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Radiology or medical imaging departments are extremely safe places to work and
to spend time in. There are state and federal regulations governing safe work
practices and radiation safety within all X-ray departments and private imaging
clinics. See Radiation Risk of Medical Imaging in Adults and Children for more
information.
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3. Why become a radiographer?
A radiographers role is challenging, rewarding and highly skilled. Radiographers
become part of a vital group of medical professionals with specialist training and
highly developed skills. There is significant patient contact and a radiographer
plays an important part in improving patient outcomes and experiences. The
profession offers excellent career prospects with qualified staff in high demand.
There are many benefits in becoming a radiographer such as:
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4. How do you become a radiographer?
A radiographer must become a graduate of a Medical Imaging Degree program.
There are several courses throughout Australia available to prospective
radiography students. The admission requirements vary between universities.
Generally there are options available for school leavers, non-school leavers,
mature students and overseas students.
All courses demand a high degree of academic study, as well as clinical expertise
in routine and advanced medical imaging procedures. Most courses are three
years in duration with a graduate needing to undertake one year of mentored
clinical experience to complement their university studies (called an intern year).
This intern year may vary in duration, structure and name depending on the
State and university.
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5. Where does a radiographer study?
Diagnostic radiography courses are available in most states in Australia. The
Universities currently running the courses include:
NSW:
The University of Newcastle: (www.newcastle.edu.au/)
The University of Sydney: (www.fhs.usyd.edu.au/mrs/)
Charles Sturt University: (www.csu.edu.au/faculty/science/)
VIC:
QLD:
Queensland University of Technology: (www.sci.qut.edu.au/)
SA:
University of South Australia: (www.unisa.edu.au/hls/)
WA:
Curtin University of Technology: (www.medicalimaging.curtin.edu.au/)
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6. What else can a radiographer do?
One of the greatest benefits in this profession is the variety and scope for
progression. Apart from performing plain examinations like chest X-rays,
radiographers have the opportunity to become expert in areas like CT, MRI,
angiography, fluoroscopy, trauma (injury) radiography, mobile radiography, and
operating theatre radiography. Radiographers also have the opportunity to take
on roles in the following areas:
Radiology is now the key diagnostic tool for many diseases and has an important
role in monitoring treatment and predicting outcome. It has a number of imaging
modalities in its armamentarium which have differing physical principles of
varying complexity. The anatomical detail and sensitivity of these techniques is
now of a high order and the use of imaging for ultrastructural diagnostics,
nanotechnology, functional and quantitative diagnostics and molecular medicine
is steadily increasing. Technological advances in digital imaging have also
enabled the images produced to be post-processed, manipulated and also
transmitted rapidly all over the world to be viewed simultaneously with the
transmitting centre.
Although the training programmes are repositioning radiology in this way, these
developments are now occurring and are affecting all radiologists who in general,
at present, are satisfied with their overall position within the respective health
care system in most European countries. Radiologists have no difficulties in
finding professionally fulfilling and well-paid employment. Indeed the rapid rise in
workload and complexity of examinations have resulted in a shortage of
radiologists in most countries which may reduce the opportunity or desire to
move and up-date sufficiently with these advances. The availability of high-speed
internet transfer of images may affect the requirement and role of local
radiologists by transferring images to major centres for rapid specialist
interpretation. Thus the rapidly developing and expanding field of imaging
becomes a challenge to our specialty, especially as it has also become so
attractive to others. We should therefore be concerned to ensure the future of
radiology as a medical specialty and take into consideration the forces and the
dynamics surrounding our profession by meeting them with foresight and
flexibility.
Public recognition of the clinical role of radiology is essential and is very much
dependent on contact with the patients [2]. However, over the past years
radiologists reading more and more complex examinations have become less and
less visible for patients and the public. Moreover, in some health care systems
the emphasis of radiology work is placed on the in-patient referrals to major
general (secondary) and university (tertiary) hospitals where the role of the
radiologist as part of the team is less obvious to the patient. There has been less
focus on the provision of radiology services to primary care (including general
practitioners and office based specialists), where the requirements are different,
with a need for a more general service but still involving a range of imaging
services, and where the individual role of the radiologist is more obvious to the
patient.
