Hologic Imaging: Current Techniques for Proper Imaging

Larry Jankowski, CDT Illinois Bone and Joint Institute, Ltd. Morton Grove, IL

Overview
y The Disclaimer! y Hologic basics keys to quality y Common spine scanning errors and fixes y Common hip scanning errors and fixes y Forearm scanning issues y VFA scanning issues y HIPAA issues

I am not a Hologic salesman

The Disclaimer!

y The information contained in this presentation represents the opinions and beliefs of the presenter, and do not necessarily reflect the official positions of the ISCD or of the manufacturer. yViewer discretion is advised!

The Disclaimer Part 2

y All scans, unless noted, are done:
Hologic 4500 series fanfan-beam fan-beam densitometers QDR for Windows software
y Delphi y Discovery

All scans done in array mode unless otherwise noted.

Hologic basics keys to quality

y Read the operators manual! y Almost everything is in there..really! y What isnt in there you can get from the manufacturer if you ask nice! y Examples:
DICOM Conformance Statement Database Dictionary HL7 Results Interface Specifications

Keys to Quality
y Quality means a predictable degree of uniformity and dependability at low cost with the quality suited to the marketplace - W. Edward Deming y Uniformity = precision y Dependability = (trueness) accuracy y Low cost = no mistakes, no repeats. No call backs, (think lawsuit)

Our Precision Values

y Two technologists - combined precision
Mean patient age: 68 yrs. 1.7 Mean T-score T1.7 spine, -2.3 -2.3 femoral neck T-score

y y y y y

Spine L10.008 g/cm2 L1-L4 L1-L4 Total Hip 0.007g/cm2 Femoral Neck 0.009 g/cm2 Gr.Troch 0.007 g/cm2 Gr.Troch Top 10th percentile of centers (meta(meta-analysis (meta-analysis of published precision values)

To Obtain the Best Precision:

y Understand the strengths and limitations of fanfanbeam systems y Consider using array mode y Use the repositioning tool freely..there is a reason why its there! y Establish quantitative descriptions of positioning and analysis routines y Write them in a procedure manual and stick to them.

Tips for New (and Old) Users

y Turn OFF autoauto-analysis auto-analysis until:

you can analyze scans manually with reasonable comfort you know a good analysis looks like instantly!

y Dont rely on software until you know how/when to intervene - humans are still bettertheoretically!

The Problem with AutoAuto-analysis Auto-analysis

Eye halve a spelling chequer that came with my pea sea It planely marques for my revue miss steaks eye can knot sea. Eye ran this poem threw it, your sure reel glad two no, It's vary polished in it's weigh, my chequer tolled me sew. To rite with care is quite a feet, of witch won should be proud, and wee mussed dew the best wee can, sew flaws are knot aloud. aloud. That's why aye brake in two averse, my righting wants too pleas. Sow now ewe sea wye aye dew prays, such soft wear for pea seas J. S. Tenn

AutoAuto-analysis Auto-analysis Examples

Tips for New (and Old) Users

y Learn how to save screen captures
Documents differences in COMPARE Capture error messages Make your own procedure manual

y Pressing PrtSc copies screen image(.bmp) into PrtSc PrtSc Windows Clipboard y Pressing AltAlt-PrtSc Alt-PrtSc PrtSc copies active window into Clipboard y Paste Clipboard contents into any document that can handle them (e.g. Wordpad, MS-Word, Wordpad, MSMS-Word, Powerpoint. Powerpoint.

Little Know Facts about Hologic Fan-Beam FanFan-Beam Scanners

y Area and BMC are affected by bone height above table, but BMD is not. y Distortion off central ray - center your scans! y Hips need to be offoff-center off-center equally. y Positioning tools assume a fixed height.
Important in extremely obese or thin patients Especially forearm

y Resolution and precision increases with slower scan speeds

Theory of Operation:
L H

Attenuation

Theory of Operation:
L H*k

Attenuation

A2(L/H)

THIS IS DXA:
b ( x) =
( / ) ln I ( x ) / I
L s H s H

L b

H b

] ln[ I ( / )
H 0 L s H s

( x ) / I 0L

] ]

s ( x) =

L H ln I L ( x ) / I 0L b / H b ln I H ( x ) / I 0H L H sH ( b / b ) sL

] (

) [

Where: = attenuation coefficient = areal density I = beam intensity subscripts b and s and 0refer to bone, soft-tissue, and incident intensity respectively superscripts L and H refer to low and high energies

Theory of operation: Hologic

GeW

Collimator Rack Filter Drum

THIS IS DXA: (Hologic)

( x) q( x) = k ln I H ( x) ln I L( x)
b H Io and IL 0

( x) = q( x)
b d

cb

Where: k = constant which zeros effect of soft-tissue segment of filter wheel and d= calibration factor computed from insertion of calibration bone segment of filter wheel

Hologic Calibration Filters and Collimator Rack

HV

Fan-beam Considerations:

FanFan-beam Fan-beam Demonstration

WARNING : OLD DOS PRINTOUT!

10 cm.

0 cm.

How Fat is Too Fat?

y Thickness number (EET) > 10.0
Precision begins to suffer.

y Thickness number > 12.0

Patient is too fat.

