XRAYS ON THE NET - DIGITIZING IMAGES 1995
Date: Sun, 3 Dec 1995 18:54:20 -0500
From: hwb@eideti.com (Bill Burman)
On 29 Nov. 1995, a colleague (TDECOSTE@medusa.unm.edu) posted a message
describing a complex lower extremity orthopaedic injury. Quite shortly
there were two replies ("Alexander N. Chelnokov" alex@uniito.e-burg.su ;
"Jeffrey Anglen" jeffrey_anglen@SURGERY.MISSOURI.EDU) in terms of case
discussion. Thus, the stage is set for a fracture conference in cyberspace.
Unfortunately, as noted by Dr. Chelnokov, there was a lack of image data
(xrays, clinical photographs, etc.). This could inhibit case discussion at
even the local level - where the centerpiece of most clinical presentations
is an image - rendered if need be on a chalk board if not a paper towel.
For the past few years I have been involved with the digital presentation
of orthopaedic cases with the AAOS CD-ROM project "Orthopaedic Grand
Rounds". I would like to offer to extend experience obtained in that exercise
to the present problem of the text-bound orthopaedic trauma case presentations.
I would caution at the outset that this experiment will not necessarily be
an easy undertaking and all that participate should be steeled for
frustration and failure. On the other hand, it could present us all with an
opportunity to gain hands-on experience with orthopaedic telemedicine.
I would propose the following:
Presenters could e-mail me the text and either e-mail or conventional-mail
me the images associated with their cases. The address is :
hwb@eideti.com
Ron Hoering and I would try to post the cases and the discussion in the
Orthopaedic Trauma Forum of the HWB Foundation Home Page.
http://www.hwbf.org
There are some sample cases posted there already which may serve as a
baseline in terms of suggesting a format for such discussions.
The case text (sent preferably as e-mail so that I don't have to re-type
it) should indicate the position of the accompanying graphics.
e.g. A 21 year old white male S/P MCA 8/8/95 is admitted with the following
injuries :
CHI
Lt hemopneumothorax
Rt comminuted femur shaft fx
Rt intra-articular comminuted open proximal tibia fx
Figures :
AP Rt femur
Lat Rt femur
AP Rt tibia
Lat Rt tibia
Wound photograph Rt tibia
etc.
If the images are in digital format (either PICT, BMP, Compuserve GIF or
JPEG) they may be sent along as attachments to e-mail to:
hwb@eideti.com
Bin-hexing and compression of the images prior to sending may be advisable.
Some image formats may get chewed up with internet transmission so one
would have to be prepared for some adversity as we worked out the difficulties
in the early phases of this process.
If the images are not in digital format, there are several digitizing methods
which may be considered. The digitized images could then be sent as
attachments to e-mail.
1) Radiology Xray scanner - Perhaps your radiology department is digitally
archiving xrays at this time. The American College of Radiology is
recommending the DICOM 3 format for the image files. These are usually
large image files 2kx2k (8-10 Meg) and are not readily readable by PC
computers without special software. The large size can make them a bulky,
time-consuming transmission - impossibly slow over phone lines (many
hours). Also, we would quickly run out of disc space if we tried to store
images of this size. It is possible to convert DICOM 3 images into the
more common PC formats (such as PICT, BMP, Compuserve GIF or JPEG) which
can more readily be compressed and transmitted. This would depend on an
ability to network access and open files in your radiology department
archive. This can be technically and politically tricky to do.
Bottom line : A complex acquisition. Forget this option for now.
2) Your own xray scanner - Common types would be the Vidar VXR-12, Vidar
VXR-8 , Lumisis, Howtek and Kodak film digitizers. Many of these
professional film SCSI digitizers can be driven with plug-ins to standard
PC image manipulation software such as Adobe Photoshop. They can rapidly
scan standard 17"x24" films. The present price of such scanners is in the
$12,000 to $20,000 range.
Bottom line : Too expensive.