Go to:
Specialisation in radiology
One solution has been a gradual increase in the degree of specialisation of
radiologists along systems and disease-related specialties, which has been
strongly advocated by the ESR in its curriculum. Some radiologists have focussed
on particular imaging modalities which may have assisted the development of
these modalities, but the range of imaging techniques to evaluate particular
clinical scenarios is such that this approach is not appropriate when dealing with
clinicians who have all specialised along systems and disease-based pathways.
The current curriculum for training has been adapted to take this process into
account. It now separates radiologists, following training to a core level in all
aspects of radiology including all techniques, into two main categories:
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Reasons for subspecialisation
The argument for subspecialisation is strong and a number of factors should be
taken into account.
Information overload:
Our field has become so complex that no individual can maintain the level of
expertise needed to practice the entire field of radiology. At present we insist that
radiologists become at least minimally competent in the entire field although it is
virtually impossible today to remain a radiologist with competence in all areas of
our specialty [5]. However, in interventional radiology, for example, sub-specialist
training is needed to gain deeper knowledge, new techniques and practical
experience to provide a high level of clinical service. The technical demands for
procedural skills and familiarity with new devices mean that only a few members
of a group can develop the expertise to practice interventional radiology.
Mammography quality standards require that physicians practising
mammography interpret a minimum number of cases and attain specific breastrelated continuing medical education to continue the practice.
Developments too rapid:
There are many examples of the effect of rapid developments but the increase in
the temporal and spatial resolution of acquisition in CT and the complexities of
new software packages in MR have been paramount. The former has involved
radiologists in many non-invasive vascular imaging interpretations that were
previously the domain of the sub-specialist. The latter has resulted in functional
imaging, spectroscopy and diffusion imaging requiring specialist knowledge to
conditions which hitherto have been the responsibility of the clinical radiologist
such as the early evaluation of stroke patients. The emergence of fusion imaging
presents further challenges to staying abreast of this evolving technology. As the
radiologist or a clinician who has done some imaging training as part of their
specialist clinical training.
Access to subspecialty training is limited in some parts of Europe:
In many countries in Europe sub-specialisation and access to complex equipment
is limited. Therefore no opportunities are available to train or practice in a
subspecialty. This situation is changing by implementing fellowship programmes
and by the use of electronic teaching files and internet-accessible case
collections but it may be resource-limited and the complex sub-specialisation
model may not be appropriate outside the major university hospital setting.
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How should sub-specialisation be implemented in radiological practice?
Subspecialisation is established in university hospital settings and large hospitalbased non-academic practice groups, who are increasingly appreciating the value
of having this high level of expertise within their groups, and the process towards
increasing super-specialisation is already upon us and is continuing.
Neuroradiologists focus on spinal, paediatric, interventional, or head and neck
radiology. Interventional radiologists may concentrate on vascular procedures,
non-vascular intervention, or oncologic procedures, such as percutaneous tumour
ablation or chemo-embolisation. Thoracic radiologists are often divided into those
who provide cardiac imaging and those limiting their practice to the lungs and
mediastinum.
However the primary care physician will need help from radiologists to decide
which imaging procedure will most likely provide the diagnosis without having to
go through the escalating sequence of imaging or other tests. Radiologists will
also be expected to manage and report these examinations, many of which will
cover a spectrum of common disorders which form the mainstay of any primary
care service. To be able to render these consultative services, the radiologist will
need to keep abreast with the new key developments in most subspecialties [1].
It is therefore likely that more than one model of practice will continue,
depending on the physical circumstances of the service required, but in order to
be valuable to the clinicians, the radiologists must have sufficient insight into the
clinical problems being investigated and greater skills in interpreting more
complex images than the clinicians themselves. In areas where there are
significant turf strains, of which there are an increasing number, subspecialty
qualifications may be a requirement. Radiologists should therefore have areas of
subspecialty competence, even if they still provide a broad service most of the
time.
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Clinical competence
One of the main reasons why radiologists are losing many turf issues is their
inadequate clinical culture. A high level of technical training is not sufficient for
dealing with clinicians and their clinical queries. Medical practice is becoming
increasingly interdisciplinary due to the vastness of knowledge involved. The
importance of clinical training has been emphasised previously by the ESR but it
is still not a requirement for entry into radiology in a number of European
countries. It is essential that, if radiologists are expected to understand the
clinical features and treatment of sub-specialist areas, they have a good clinical
base on which to build that knowledge. Good clinical training will enable
radiologists to interact at the appropriate level with clinicians. Therefore
radiologists, to be able to take part in an interdisciplinary discussion as a key
player, will not only have to be specialised in the imaging of a specific organ
system but also to be able to discuss complex clinical cases. Clinicians require
radiologists who understand the clinical questions, keep updated with the most
recent advances in the disease processes and have knowledge of the relevant
therapies.
