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DR for small-bowel exams: What's not to like?
By Brian Casey
AuntMinnie.com staff writer
September 22, 2008
A group of Israeli researchers compared a digital radiography (DR) system to analog
film-screen x-ray for small-bowel follow-through studies and found the DR system
superior in image quality, radiation dose, and workflow.
While the benefits of DR have been well-documented in areas such as chest imaging
and skeletal radiography, fewer studies exist on its use for small-bowel followthrough
(SBFT) exams, according to a research team led by Dr. Olga Brook of
RAMBAM Health Care Campus in Haifa. Brook and colleagues sought to compare
DR for SBFT to film-screen radiography, and the group published their results in the
October 2008 issue of Computerized Medical Imaging and Graphics (Vol. 32:7, pp.
For the prospective study, the RAMBAM team looked at a population of 11
consecutive patients referred for SBFT exams, ages 18-27 years old. Patients
underwent a standard SBFT preparation regimen, including an initial overhead film
and ingestion of oral contrast, and then an overhead film every 20-30 minutes, with
the option of spot-film fluorography.
For each of the studies, one of the intermediate radiographs was taken with a DR
system (SmartRAD, CMT Medical Technologies, Yoqneam, Israel) while
another was taken using a film-screen system (Siemens Healthcare, Erlangen,
Germany). Images were output to film for review but were distinguishable by their
"inherent properties," such as spatial and contrast resolution, according to the authors,
Exam parameters were as follows: identical focus size, source-to-image distance of
100 cm, 102 kV, and automatic exposure control. The analog system worked with a
film-speed combination of 400, and the DR unit operated at an equivalent of 400 film
speed. In five cases, DR images were acquired prior to film-screen, and in six cases
the opposite was true.
The researchers then assessed both types of studies based on three criteria: image
quality, radiation dose, and impact on workflow. For the image quality test, a panel of
five attending radiologists (three of whom were gastrointestinal specialists) and four
resident radiologists compared the images and rated them for overall image quality,
intestinal mucosa definition, and bone visualization.
Radiation dose measurements were based on kV, tube current (mA), exposure time
(ms), and mAs parameters, as well as a dose meter used to calculate entrance skin
dose exposure. Workflow was calculated as the time required for the radiologic
technologist to obtain a radiograph from the time the patient entered the room to the
production of a final image.
DR scores well
Brook and colleagues found that every radiologist gave DR higher marks for image
quality relative to film-screen x-ray, and the difference was statistically significant for
the vast majority. On a five-point scale, with five representing the highest quality, DR
received an overall median grade of 4.5, versus 3.3 for film-screen. Mean and median
average scores for the three image quality criteria are as follows (p < 0.001 for all
Image quality scores, DR versus film-screen x-ray
Mean (median) for
4.49 (4.5) 3.17 (3.3)
4.38 (4.42) 3.4 (3.4)
Bone visualization 4.5 (4.6) 2.4 (2.33)
DR also bested its analog counterpart in terms of radiation dose, with the team's
calculations indicating that DR produced 41% less dose for SBFT exams compared to
film-screen. The average DR dose was 0.93 ± 0.54 cGy, compared to 1.58 ± 0.63 cGy
Finally, DR also conferred workflow advantages over film-screen. The average time it
took for technologists to complete a DR-based SBFT exam was 3.5 ± 1.3 minutes,
compared to 5.5 ± 1.5 minutes for analog SBFT. That represents a 37% reduction,
according to the authors.
In conclusion, the team stated that the study confirmed that the advantages found for
DR in areas like chest imaging also translate to SBFT exams. Although there were
some limitations to the research, such as the study's small sample size, DR could have
performed even better if images were reviewed on soft-copy displays rather than film,
due to the image manipulation tools available on workstations, they wrote
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