3) Flatbed scanners - Flatbed scanners are becoming quite affordable ($400
- 1000). They require backlighting to scan xrays. Generally, the
backlighting attachments transilluminate an area on the order of 6"x8"
which is an inadequate size for most xrays. It is possible to make standard
photographic prints of xrays and soft tissue conditions, develop with a 1
hour print service and then digitize the photograph. Xerox prints of xrays
do not appear to be of adequate resolution, however xerox camera shots of
wounds may be sufficient.
Bottom line: Too small for xrays. Can be used to scan photographic prints.
4) Slide scanners - Nikon Coolscan, Polaroid SprintScan run between $1400 -
$2000. Standard 35 mm slides can be digitized with these devices. A
possibility exists to shoot high speed ektachrome film which can be
developed in an xray processor and then scanned with the slide scanner.
Bottom line : OK if your images are first captured in 35 mm kodachrome format.
5) Digital cameras - There are excellent digital cameras which take a
digitized image which can be copied directly on to the hard drive of a PC.
They cost upwards of $12,000. There are some low-end digital cameras (Apple
Quicktake 150, Kodak DCS 40) for under $1000 which are mainly used for
photographing houses in the real estate market. The resolution of these
cameras are probably not of diagnostic quality but possibly, they are worth
experimenting with. The direct digital capture of xrays and other clinical
photographs makes this method appealing. Another option for this so-called
"camera on a stick", is an inexpensive NTSC digitizer attachment for a
camcorder called "Snappy View".
Bottom line : Simplest, most direct method of capturing images but the
images are probably inadequate when an inexpensive camera is used.
At the Radiological Society of North America Annual meeting in Chicago this
past November, the jury is still out with respect to the minimum resolution
standards of digitized xrays. Even with "optimal" images (2kx2k,
recommended by ACR-NEMA for the DICOM 3 standard of diagnostic quality),
musculoskeletal radiologists from Harborview missed subtle fractures which
they were able to detect on conventional films (Radiology, August 1995,p
565).
If none of these options are available, the images as either photographic
slides or prints or as xray duplicates could be sent via conventional mail
to :
Bill Burman, MD
HWB Foundation
604 Stage Rd
Monroe, NY 10950
USA
and we could undertake the digitization along with the internet posting of
these materials.
******************
Date: Mon, 04 Dec 1995 09:28:56 -0600
From: Jeffrey Anglen
Bill has made a very interesting proposal. The cases would be sent in by
members of this discussion list, or others I assume, then assembled and
posted to the web site, where everyone with a web browser could
view the images and read the details. The case could then be discussed
on the list or perhaps by a designated OTA member, - in an interactive
manner with other list members; then the comments of the list discussion
could be added to the web page for the benefit of other docs, students,
residents. This would be similar to the "fireside discussions" at the AO
courses where the participants bring cases and discuss them with a
group of faculty.
The cases could be updated with followup data and Xrays by the
submitters so that we could all actually follow the course of particularly
instructive cases as they evolve, discuss and learn from each others
experience. There are 30+ people presently on this list, and I expect it to
grow; if we had one case a month each list member would have to put
together a case every couple years. And of course we could ask non
list members to contribute. Given the willingness of OTA members to
serve as educators (witness the participation in the recent resident's
course) I think it would be no problem with a little organization.
This might even be a project for the OTA education committee?
The web site would not be limited to static images, but could of course
potentially have sound and video. Someday.
What does everyone think?
*******************
Date: Mon, 4 Dec 95 21:22:45 -0600
From: Andrew H. Schmidt
I think that the proposals by Bill and Jeff sound great. I have also been
following the Orthopedic Mailing List run by Wes Spears and Randale Sechrest,
which has been fairly successfully utilizing images uploaded by the members of
the list and archived for later retrieval by anyone interested.
Another easy option for digitizing images that I didn't see in the list of
alternatives that Bill Burman presented is the Photo CD format, which is done at
minimal cost and is readily available at most "professional" photo processing
labs. Once saved on a photoCD, I suspect the images could readily be converted
to one of the other formats (jpeg, etc) for transmittal. Anyone tried this?
******************
Date: Mon, 4 Dec 1995 19:45:11 -0500
From: Bill Burman
Thank you for mentioning this, Andy. It completely skipped my mind. Nearly
all the images used for the AAOS Orthopaedic Grand Rounds were digitized
via Kodak Photo CD. It costs about $1.50 per image and the CD costs $10.