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Interventional radiology
The field of interventional radiology has moved at great speed over the last few
years, and there is no evidence of a reduction in the pace. Indeed quite the
opposite is true as more and more surgical procedures are performed with
minimal invasion. Radiology has led the field but is being overwhelmed by the
volume of work and the desire of surgeons and physicians to take over this work.
In order to preserve radiologys place, it is essential that a radiologists training in
interventional radiology is structured in such a way to ensure that they not only
have the core diagnostic imaging skills, knowledge and technical interventional
competence, but also have sufficient clinical skills and training to care for their
patients. Interventional radiologists must also be given the necessary resources
of clinic time, hospital facilities and support to take and treat direct referrals. An
innovative approach to training in conjunction with our surgical, cardiological and
oncological colleagues is required to ensure that radiologists remain key
operators in this subspecialty. Interventional radiology should also be funded and
recognised for the clinical work they provide. In health economies that use
Diagnostic Related Groups (DRG) for payment purposes, it is of utmost
importance that patients admitted for an interventional procedure create income
for the radiology department in due proportion to the gain provided to the
hospital by the intervention and the hospital stay.
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Training implications
The European Training Charter for Clinical Radiology [7] identifies the first 3 years
devoted to developing the core skills and knowledge in all aspects of diagnostic
radiology. The following 2 years may be spent either undertaking subspecialty
training or gaining further experience while developing areas of special interest
by focussing more time in two or three organ- or disease-related specialties.
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Teleradiology: an opportunity
Teleradiology is now an established method of providing radiological services. It is
well developed in the provision of on-call emergency reporting being used by
over 70% of radiological practices in the US both by groups in the US and by
Night hawk services around the world. Teleradiology is also established for the
provision of radiological services to remote rural communities and for subspecialist opinions and for specialist case transfers. In the UK it is now used to
provide primary reporting services from centres both in Europe and by
international providers.
With the costs of data transmission decreasing as fast as the costs of computing
power, practical opportunities for global teleradiology are rapidly increasing as
the cost effectiveness of PACS and digital radiology increases. In our financially
constrained world, the clinical losses associated with generalised use of
teleradiology may be accepted by governments and health care insurers as a
means of cost containment [1].
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Patient relations
Radiological societies maintain (and radiologists do not publicly disagree) that to
improve the public perception of the role radiologists play in patient care, closer
contact with patients is essential [9]
imaging examinations. For many patients, radiologists are identified only with the
equipment used and not as physicians who play a vital role in the decisions that
affect them. The use of technologists, nurses, and physician assistants for
intravenous injection of contrast material makes radiologist-patient contact even
less common [2]
Patients believe that the clinician who requested the examination and has
received the report is actually the physician who has interpreted the study [2].
On the other hand, there is widespread agreement that patients prefer to hear
the results of imaging examinations from the radiologist at the time of the
procedure rather than to hear them later from the referring physician, regardless
of the findings [11]. And in another study it has been shown that radiologists and
referring physicians alike tend to support the proposition that, if asked,
radiologists should disclose the results of imaging studies to patients [12].
It seems to be important for the future of the specialty for radiologists to have
more contact with patients in the setting of high-cost, high-impact imaging
procedures. The very position of radiology in a variety of hierarchies ranging from
political to economic may depend on increased recognition by the public of
radiologists as physicians. However, results of a survey by Margulis and Sostman
[2] show that more than a half of the injections of contrast medium in radiological
practices are performed by non-physicians. Radiologists are often but by no
means always present in the facility during performance of the study and
radiologists rarely introduce themselves to the patient. Radiologists should
always introduce themselves to patients before any interventional procedure.
This is not only good manners but it also establishes the radiologists clinical role
in the whole spectrum of planning the treatment and assessing the prognosis and
the response during follow-up.
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Involvement in primary care (general practice (GP) and office based practice)
Primary care is the point of first patient contact and offers continuous
comprehensive and coordinated care to populations undifferentiated by gender,
disease or organ system. In order for comprehensive care to take place in the
primary care setting, the GP often requires access to a wide range of imaging
services. This enables the GP to diagnose and treat the more common diseases
without recourse to hospital services. It also empowers the GP to investigate the
patient more fully so that, if a transfer to a hospital specialist is required, such
referral can, in many cases be for therapeutic care rather than for further
investigation.
