Hepatocellular carcinoma in cirrhotic livers: detection with unenhanced and iron oxide-enhanced MR imaging

PURPOSE

To evaluate diagnostic accuracy with unenhanced and superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for detection of hepatocellular carcinoma (HCC) in cirrhotic livers.

MATERIALS AND METHODS

Fifteen patients with 26 histologically proved HCCs associated with liver cirrhosis underwent imaging with T1-, T2-, and proton-density-weighted spin-echo (SE) and fast low-angle shot (FLASH) sequences. Lesion-to-liver contrast-to-noise ratios were measured in all sequences. Diagnostic performance of the imaging techniques was assessed by using receiver operating characteristic analysis.

RESULTS

Enhanced SE and FLASH sequences were significantly more accurate (P < .005) for the detection of small HCCs. Among the unenhanced pulse sequences, the accuracy of tumor localization was highest with the T2-weighted SE sequences; however, 25% of the lesions were located incorrectly. Compared with unenhanced images, lesions were correctly located more often when SPIO-enhanced SE and FLASH sequences were used.

CONCLUSION

SPIO-enhanced MR imaging with proton-density-weighted or FLASH sequences was more accurate in the detection of small HCCs in cirrhotic livers.

Adnexal masses: accuracy of characterization with transvaginal US and precontrast and postcontrast MR imaging

PURPOSE

To determine the accuracy of transvaginal ultrasound (TVUS) and of precontrast and contrast material-enhanced magnetic resonance (MR) imaging in the differentiation of adnexal masses.

MATERIALS AND METHODS

Five blinded readers analyzed images of 80 masses in 72 patients. MR and TVUS images were interpreted in separate sessions. Findings were confirmed at surgery or laparoscopy.

RESULTS

Higher diagnostic accuracy was attained with MR imaging in mature cystic teratomas and endometriomas. However, better accuracy was achieved with contrast-enhanced MR imaging and TVUS in simple cysts, cystadenomas, and malignant tumors because internal details could be visualized. Receiver operating characteristic study indicated that observer confidence was significantly higher with contrast-enhanced MR imaging than with precontrast MR imaging (P = .011) or TVUS (P = .002) in the differentiation of benign and malignant masses.

CONCLUSION

Contrast-enhanced MR imaging is superior to precontrast MR and TVUS imaging in the characterization and differentiation of adnexal masses.

Gastrointestinal examinations with a 2,048- x 2,048-pixel image intensifier television digital radiography system

The clinical usefulness of a 2,048- x 2,048-pixel matrix image intensifier television digital radiography system was evaluated. Screen-film and digital images (with and without postprocessing) of the upper and lower gastrointestinal (GI) tract were used for clinical evaluation. For the upper GI tract, digital images processed with unsharp mask techniques were comparable in quality to screen-film images before and after upgrading the system. For the lower GI tract, screen-film images were better than digital images, except for those processed with a 2,048- x 2,048-line monitor was comparable to a screen-film system.

[Preliminary clinical applications of asymmetric screen-film systems in chest radiography]

The physical imaging properties of asymmetric systems and a conventional system were evaluated by measuring characteristic curves, resolution properties and noise Wiener spectra. The potential clinical application of asymmetric screen-film systems was studied by evaluating the visibility of the anatomical structures and various types of abnormalities in comparison with those of a conventional screen-film system. The asymmetric systems showed a wider dynamic range than the conventional system. The resolution properties of asymmetric systems depend on the combination of front and back screens used. Chest radiographs obtained with asymmetric systems improved the visibility of the mediastinal area. The visibility of the lung field in the asymmetric systems was slightly inferior to that with the conventional system when the same tube potential was used. However, the image quality and visibility of various abnormalities showed greater improvement with the asymmetric systems when a lower tube potential was applied. We conclude that the selection of radiographic techniques and combination of screens are important for the clinical use of asymmetric systems.

Development of a 2,048 x 2,048-pixel image intensifier-TV digital radiography system. Basic imaging properties and clinical application

RATIONALE AND OBJECTIVES

A 2,048 x 2,048-pixel matrix image intensifier (II)-TV digital radiography system has been developed. Potential clinical applications of this new II-TV system were investigated.