You can store about 120 images on a single CD. The CD's are multisession
which means you can fill them up over time instead of having to save up 120
images and do it all at once. Each image is stored on the CD in 5 different
resolutions:
1) 192x128 - thumbnail
2) 384x256 - quarter screen
3) 768x512 - full screen
4) 1536x1024 - full page ad NY Times
5) 3072x2048 - good for highway billboards
The advantages are that you don't have to fool with any scanning equipment
and techniques. You take your 35 mm film or slides to Kodak and they scan
it for you with a $50,000 scanner and you get your images back on a CD-ROM.
Needless to say, the quality is exceptional. You don't have to burn up
space on your hard disk(s) because it is archived on CD (for 100 years -
good for long term follow-up - even in Iowa).
The disadvantage is that unless you are near a busy service bureau,
turn-around time can be slow. I have had to wait 10 business days. The
Photo CD format usually requires conversion of the image to other formats
in order to permit image compression or import into other programs.
Generally, this requires a program like Adobe Photoshop which can take some
time to get used to. Compression is probably necessary for this project as
one full screen image, 768x512, could take up to an hour to transmit on a
phone line.
Bottom line : Great images, great storage, slow process, image file format
manipulation usually required.
*******************
Date: Tue, 5 Dec 95 10:32:26 +0500
From: Alexander N. Chelnokov
Hi
> Presenters could e-mail me the text and either e-mail or conventional-mail
> me the images associated with their cases. The address is :
> hwb@eideti.com
> Ron Hoering and I would try to post the cases and the discussion in the
> Orthopaedic Trauma Forum of the HWB Foundation Home Page.
> http://www.hwbf.org/hwb/
There is also Randale Sechrest's web site
"htp:/ww.cyberport.net/ortho/ortho.html"
> 1) Radiology Xray scanner - Perhaps your radiology department is digitally
[...]
> Bottom line : A complex acquisition. Forget this option for now.
Noted
> 2) Your own xray scanner - Common types would be the Vidar VXR-12, Vidar
> Bottom line : Too expensive.
Yes...
> 3) Flatbed scanners - Flatbed scanners are becoming quite affordable ($400
> - 1000). They require backlighting to scan xrays. Generally, the
> backlighting attachments transilluminate an area on the order of 6"x8"
> Bottom line: Too small for xrays. Can be used to scan photographic prints.
:-/ HP ScanJet II/III - is too small? It is 400 dpi, and with transparency
adaptor is ~$2000. I saw also Mustek Paragon Combo - it is A4 (too small for
chest films but quite enough for any fracture), of 600x1200 dpi optical
resolution, with transparency adaptor and less than $1000 even in Russia.
**********************
Date: Tue, 5 Dec 1995 06:54:24 -0500
From: Bill Burman
The resolution provided by these scanners is more than adequate. When I
said "small", I was referring to the physical size of the scanning bed
which is generally 8"x12" - some going up to 11"x14". However, the backlit
transparency adaptors usually transilluminate only a portion of the scan
bed - generally 8"x10". This is probably OK for hand and foot films but
xrays of the long bones, spine and pelvis generally are 14"x17".
Presentation of these studies using conventional flatbed scanners could
lead to the serving up of the notorious "key-hole" views. In the absence of
alternatives, the argument can be made that a "key-hole" view is better
than no view. But, of course, it can be misleading.
******************
Date: Wed, 6 Dec 95 10:21:39 +0500
From: Alexander N. Chelnokov
Ok I realized what's a problem. Hmm...
I can say that if somebody would pay me difference between A4 scanner price
and genuine Xray scanner i would scan for him large films partially and then
paste the parts with Photo(Styler/Paint/Shop/etc.) or automatically (i suppose
there is such software or it is easy to create).
So my opinion is - if you need scanner for time-to-time job like to send
a case to the list or prepare a presentation/slide/paper - cheap A4
models with transparency adaptor would be quite enough (and you could use this
device for pictures and OCR). But if you need a systematic duty like
electronic Xray archive of each patient - you need Xray scanner, better if
with autofeeding.