A GP may wish to work up a patient more fully in conjunction with the clinical
radiologist, who may be a sub-specialist or a radiologist with special interests, so
that the requirement for outpatient referral to specialty services may be avoided
or may be a more focussed and constructive consultation. For such a means of
referral to be effective, the radiologist will need to establish preferred
investigation pathways with the clinicians to whom ultimately the patients may
be referred. Finally, the GP may be able to treat a patient directly with the
assistance of the radiologists and some image-guided therapeutic procedures can
be undertaken by radiologists directly for GPs on an outpatient, day-case or
short-stay basis.
Electronic transfer has also developed rapidly over the last few years and the
transmission of images and reports between radiology departments and
surrounding GPs is now easily undertaken.
Go to:
Maximising the use of resources
There has been a tendency in teaching and large regional hospitals for
subspecialty services to pursue the development of satellite departments
isolating radiologists from each other. While this may be essential in some clinical
situations such as emergency departments, it potentially reduces the interaction
between sub-specialist radiologists to the detriment of their wider knowledge and
technological development. It may also reinforce the desire for clinicians to set up
their own units and encourages the concept of radiologists working in clinical
groups rather than providing a comprehensive imaging service. Radiologists
should work towards a single strong well-staffed and funded department which is
able to accommodate those clinicians who justifiably need prompt access to
expert imaging [3].
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Conclusion
The world of radiology is changing rapidly and radiologists have to be proactive in
this process to survive. The subject is now too broad and complex for an
individual to remain a comprehensive provider. As a result radiologists need to
group themselves as specialists in particular systems or disease-based areas
while finding a mechanism to provide a high-quality service. Radiologists must
also be clinicians and understand the clinical features, natural history and
treatments of the diseases that they are requested to investigate. Therefore, if
radiologists want to add value to the chain of healthcare they need to subspecialise to a greater or lesser extent according to their working circumstances.
Teleradiology services may be appropriate for small and rural practices as part of
an area network especially during nights and weekends and for interaction with
GPs and patients. Radiologists must also interact more directly with patients and
primary care physicians to provide a comprehensive diagnostic and advisory
service prior to the patient entering the secondary care service by managing the
investigations of the patients themselves. This will increase efficiency, clinical
effectiveness of the service and speed up the referral process. Radiologists in the
teaching hospitals will also need to specialise to a higher degree in order to
provide a tertiary referral service, communicate and advise clinical experts and to
conduct and drive imaging research as true experts in their field.
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Recommendations
Sufficient radiologists are in training to ensure that the workforce is large enough
to undertake the workload.
System- (or disease-) based subspecialisation or the development of system- (or
disease-) based areas of special interest is essential for all radiologists to respond
to the complexity and technological advances of imaging.
Encouraging radiologists to build strong networks with clinicians. In order to
achieve this, all radiologists should have sufficient clinical knowledge in order to
understand the fundamentals of clinical presentations, natural history, treatment
and prognosis of all common and/or severe diseases. They should also obtain a
more in-depth clinical knowledge of particular diseases related to any
subspecialty in which they wish to practice. This may involve a number of
strategies, but subspecialty and special interest curricula should ensure that
trainees participate in clinical rounds, multidisciplinary meetings and provide
opportunities for interaction with relevant clinicians.
Wide clinical experience should be obtained before entering radiology. In such
circumstances further clinical experience may only be required in a chosen
subspecialty and to a level dependent on previous experience.
Expanding consulting activities of radiologists with clinical specialists in
multidisciplinary conferences.
Intensifying relations with GPs offering diagnostic management of their patients
including referral to clinical specialists if needed or full work-up in conjunction
with the GP.
Communicating with the patient and discussing options particularly in cases of
primary care (patient referred by GP).
Making use of teleradiology services in a proactive way through local area
networks under the control of radiologists to incorporate general and subspecialist radiologists in a comprehensive coverage of clinical scenarios.
Ensuring that all radiologists involved in such networks keep close contact with
referring physicians through both personal interaction and video conferencing.