METHODS

Basic imaging properties were assessed with clinical applications to gastrointestinal (GI) tract and chest examinations.

RESULTS

Basic imaging properties showed improvement of modulation transfer functions (MTFs) from the 1,024 x 1,024- to the 2,048 x 2,048-pixel matrix and approximated the screen-film system at low spatial frequencies. Receiver operating characteristic (ROC) curves of simulated linear shadows improved similarly. Clinical applications showed that the image quality of the 2,048 x 2,048-pixel matrix was comparable with that of the screen-film system for upper GI and chest radiography, but the image quality of the screen-film system was better for the lower GI tract.

CONCLUSIONS

The authors' II-TV digital radiography system is clinically applicable to gastrointestinal and chest examinations.

Gastrointestinal examinations with digital radiography

Basic imaging properties and clinical usefulness of an upgraded digital radiography system were evaluated. The system, which has 1,024 x 1,024 and 2,048 x 2,048 matrices, was upgraded with smaller focal spots (0.3 and 0.8 mm) and reduced thickness of the photoconductive layer of the video camera. Screen-film and digital images (with and without postprocessing) of the upper and lower gastrointestinal (GI) tract were used in the clinical evaluation. Overall modulation transfer functions of the upgraded digital system were comparable to those of the screen-film system, especially at the lower spatial frequency. Threshold contrasts of the two systems were similar despite a 50% reduction in incident exposure for the digital system. For the upper GI tract, digital images processed with unsharp masking techniques were comparable in quality to screen-film images before and after upgrade of the system. For the lower GI tract, screen-film images were better than digital images, except for those produced with a 2,048 x 2,048 matrix with unsharp masking. Further evaluation of the system for examination of other parts of the body seems warranted.

Detection of subtle microcalcifications: comparison of computed radiography and screen-film mammography

Observer performance tests were conducted to compare the effects of image-processing technique (unsharp mask filtering) on the diagnostic accuracy of computed radiography (CR) with storage phosphors in the detection of microcalcifications. Comparison of detectability of microcalcifications with CR and with screen-film mammography was also performed. Clusters of microcalcifications (125-250 microns in diameter) were randomly superimposed on human breast specimens. Observer performance tests were carried out with receiver operating characteristic (ROC) analysis. The area under the ROC curve and the cumulative true-positive-localization fraction were both used as indexes of performance. Observer performance experiments with nine observers indicated that the two types of screen-film images used provided higher detectability than the CR images. The detectability of microcalcifications on the CR images improved slightly with use of the unsharp masking technique. However, no statistically significant difference was found between processed and unprocessed CR images, and detectability still did not reach the level achieved with the screen-film images.

Quantitative measurement of high flow velocities by a spin echo MR technique

A new method of flow measurement using a spin echo (SE) technique has been developed on the basis of the flow effect that at high velocities signal intensity decreases linearly with increasing flow velocity. Flow velocity is calculated from the signal intensity ratio of the flowing material in two images with the same imaging parameters but different echo times. The linear relationship between the signal intensity and flow velocity was examined with a steady flow phantom. When assessed with steady flows in the phantom, flow velocities calculated by this method were in good agreement with velocities measured by a flow meter. This method was used with ECG gating to measure the blood flow of the right common carotid artery of a healthy volunteer. The measured peak flow velocity and the pattern of flow velocities during systole correlated well with the results obtained by Doppler ultrasound.

Digital TV tomography: description and physical assessment

A digital TV tomography system, capable of retrospective reconstruction of multiple digital tomographic images, has been developed and its basic physical characteristics have been evaluated. The multiple tomographic images were formed through retrospective reconstruction of digital data acquired on a linear tomographic x-ray unit and an image intensifier-television system. Digital data were obtained with a series of 30 pulsed exposures during linear motion of the system. A distortion correction algorithm for the convex surface of the image intensifier was developed in order to reduce image distortion. A phantom study showed that the square-wave response at the fulcrum plane was slightly inferior to that in conventional tomography. There was also a slight decrease in the square-wave response away from the fulcrum plane and upon application of a correction algorithm, as compared with the response of the original reconstructed image at the fulcrum plane. The exposure dose for a single image was approximately half that in conventional tomography. Because of many advantages, including low exposure, short examination time, digital image manipulation, and applicability to picture archiving and communication systems, this is likely to become an important method in radiology when further technical refinements have been made.