*********************
Date: Wed, 6 Dec 1995 04:24:03 -0500
From: Bill Burman
This is possible - but time consuming and tricky. However, your suggestion
of segmental scanning of xrays which are later stitched together brings to
mind another idea.
An xray could be placed on an xray view box laying horizontal on a table.
They used to make hand held scanners which are inexpensive (ArcTec 800 dpi
24 bit - $129.99), of reasonable resolution and used to come with
"stitching" software which would assist the joining of the image segments
resulting from the several passes that would be required to capture a large
image. If somebody had access to this sort of equipment, it would be
certainly worth a try.
**********************
From: Alexander N. Chelnokov
Date: Wed, 6 Dec 95 23:04:14 +0500
Hi again
Yes sure but AFAIK hand held scanners may cause problems with OCR.
But it is another story.
******************
Date: Tue, 5 Dec 95 14:49:50 PST
From: CAPT A. Herbert Alexander, MC, USN
In regards to imaging of radiographs. . .
I have a Microtek ScanMaker IIXE with a transparency adaptor. It limits the
size of my radiograph scans to about 8x10". I solved that problem by taking
a 35mm slide of the radiograph I want and then scanning it. I don't know if
my scanned image (.tif, .pcx. or etc.) can be transmitted intact via Internet.
********************
Date: Tue, 5 Dec 1995 17:17:45 -0500
From: Bill Burman
I don't know either. You could try and send a small tif or bmp as an e-mail
attachment to me at the above address and let's see if I can read it.
*********************
Date: Wed, 6 Dec 95 07:56:14 PST
From: CAPT A. Herbert Alexander, MC, USN
X-Attachments:
C:\PHOTOSHP\ACLXRAY1.JPG;C:\PHOTOSHP\ACLXRAY1.EPS;C:\PHOTOSHP\ACLXRAY1.TIF;
Bill,
Attached are files of the same x-ray in 3 formats: .jpg (7kb), .eps (10kb),
.tif (48kb). Hopefully the smaller one, .jpg works. Let me know.
I use Eudora and attached the files using the "Attach Document" command.
Files transmitted as is without conversion or compression.
********************
Date: Wed, 6 Dec 95
From: Bill Burman
Works Fine ! I am on a Mac Powerbook using Eudora and I could receive and
open the images without a problem. I used a viewer called "JPEGVIEW". I
needed Adobe Photoshop fot the eps file.
********************
Date: Thu, 07 Dec 1995 09:48:24 -0600
From: Jeffrey Anglen
I would be interested in seeing those images. I wonder if you attached
the jpeg file to a message to the list, would ListProc copy the attachment
to everyone?
********************
Date: Thu, 7 Dec 1995 09:20:11 -0500
From: Bill Burman
Jeff,
I will attach the jpg image to this letter which is being composed with
Eudora on a Mac. There is no special treatment of the file. Distribution
will be to you and the listserver. Perhaps Dr. Alexander can run the same
experiment from his PC.
*********************
Date: Thu, 07 Dec 1995 16:29:37 -0600
From: Jeffrey Anglen
Got something, but I can't make it into an image. Apparently it can't be
transferred back and forth through the email program.
**********************
Date: Thu, 7 Dec 1995 18:17:14 -0500
From: Bill Burman
I was able to open and view the image sent by Dr. Alexander as well as the
image bounced off the listserver using a public domain program called JPEG
View. The e-mail program here is Eudora.
Look on your computer for the file "ACLXRAY1.JPG"
What image viewing program are you using to open the image ?
Does that program recognize the JPEG file format ? (Does it have an "open
as" or "save as" jpg option ?)
What is your e-mail program ?
Was anybody else out there able to open and view the image ?
************************
Date: Fri, 8 Dec 95 12:10:34 +0500
From: Alexander N. Chelnokov
Hi
All is fine - the image can be successfully decoded and viewed by any
jpeg viewer (i use QPEG (DOS) and ACDSee (Windoze))
To unpack use MIME decoder instead of usual UUDECODE.