Encouraging radiologists to network with interventional radiologists to learn the
basic aspect of the techniques, indications and imaging follow-up in order to
increase the quality of care to patients and the potential referral to both.
Ensuring that radiologists are conversant with the technical aspects of the
equipment they are utilising and that sub-specialists involve themselves where
possible in the development and implementation of new innovations.
Reinforcing the clinical role of radiologists to use resources to increase day-case
work, to make decisions regarding imaging strategies, and to explain the results
and further examinations to the patients.
Reinforcing the status of the radiologist with special interests.
Up until 2010, 5 billion medical imaging studies had been conducted worldwide.
[1] Radiation exposure from medical imaging in 2006 made up about 50% of total
ionizing radiation exposure in the United States.[2]
Contents [hide]
1 Imaging modalities
1.1 Radiography
(a) The results of a CT scan of the head are shown as successive transverse
sections. (b) An MRI machine generates a magnetic field around a patient. (c) PET
scans use radiopharmaceuticals to create images of active blood flow and
physiologic activity of the organ or organs being targeted. (d) Ultrasound
technology is used to monitor pregnancies because it is the least invasive of
imaging techniques and uses no electromagnetic radiation.[3]
Radiography[edit]
Main article: Medical radiography
Two forms of radiographic images are in use in medical imaging; projection
radiography and fluoroscopy, with the latter being useful for catheter guidance.
These 2D techniques are still in wide use despite the advance of 3D tomography
due to the low cost, high resolution, and depending on application, lower
radiation dosages. This imaging modality utilizes a wide beam of x rays for image
acquisition and is the first imaging technique available in modern medicine.
to the area of the body to be examined. The pulse makes the protons in that area
absorb the energy needed to make them spin in a different direction. This is the
"resonance" part of MRI. The RF pulse makes them (only the one or two extra
unmatched protons per million) spin at a specific frequency, in a specific
direction. The particular frequency of resonance is called the Larmour frequency
and is calculated based on the particular tissue being imaged and the strength of
the main magnetic field. MRI uses three electromagnetic fields: a very strong (on
the order of units of teslas) static magnetic field to polarize the hydrogen nuclei,
called the static field; a weaker time-varying (on the order of 1 kHz) field(s) for
spatial encoding, called the gradient field(s); and a weak radio-frequency (RF)
field for manipulation of the hydrogen nuclei to produce measurable signals,
collected through an RF antenna.
Like CT, MRI traditionally creates a two dimensional image of a thin "slice" of the
body and is therefore considered a tomographic imaging technique. Modern MRI
instruments are capable of producing images in the form of 3D blocks, which may
be considered a generalisation of the single-slice, tomographic, concept. Unlike
CT, MRI does not involve the use of ionizing radiation and is therefore not
associated with the same health hazards. For example, because MRI has only
been in use since the early 1980s, there are no known long-term effects of
exposure to strong static fields (this is the subject of some debate; see 'Safety' in
MRI) and therefore there is no limit to the number of scans to which an individual
can be subjected, in contrast with X-ray and CT. However, there are wellidentified health risks associated with tissue heating from exposure to the RF
field and the presence of implanted devices in the body, such as pace makers.
These risks are strictly controlled as part of the design of the instrument and the
scanning protocols used.
Because CT and MRI are sensitive to different tissue properties, the appearance
of the images obtained with the two techniques differ markedly. In CT, X-rays
must be blocked by some form of dense tissue to create an image, so the image
quality when looking at soft tissues will be poor. In MRI, while any nucleus with a
net nuclear spin can be used, the proton of the hydrogen atom remains the most
widely used, especially in the clinical setting, because it is so ubiquitous and
returns a large signal. This nucleus, present in water molecules, allows the
excellent soft-tissue contrast achievable with MRI.
Nuclear medicine[edit]
Main article: Nuclear medicine
Nuclear medicine encompasses both diagnostic imaging and treatment of
disease, and may also be referred to as molecular medicine or molecular imaging
& therapeutics.[5] Nuclear medicine uses certain properties of isotopes and the
Elastography[edit]
3D tactile image (C) is composed from 2D pressure maps (B) recorded in the
process of tissue phantom examination (A).