[Investigation of low-contrast signal detection in computed radiography (CR)]

Threshold contrasts of low-contrast objects were compared between screen-film and computed radiography (CR) systems. Effects of incident exposure to the imaging plate (IP) and contrast enhancement on the detectability of low-contrast objects were also studied. We employed 18-alternative forced-choice (18AFC) experiments to study the dependence of the threshold contrasts of the test objects on the incident exposure, object size, and contrast enhancement. The results indicated that the threshold contrasts of CR system were comparable to that of the medium-speed screen-film system and increased by decreasing x-ray exposures. Although threshold contrasts decreased by contrast enhancement, the magnitude of improvement depended on the object size and incident exposure.

[Constructions of compensating screen of chest radiography and its clinical applications--evaluation of normal anatomical structures]

We have constructed compensating screens which have different sensitivities for the pulmonary hilum and mediastinum in contrast to the lung. With these screens the regions of the mediastinal and retrocardiac areas are simultaneously displayed with optimal contrast on postero-anterior (PA) chest radiographs. The potential clinical use of compensating screens was evaluated in 67 patients for visibility of the anatomical structures in comparison with conventional screens. Confidence test was used to compare the detectability of the various anatomical structures of the chest. The chest radiographs obtained with compensating screens improved visibility of the anatomical structures including the tracheal bifurcation, right and left main bronchus, and paraesophageal line.

Depth determination on stereoscopic digital subtraction angiograms

The determination of depth on stereoscopic digital subtraction angiographic (DSA) images was evaluated. A "plus" phantom that contained simulated blood vessels of various sizes with various concentrations of contrast medium was used for the study. The vessels ranged in diameter from 0.46 to 1.35 mm, with concentrations of contrast material of 1.6%-25%. The images were evaluated by seven radiologists and six radiologic technologists. The detectability of depth separation increased as the iodine concentration and the vessel size increased. With stereoscopic DSA, correct identification of depth is possible more than 80% of the time for vessels approximately 1 mm in diameter and containing 3.1% contrast medium when the vessels are separated by more than 2.8 mm.

Computed radiography utilizing laser-stimulated luminescence: detectability of simulated low-contrast radiographic objects

Threshold contrasts of low-contrast objects with computed radiography (CR) images were compared with those of blue and green emitting screen-film systems by employing the 18-alternative forced choice (18-AFC) procedure. The dependence of the threshold contrast on the incident X-ray exposure and also the object size was studied. The results indicated that the threshold contrasts of CR system were comparable to those of blue and green screen-film systems and decreased with increasing object size, and increased with decreasing incident X-ray exposure. The increase in threshold contrasts was small when the relative incident exposure decreased from 1 to 1/4, and was large when incident exposure was decreased further.

High resolution DSA: experimental and clinical evaluation

The DSA system has been upgraded for capabilities of slow scan video technique and progressive T.V. read-out of 1024 X 1024 matrix with 10 bits of depth. A square wave test pattern made of lead bar demonstrated moderate improvement in spatial resolution, but imaging of a Burger-Rose phantom revealed no significant increase in contrast resolution. Clinical study of various angiograms with intraarterial injections showed that there was slight improvement in the visibility of the vessels, especially small arterial branches, while there was no increase in visibility of the veins. There were no cases in which diagnoses were altered by application of high resolution DSA. With future improvements of the image intensifiers, DSA with 1024 X 1024 matrix may reveal its potential advantage, especially when coupled to larger image intensifiers such as 12 or 14 in.

Hybrid digital subtraction angiography: initial clinical experience

Hybrid digital subtraction angiography was performed after modification of a DSA system. Alternate high voltage (110-120 kV) and low voltage (65-70 kV) were obtained within short time intervals of 60-70 ms with a high voltage switching generator. Experimental phantom studies revealed the exposure dose per single image of hybrid subtraction was approximately 30% of that of conventional DSA. The SNR of hybrid subtraction was improved by increasing the exposure dose and application of postprocessing programs. Clinical application of intraarterial and intravenous DSA revealed that soft tissue artifacts were removed surprisingly well, but image quality decreased because of lowered SNR. Frame integration and matched filtering improved image quality of hybrid subtraction.