**************************
Date: Fri, 08 Dec 1995 08:57:46 -0600
From: Jeffrey Anglen
I got the data for the image not as a separate file but as a character
sequence appended to the message. I attempted to copy it as a
separate file and open it using a viewer called Vueprint which
recognizes jpeg as well as gif images but it would not open. I don't have
a decoder which is apparently the missing element. Anybody know of a
public domain or shareware decoder that I can ftp?
My email program is Novell Groupwise 4.1.
******************
Date: Fri, 08 Dec 1995 15:46:30 -0700 (MST)
From: Tom DeCoster
I have posted xrays of the comminuted tibia shaft case which I previously
discussed on the OTA email group. It seemed best to me to post those
radiographs on the orthopedic surgery mailing list ftp site on the
internet since our email didn't easily accept images. The files can be
viewed by accessing the mailing list web site at:
http://www.cyberport.net/ortho/ortho.html
directions are given for gaining access to the ftp site and downloading images
at the web site.
***************************
Date: Mon, 11 Dec 95 07:52:52 PST
From: CAPT A. Herbert Alexander, MC, USN
X-Attachments: C:\PHOTOSHP\ACLXRAY1.JPG;
The ACLXRAY1.JPG came back to me intact. I opened it with Adobe Photoshop.
I did not post the original transmission to the bulletin board, not wishing
to trouble everyone with the detail work. Here it is again for everyone.
**********************
Date: Mon, 11 Dec 1995 12:33:37 -0600
From: Jeffrey Anglen
The jpeg image came through perfectly as an attached file! Very
exciting - apparently we can send graphic files through the ListProc
program as attachments to list messages and they will be copied and
distributed intact.
**********************
Date: Mon, 11 Dec 1995 04:04:09 -0500
From: Bill Burman
Dr. Alexander,
I am still working on the issue of trying to simplify the transmission of
graphics for case presentation. Netscape (as well as Eudora) has the
ability to send mail with attachments.
Could you please re-send the ACLXRAY1.JPG file to me by this time visiting
the HWB Page http://www.hwbf.org./hwb/ and click the "Send Mail"
button near the top of the page. Type "Graphics Test" in the body of the
message and use the "Attach document" button to affix the ACLXRAY1.JPG
file. This method has worked on the Mac side and I would appreciate your
assistance in testing it on the PC side.
Thanks for your help.
*********************
Date: Mon, 11 Dec 95 14:13:19 -0800
From: A. Herbert Alexander, M.D
Attachment converted: PB 520:x-ray on the net (JPEG/JVWR) (0000474A)
Bill,
Graphics Test. Let me know how it goes.
********************
Date: Mon, 11 Dec 1995 22:08:05 -0500
From: Bill Burman
Herb,
I was able to read the graphic you sent via Netscape loud and clear. The
only problem that I am having is that the Netscape mailer renamed the
graphic to "xray on the net" - same as your message header.
If the image file names are changed, then confusion in image placement can
result, especially if we hand the job of posting the www cases over to
anyone who is not an orthopaedist. Eventually, everybody should be able tp
write and arrange their own case web page (html source code) by converters
attached to standard word processing applications - but I think that is too
complicated for right now.
I am looking for the most straight-forward method of transmitting images
and text for posting www case presentations. Perhaps, the best method
would be to post mail with attached image files using Netscape. I do not
know what the results would be like with Mosaic. This assumes most people
have access to www browsers.
It may be perfectly acceptable for case presentation to simply bounce
e-mail with images off the reflector to each other or download the same
from an ftp site. However, given the wide variety of e-mail programs, image
formats and time to separately find, download, open, organize and orient
the images, this path will probably be fraught with frustration. If you
have a Mac and you download a bunch of zipped (PC compressed) files - you
are out of luck. Vice versa with Compact Pro.