Tactile imaging[edit]
Main article: Tactile imaging
Tactile imaging is a medical imaging modality that translates the sense of touch
into a digital image. The tactile image is a function of P(x,y,z), where P is the
pressure on soft tissue surface under applied deformation and x,y,z are
coordinates where pressure P was measured. Tactile imaging closely mimics
manual palpation, since the probe of the device with a pressure sensor array
mounted on its face acts similar to human fingers during clinical examination,
slightly deforming soft tissue by the probe and detecting resulting changes in the
pressure pattern. Figure on the right presents an experiment on a composite
tissue phantom examined by a tactile imaging probe illustrating the ability of
tactile imaging to visualize in 3D the structure of the object.
This modality is used for imaging of the prostate,[9] breast,[10] vagina and pelvic
floor support structures,[11] and myofascial trigger points in muscle.[12]
Photoacoustic imaging[edit]
Main article: Photoacoustic imaging in biomedicine
Photoacoustic imaging is a recently developed hybrid biomedical imaging
modality based on the photoacoustic effect. It combines the advantages of
optical absorption contrast with ultrasonic spatial resolution for deep imaging in
(optical) diffusive or quasi-diffusive regime. Recent studies have shown that
photoacoustic imaging can be used in vivo for tumor angiogenesis monitoring,
blood oxygenation mapping, functional brain imaging, and skin melanoma
detection, etc.
Thermography[edit]
Primarily used for breast imaging. There are three approaches: telethermography, contact thermography and dynamic angiothermography. These
digital infrared imaging thermographic techniques are based on the principle that
metabolic activity and vascular circulation in both pre-cancerous tissue and the
area surrounding a developing breast cancer is almost always higher than in
normal breast tissue. Cancerous tumors require an ever-increasing supply of
nutrients and therefore increase circulation to their cells by holding open existing
blood vessels, opening dormant vessels, and creating new ones (neoangiogenesis theory).
Tomography[edit]
Tomography is the method of imaging a single plane, or slice, of an object
resulting in a tomogram. There are two principal methods of obtaining such
images, conventional and computer assisted tomography. Conventional
tomography uses mechanical means to record an image directly onto X-ray film,
while in computer assisted tomography, a computer processes information fed to
it from detectors then constructs a virtual image which can be stored in digital
format and can be displayed on a screen, or printed on paper or film.
Conventional tomography[edit]
In conventional tomography, mechanical movement of an X-ray source and film
in unison generates a tomogram using the principles of projective geometry.[15]
Synchronizing the movement of the radiation source and detector which are
situated in the opposite direction from each other causes structures which are not
in the focal plane being studied to blur out. This was the main method of
obtaining tomogaphic images until the late-1970s. It is now considered obsolete
(except for certain dental applications), having been replaced with computer
assisted tomographic techniques. Historically, there have been various
techniques involved in conventional tomography:
Linear tomography: This is the most basic form of conventional tomography. The
X-ray tube moved from point "A" to point "B" above the patient, while the
cassette holder (or "bucky") moves simultaneously under the patient from point
"B" to point "A." The fulcrum, or pivot point, is set to the area of interest. In this
manner, the points above and below the focal plane are blurred out, just as the
background is blurred when panning a camera during exposure. Rarely used, and
has largely been replaced by computed tomography (CT).
Poly tomography: This was achieved using a more advanced X-ray apparatus that
allows for more sophisticated and continuous movements of the X-ray tube and
film. With this technique, a number of complex synchronous geometrical
movements could be programmed, such as hypocycloidic, circular, figure 8, and
elliptical. Philips Medical Systems for example produced one such device called
the 'Polytome'.[15] This pluridirectional unit was still in use into the 1990s, as its
resulting images for small or difficult physiology, such as the inner ear, was still
difficult to image with CTs at that time. As the resolution of CTs got better, this
procedure was taken over by CT.
Zonography: This is a variant of linear tomography, where a limited arc of
movement is used. It is still used in some centres for visualising the kidney during
an intravenous urogram (IVU), though it too is being supplanted by CT.
Orthopantomography (OPT or OPG): The only common tomographic examination
still in use. This makes use of a complex movement to allow the radiographic
examination of the mandible, as if it were a flat bone. It is commonly performed
in dental practices and is often referred to as a "Panorex", but this is incorrect, as
it is a trademark of a specific company.