To Minimize FanFan-Beam Fan-Beam Effect:

ALWAYS center image on screen Use repositioning tool freely Use COMPARE feature to insure little left to right adjustment is necessary y Move image half the desired movement on forearms (maximum magnification) y For hip and spine:
Slightly more in heavy patients Slightly less in thin patients

y y y

Just a Few Words about Daily Phantom Scanning

y Try to scan the phantom daily even if patients are not done every day y Dont leave phantom on table overnight y Let the machine warm up same length of time every day (I go for coffee). y Position phantom carefully

Phantom BMD Plot

+/- 1 SD
1.13

Daily QA Plots for 100 days

+/1SD

1.08 0 20 40 Days 60 80 100

Frequency
BMD 1.05g/cm2

BMD

Array mode Express Mode

Positioning Phantom Aids

Liquid Correction Fluid

Monitoring System Error

Stable System
1.03

+/- 1 SD
1.015

<> 1 SD

+1.5%

BMD

0.985

-1.5%

0.97 12/25/2000 2/13/2001 4/4/2001 5/24/2001 7/13/2001

Date

10

Machine Error - Drift

Unstable System
1.030
"+/- 1SD" "+/- 2SD"

1.015

+1.5%

BMD

1.000

0.985

-1.5%

0.970 12/25/2000 2/13/2001 4/4/2001 5/24/2001 7/13/2001

Date

Machine Error - Drift

1.030

1.015 BMD (g/cm2)

+1.5%

1.000

0.985

-1.5%

0.970 29-Dec 17-Feb 8-Apr Date 28-May 17-Jul

Machine Error - Shift

Unstable System - Shift
1.030
"+/- 1SD" "+/- 2SD"

1.015

+1.5%

BMD

1.000

0.985

-1.5%

0.970 12/25/2000

2/13/2001

4/4/2001

5/24/2001

7/13/2001

Date

11

Machine Error - Shift

1.030

Unstable System - Weekly Plot

1.015 BMD

+1.5%

1.000

0.985

-1.5%

0.970 29-Dec 17-Feb 8-Apr Date 28-May 17-Jul

General Scanning Errors

y Incorrect or inconsistent biography entries
Is it:
y OBRIEN, William? y OBRIEN, William? y O BRIEN,Willie? y OBRIAN, Bill?

Spine Scanning Errors and Fixes

y Bone map (low density vs auto low density) and how to turn it off! y Centering - Use the positioning tool! y Spinal segmentation - Count Bottom - Up! y Insufficient or variance in reduction of lumbar lordosis y Not taking advantage of information in COMPARE view, use oldest scan for baseline

12

Bone Mapping Errors Auto-Low AutoAuto-Low Density

y You can turn off autoauto-low auto-low density on the next analysis, but you cannot turn it on for the next analysis.

How Do You Know Its AutoAuto-Low? Auto-Low?

Positioning Pearls
y Use exam table paper not cloth sheets
Patients slide easier for positioning Makes noise when they start to move Keeps lint generation down

y Cheaper y Use recycled content to ease your conscience

13

Use Bolster Consistently

Use Turbo/Express Mode for Scout

y y y y Faster Less beam-on beambeam-on time is ALARA Identify landmarks Start at ASIS

Spinal Landmarks
Sacral Ala

14

Spend Most Time on General ROI:

How Many Lumbar ?

(eg02)

Remember Wheres Waldo? Find the pope in the pizza Find

15

Find the Pope in the Pizza

Find the Pope in the Pizza

Find the Pope in the Pizza

eg009

16

Find the Pope in the Pizza

Hip scanning errors and fixes

y Know what a correct scan analysis looks like y Know how the software places lines and regions

Mark Femoral Midline

y Find narrowest portion of femoral neck shortest chord (red) y Bisect green line and place femoral midmid-line perpendicular to and at midmid-point of chord.

90

17

Position Box on Femoral Neck

y Default position centered over chord 90 y Move until one corner is in notch of Gr. Trochanter and other three corners are in soft tissue y Shorten length, then erase ischium, then try other hip, then narrow neck box.

Position Box on Wards Triangle

y Computer generates search region (Shift(ShiftTab) inside femoral neck. y Moves 1 cm. box through search region and stops at least dense area.

90

Mark Base of Trochanter

90

y Draw line from midpoint of chord to inflection point of greater trochanter y If below midmid-line, move until one click above midmid-line.

18

Plumb, level, square!

Proper Positioning Rules

No Shoes

Proper Analysis Rules

y Control abduction angle with positioning tool Auto-position y Use AutoAuto-position whenever bone map is manipulated y Only move the mid-line midmid-line if patient is properly positioned. y Dont move any other regions

Learn to Use the MidMid-line Mid-line Co-ordinates CoCo-ordinates

48 0 102 24

108

19

Learn to Use the MidMid-line Mid-line Co-ordinates CoCo-ordinates

Expected Rate of Change

y 48 yr female y RA y H/o High dose GCCs y GCC d/cd 1995

4/97
sb

Positioning Errors

4/97

8/95
sb

20

Forearm Scanning Issues

y Use the positioner whenever possible y Consider alternative positioning
Frozen shoulder Patients unable to sit for exam

Steps to Positioning
y Move positioner anterior to chest y Form 1350 angle not 900

Adapting to the situation?

Region Total R+U 1/3 R+U UD R+U

Upright BMD 0.661 0.816 0.450

Supine BMD 0.664 0.830 0.438

21

VFA Scanning Issues

y Time breathbreath-hold breath-hold just before scanner reaches diaphragm y Can exhale SLOWLY after scanner clears diaphragm y May need scan on expiration for suspected T -12 fracture T-12

HIPAA issues
y y y y See up a password protected screenscreen-saver screen-saver Turn off monitor when you leave the room NEVER ee-mail e-mail unencrypted patient scan results Double back-up backback-up your scans and system backups
Maintain second archive separate safe location

y Consider using magnetomagneto-optical magneto-optical storage devices

Less change of data loss CD-RW CDlongCD-RW not recommended for long-term long-term storage (scans) CD-RW CDCD-RW ok for system backups done on a regular basis

22