Stereoscopic technique in digital subtraction angiography

Stereoscopic technique was applied to digital subtraction angiography (DSA) with alternate exposures from twin focus spots (6.5-cm separation) of an x-ray tube. Correct identification of two crossed aluminum wires was obtained more than 90% of the time when there was separation of more than 5 mm. Excellent clinical images of intravenous as well as intraarterial DSA have been obtained, and the clinical value of DSA was enhanced by application of the stereoscopic technique.

Performance of antiscatter grids in diagnostic radiology: experimental measurements and Monte Carlo simulation studies

We have devised an experimental method with which one can accurately measure the transmission of primary radiation and the transmission of total radiation by an antiscatter grid in a setting similar to a practical radiographic examination. We measured the transmission values for 27 combinations of x-ray tube potentials, phantom thicknesses, screen-film systems, and grid parameters. The standard deviation of one measurement was estimated to be 2.9% and 1.5% for the total and primary transmissions, respectively. The measured grid transmission was compared with results predicted by our Monte Carlo calculations; 92% of the measured and calculated values agree within two standard deviations. This close agreement indicates that our Monte Carlo calculation can accurately predict the performance of antiscatter grids under diagnostic imaging conditions.

Ultra-high-strip-density radiographic grids: a new antiscatter technique for mammography

We conducted a comprehensive study on the application of ultra-high-strip-density (UHSD) grids to mammography for the improvement of image contrast. These UHSD grids have strip densities of 70 to 100 lines/cm. After investigating the performance of mammographic grids with various design parameters through Monte Carlo simulation studies, we made prototypes of UHSD grids having lead strip thicknesses of 20 to 37 micron, aluminum interspacer thicknesses of 80 to 120 micron, and grid ratios of 2 to 6. The UHSD grids can be placed inside the cassette without a Bucky tray and thus will not increase geometric unsharpness. The measured physical characteristics and the phantom images obtained confirmed our findings in the simulation studies. A 40 to 90% increase in contrast was achieved at Bucky factors of 2 to 3.5; these results are comparable with those from conventional antiscatter grid techniques in mammography. The potential usefulness of the UHSD grids was demonstrated in a preliminary clinical comparison of mammograms.

Dual-film cassette technique for studying the effect of radiographic image quality on diagnostic accuracy

In order to investigate the relationship between diagnostic accuracy and radiographic image quality, we have developed a dual-film cassette which produces two radiographs simultaneously with a single exposure. One of these radiographs is of standard quality; the second is of lower quality because of degraded spatial resolution and a significantly lower exposure. We have studied the basic physical properties of the standard and low-dose screen-film systems which we use in the dual-film cassette by comparing their beam hardening, scatter fractions, contrasts, modulation transfer functions (MTFs), and Wiener spectra. The x-ray spectrum incident on the low-dose system contained more high-energy photons than that incident on the standard system, and the scatter fractions for the low-dose system were slightly less than or comparable to those for the standard system. While the radiographic contrast produced by the two systems were generally comparable, the standard system had a slightly higher contrast than the low-dose system in some cases. The MTF of the low-dose system was considerably lower than that of the standard system, and the low-dose system had a noise level considerably greater than did the standard system. Phantom images and clinical radiographs indicated that, for the low-dose system, the image quality degraded significantly.

High-speed, single-screen/single-emulsion film systems: basic imaging properties and preliminary clinical applications

We investigated the potential clinical use of single-screen/single-emulsion film systems by comparing their relative speeds, modulation transfer functions (MTFs), Wiener spectra, and H & D curves with those of conventional screen-film systems. The relative speeds of single screens with single-emulsion Kodak OM film (single systems) were 50-60% lower than those of the conventional double screens with double-emulsion Kodak OG film (double systems), but the single systems yielded a 75-110% increase in the MTF at 2 cycles/mm. The single system had a noise level comparable to or slightly greater than that of the double systems. Phantom images and preliminary clinical radiographs indicated that single systems can improve image resolution over that obtainable with double systems under the same exposure conditions. More importantly, the use of a single system provided an approximately 40% reduction in patient exposure while providing a comparable radiographic image quality.