A lot of people who know a great deal about orthopaedics and perhaps not so
much about computers will be turned off and subsequently unavailable for
the discussion. While I have my own ideas about the management of the tibia
fx presented, I would like to hear what Ken Johnson, Don Wiss, Bob
Winquist, Jim Kellam, Mike Bosse, Sig Hansen, Bob Brumback, Marc
Swiontkowski, Jeff Mast, Joldas Kuldjanov, Dean Cole, Caudle and Stern and
others would have to say. While one does not need to be a physicist to read
xrays in their own hospital, the ideal design of www case presentation
should not require them to be computer wizards to read or show xrays over
the internet.
I would be grateful if you could help me with another experiment in
shipping multiple graphics files (2 or more) as e-mail attachments to the
Netscape mailer activated by clicking the "Send Mail" button at
http://www.hwbf.org
and let's see if the names of these image files are properly retained.
Thanks.
****************
Date: Wed, 13 Dec 95 11:44:30 PST
From: CAPT A. Herbert Alexander, MC, USN
X-Attachments:
C:\PHOTOSHP\DRUJ4P.JPG;C:\PHOTOSHP\ACLXRAY1.JPG;C:\PHOTOSHP\BBFX1.JPG;
Bill,
For some reason it has been difficult for me to connect to your Home Page.
I don't know why, but either the message comes up that server is unknown
or I get only the the list of the Board of Directors and cannot page down
to the "send mail" icon.
At any rate, when I did get through, I was allowed to list only 1 graphics
file to attach. More than one listed resulted in an unrecognized file
notice. At any rate, I am sending you the files by Eudora to see if that
works. The files are: our favorite aclxray1.jpg (which you already know
and love); bbfx1.jpg (x-ray of both bone forearm fracture); druj4p.jpg
(intraop photo of a complex DRUJ dislocation).
I think it is just a matter of time before everyone has easy access to
digitized x-rays and can ZAP them anywhere they want. Some places already
can access x-rays on their monitors and are without the need to use hard
copy x-rays. I hope we are not trying to reinvent the wheel here.
**********************
Date: Wed, 13 Dec 1995 18:34:22 -0500
From: Bill Burman
Herb
>For some reason it has been difficult for me to connect to your
>Home Page. I don't know why, but either the message comes up
>that server is unknown or I get only the the list of the Board
>of Directors and cannot page down to the "send mail" icon.
I am sorry about that. I gave you a faulty address at first - with an extra
dot.. Did it clear up with "http://www.hwbf.org/hwb/" ? Are others
out there having trouble connecting to the HWB page.
>when I did get through, I was allowed to list only 1 graphics file
>to attach. More than one listed resulted in an unrecognized file notice.
I had the same problem. That is a pity. If we use the Netscape mailer,
people will have to bundle the graphics in a zip or compact pro file and
send that as the attachment. That is another step I was hoping to avoid.
>At any rate, I am sending you the files by Eudora to see if that works. The
>files are: our favorite aclxray1.jpg;bbfx1.jpg;druj4p.jpg
Got them all and can see them just fine - nice DRUJ image.
>I think it is just a matter of time before everyone has easy
>access to digitized x-rays and can ZAP them anywhere they want.
I hope you are right. I went to the RSNA meeting in Chicago 2 weeks ago to
find out what I could about capturing xray images. It is definitely coming.
The question is when. The 2 big stumbling blocks now are the cost of film
digitizing systems - starting at $15 - 20,000 and the time and know-how
involved with manipulating, cropping, labelling and archiving the image
files. Teleradiology adds a few steps more to this already involved
process.
> Some places already can access x-rays on their monitors and
> are without the need to use hard copy x-rays.
Usually these are well-endowed paces with direct digital radiography, fiber
optic backbones, optical jukeboxes, a vast array of high resolution
monitors, technical support and right now, people yearning for the good old
days.
> I hope we are not trying to reinvent the wheel here.
While I have seen cases presented on the net, I haven't seen any examples
of real interactive presentation - where anybody, anywhere can pipe right
into the discussion - grab down the xray as they would in a conference and
put an arrow on the "critical" spot, throw it back up on the viewbox with
appended comment or reach into their image archives to throw up a visual
counter-example or pop an abstract off their Medline CD ROM database. I
don't think this has been done yet - at least using home PC's.
All the best.
What do you think we ought to do with respect to presenting cases ?
Remember not everybody is using Eudora.