Computer-assisted tomography[edit]
In computer-assisted tomography, a computer processes data received from
radiation detectors and computationally constructs an image of the structures
being scanned. Imaging techniques using this method are far superior to
conventional tomography as they can readily image both soft and hard tissues
(while conventional tomography is quite poor at imaging soft tissues). The
following techniques exist:
Following upon the success of the Image Gently campaign, the American College
of Radiology, the Radiological Society of North America, the American Association
of Physicists in Medicine and the American Society of Radiologic Technologists
have launched a similar campaign to address this issue in the adult population
called Image Wisely.[18] The World Health Organization and International Atomic
Energy Agency (IAEA) of the United Nations have also been working in this area
and have ongoing projects designed to broaden best practices and lower patient
radiation dose.[19][20][21]
Non-diagnostic imaging[edit]
Neuroimaging has also been used in experimental circumstances to allow people
(especially disabled persons) to control outside devices, acting as a brain
computer interface.
Many medical imaging software applications (3DSlicer, ImageJ, MIPAV [3], etc.)
are used for non-diagnostic imaging, specifically because they don't have an FDA
approval[24] and not allowed to use in clinical research for patient diagnosis.[25]
Note that many clinical research studies are not designed for patient diagnosis
anyway.[26]
A typical clinical trial goes through multiple phases and can take up to eight
years. Clinical endpoints or outcomes are used to determine whether the therapy
is safe and effective. Once a patient reaches the endpoint, he or she is generally
excluded from further experimental interaction. Trials that rely solely on clinical
endpoints are very costly as they have long durations and tend to need large
numbers of patients.
A realistic imaging protocol. The protocol is an outline that standardizes (as far as
practically possible) the way in which the images are acquired using the various
modalities (PET, SPECT, CT, MRI). It covers the specifics in which images are to be
stored, processed and evaluated.
An imaging centre that is responsible for collecting the images, perform quality
control and provide tools for data storage, distribution and analysis. It is
important for images acquired at different time points are displayed in a
standardised format to maintain the reliability of the evaluation. Certain
specialised imaging contract research organizations provide to end medical
imaging services, from protocol design and site management through to data
quality assurance and image analysis.
Clinical sites that recruit patients to generate the images to send back to the
imaging centre.
Shielding[edit]
X-rays generated by peak voltages below
Minimum thickness
of lead
75 kV 1.0 mm
100 kV
1.5 mm
125 kV
2.0 mm
150 kV
2.5 mm
175 kV
3.0 mm
200 kV
4.0 mm
225 kV
5.0 mm
300 kV
9.0 mm
400 kV
15.0 mm
500 kV
22.0 mm
600 kV
34.0 mm
900 kV
51.0 mm
Lead is the most common shield against X-rays because of its high density
(11340 kg/m3), stopping power, ease of installation and low cost. The maximum
range of a high-energy photon such as an X-ray in matter is infinite; at every
point in the matter traversed by the photon, there is a probability of interaction.
Thus there is a very small probability of no interaction over very large distances.
The shielding of photon beam is therefore exponential (with an attenuation
length being close to the radiation length of the material); doubling the thickness
of shielding will square the shielding effect.
The following imaging modalities are used in the field of diagnostic radiology:
Plain radiography was the only imaging modality available during the first 50
years of radiology. It is still the first study ordered in evaluation of the lungs,
heart and skeleton because of its wide availability, speed and relative low cost.
Fluoroscopy
Fluoroscopy and angiography are special applications of X-ray imaging, in which a
fluorescent screen and image intensifier tube is connected to a closed-circuit
television system. This allows real-time imaging of structures in motion or
augmented with a radiocontrast agent. Radiocontrast agents are administered,
often swallowed or injected into the body of the patient, to delineate anatomy
and functioning of the blood vessels, the genitourinary system or the
gastrointestinal tract. Two radiocontrasts are presently in use. Barium (as BaSO4)
may be given orally or rectally for evaluation of the GI tract. Iodine, in multiple
proprietary forms, may be given by oral, rectal, intraarterial or intravenous
routes. These radiocontrast agents strongly absorb or scatter X-ray radiation, and
in conjunction with the real-time imaging allows demonstration of dynamic
processes, such as peristalsis in the digestive tract or blood flow in arteries and
veins. Iodine contrast may also be concentrated in abnormal areas more or less
than in normal tissues and make abnormalities (tumors, cysts, inflammation)
more conspicuous. Additionally, in specific circumstances air can be used as a
contrast agent for the gastrointestinal system and carbon dioxide can be used as
a contrast agent in the venous system; in these cases, the contrast agent
attenuates the X-ray radiation less than the surrounding tissues.
CT scanning
CT imaging uses X-rays in conjunction with computing algorithms to image the
body. In CT, an X-ray generating tube opposite an X-ray detector (or detectors) in
a ring shaped apparatus rotate around a patient producing a computer generated
cross-sectional image (tomogram). CT is acquired in the axial plane, while coronal
and sagittal images can be rendered by computer reconstruction. Radiocontrast
agents are often used with CT for enhanced delineation of anatomy. Although
radiographs provide higher spatial resolution, CT can detect more subtle
variations in attenuation of X-rays. CT exposes the patient to more ionizing
radiation than a radiograph. Spiral Multi-detector CT utilizes 8,16 or 64 detectors
during continuous motion of the patient through the radiation beam to obtain
much finer detail images in a shorter exam time. With rapid administration of IV
contrast during the CT scan these fine detail images can be reconstructed into 3D
images of carotid, cerebral and coronary arteries, CTA, CT angiography. CT
scanning has become the test of choice in diagnosing some urgent and emergent
conditions such as cerebral hemorrhage, pulmonary embolism (clots in the
arteries of the lungs), aortic dissection (tearing of the aortic wall), appendicitis,
diverticulitis, and obstructing kidney stones. Continuing improvements in CT
technology including faster scanning times and improved resolution have
dramatically increased the accuracy and usefulness of CT scanning and
consequently increased utilization in medical diagnosis.
The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield
at EMI Central Research Labs, Great Britain in 1972. EMI owned the distribution
rights to The Beatles music and it was their profits which funded the research. Sir
Hounsfield and Alan McLeod McCormick shared the Nobel Prize for Medicine in
1979 for the invention of CT scanning. The first CT scanner in North America was
installed at the Mayo Clinic in Rochester, MN in 1972.
Ultrasound
Medical ultrasonography uses ultrasound (high-frequency sound waves) to
visualize soft tissue structures in the body in real time. No ionizing radiation is
involved, but the quality of the images obtained using ultrasound is highly
dependent on the skill of the person (ultrasonographer) performing the exam.
Ultrasound is also limited by its inability to image through air (lungs, bowel loops)
or bone. The use of ultrasound in medical imaging has developed mostly within
the last 30 years. The first ultrasound images were static and two dimensional
(2D), but with modern-day ultrasonography 3D reconstructions can be observed
in real-time; effectively becoming 4D.
One disadvantage is that the patient has to hold still for long periods of time in a
noisy, cramped space while the imaging is performed. Claustrophobia severe
enough to terminate the MRI exam is reported in up to 5% of patients. Recent
improvements in magnet design including stronger magnetic fields (3 teslas),
shortening exam times, wider, shorter magnet bores and more open magnet
designs, have brought some relief for claustrophobic patients. However, in
magnets of equal field strength there is often a trade-off between image quality
and open design. MRI has great benefit in imaging the brain, spine, and
musculoskeletal system. The modality is currently contraindicated for patients
with pacemakers, cochlear implants, some indwelling medication pumps, certain
types of cerebral aneurysm clips, metal fragments in the eyes and some metallic
hardware due to the powerful magnetic fields and strong fluctuating radio signals
the body is exposed to. Areas of potential advancement include functional
imaging, cardiovascular MRI, as well as MR image guided therapy.
Nuclear Medicine
Nuclear medicine imaging involves the administration into the patient of
radiopharmaceuticals consisting of substances with affinity for certain body
tissues labeled with radioactive tracer. The most commonly used tracers are
Technetium-99m, Iodine-123, Iodine-131, Gallium-67 and Thallium-201. The
heart, lungs, thyroid, liver, gallbladder, and bones are commonly evaluated for
particular conditions using these techniques. While anatomical detail is limited in
these studies, nuclear medicine is useful in displaying physiological function. The
excretory function of the kidneys, iodine concentrating ability of the thyroid,
blood flow to heart muscle, etc. can be measured. The principal imaging device is
the gamma camera which detects the radiation emitted by the tracer in the body
and displays it as an image. With computer processing, the information can be
displayed as axial, coronal and sagittal images (SPECT images, single-photon
emission computed tomography). In the most modern devices Nuclear Medicine
images can be fused with a CT scan taken quasi-simultaneously so that the
physiological information can be overlaid or co-registered with the anatomical
structures to improve diagnostic accuracy.
Further Reading