Radiography (2010) 16, 304e313

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/radi

Impact of focal spot size on radiologic image quality: A visual grading analysis
Sinead Gorham, Patrick C. Brennan*
Diagnostic Imaging, Biological Imaging Research, UCD School of Medicine and Medical Science, Health Science, Beleld, UCD, Dublin 4, Ireland Received 17 October 2008; revised 27 May 2009; accepted 28 February 2010 Available online 18 June 2010

KEYWORDS
Geometric unsharpness; Cadaver; X-ray projection

Abstract Fine and broad focal spot sizes are available on general X-ray tubes. Excessive use of ne focus can impact on tube life and whilst it is established that ne focal spot size reduces geometric unsharpness, the extent of this benet on clinical image quality is unclear. The current cadaver-based work compares images produced with effective focal sizes of 0.8 mm and 1.8 mm. Four projection types were included, lateral ankle, anteroeposterior (AP) knee, AP thoracic spine and horizontal beam lateral (HBL) lumbar spine, and a visual grading analysis was used to assess visibility of anatomical criteria. Five clinicians scored each image using a 1e4 scoring scale, a reference image was employed for standardization and a ManneWhitney U statistical test compared results derived from each focus. Radiation doses were monitored using a dose area product (DAP) meter. Statistical analyses demonstrated no signicant differences between images produced at each focus, although a relationship between body part thickness and number of criteria with a higher (non-signicant) score for the ne focus compared with the broad focal spot size was demonstrated. Choice of focus had no radiation dose implications. Fine foci X-ray sources are used predominantly for extremity imaging to enhance visualization of ne detail such as trabecular patterns, yet there is no evidence to support this practice. The argument for regular employment of ne foci, particularly for the type of acquisition and display devices used in this study, needs to be revisited. 2010 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction
The focal spot is the origin of X-rays used to produce a radiograph. The area of the anode target hit by electrons

* Corresponding author. Tel.: 35317166545; fax: 35317166547. E-mail address: patrick.brennan@ucd.ie (P.C. Brennan).

is described as the actual focal spot area, whereas the rectangular area projected downwards to produce an X-ray eld is known as the effective focus. The limitations of a single focal spot size was soon realized after the discovery of X-rays and a dual focus X-ray tube was rst presented in 1923 by Siemens in the DOFOK tube.1 Presently dual (and sometimes triple) foci combinations, such as 0.6 and 1.0 mm, are commonplace in conventional diagnostic radiography.1 The two foci are obtained by two cathode-focusing

1078-8174/$ - see front matter 2010 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2010.02.007

Impact of focal spot size on radiologic image quality sources, the choice of which is generally determined by the examination type and the competing demands of a high level of detail and minimal X-ray tube loading. The relationship between focal spot size and geometric unsharpness is established, with an increase in focal spot size resulting in a larger penumbra about the region of interest when other factors such as focus object and object receptor distances remain constant, Fig. 1. The size of this penumbra can be characterized by psychophysical techniques such as line and edge spread functions.2e4 The importance of focal spot sizes on this penumbra and apparent direct relationship with visible image degradation is evidenced by the continuing effort by X-ray manufacturers to produce increasingly smaller X-ray foci.5 On the other hand, to minimize X-ray tube damage, the large amount of heat produced by characteristic and bremstrahlung interactions at the anode should be dispersed over a large area, which is restricted with small tube foci. Thermal damage results in pitting of the focal area surface,6 leading to heterogeneous intensities across the X-ray beam and deterioration of image quality. The Line Focus Principle, which to some extent has enabled a compromise between these two conicting requirements of minimizing heat and penumbra,1 has not removed the need for, and associated expense of multi-foci X-ray tubes. The physical and theoretical inuences of focal spot size and its impact on radiographic exposure selection each time a patient is exposed is not under debate, however, it is interesting to note that the link between these inuences and clinical image quality is much less understood. Nevertheless, international guidelines, aiming to promote image quality and diagnostic efcacy,7 state specic focal spot sizes for individual examinations, and the basis for these recommendations are currently unclear. There is some work linking poor clinical image quality with large focal spot size, but previous ndings are either not relevant to the majority of diagnostic examinations or were not supported by recognized image analysis techniques: Muntz and Logan8 assessed the impact of focal spot size and magnication on detection of microcalcications within breast phantoms, however, the focal spot dimensions of 150e290 microns are smaller than that used for general X-ray tubes; Katz and Nickoloff9 reported that smaller focal spot sizes (1.14e1.25 mm) should be used rather than larger foci (1.97e2.3 mm) for lymph angiographic examinations, but this assertion was largely based on

305 a subjective assessment of clinical image quality. Conversely Platin et al.,10 who focused on dental radiography, established that varying the focal spot size from 0.86 0.68 mm to 2.61 1.21 mm had negligible impact on the diagnosis of caries. It is of concern that in this era of rigorous clinical audit there is such a paucity of data to support such a practice as focal spot selection which impacts on every diagnostic nonCT X-ray exposure. Through quantitative research it needs to be established which examinations require a ne focus to maximize visualization of ne detail and if a clear difference cannot be shown between focal options, the accepted practice of producing, and the perceived clinical need for dual or triple focus combinations should be questioned. The current work examines the impact of employing specic focal spot sizes on the demonstration of anatomic features within various examination types that typically demand high spatial resolution (extremities), involve large exposure elds (thoracic spine) or require high tube loading and have large object to receptor distance (lateral lumbar spine).

Method
The study describes the impact of a ne and broad focal spot size on the visualization of normal anatomical parameters within a cadaver for four common X-ray projections.11 A visual grading analysis technique12e18 was used to score each image. For clarication, denitions of some focal spot terms are given below: Effective focal spot: the projected focal spot size as seen from the patient; Nominal focal spot: the effective focal spot size as stated by the manufacturer; Actual focal spot: the effective focal spot size as measured using the RMI 112B tool described below.

X-ray production, capture and display

A revolution XR/d X-ray unit (General Electric Company, Milwaukee, USA) with a 350 KHU A195 rotating anode X-ray tube insert (Varian Medical Systems, X-ray Products, Salt Lake City, Utah, USA) was used throughout the work. It contained a 12 tungstenerheniumemolybdenum alloy target, nominal focal spot sizes of 0.6 and 1.25 mm, and was supported by a JEDI 80 RD 1 T generator (General Electric Medical Systems, X-ray Generation Subsystems, Milwaukee, USA). Image capture was performed using a Kodak DirectView CR500 image processor and Kodak DirectView GP phosphor screen cassettes of 35 cm 43 cm containing 5.8 pixels per mm (0.168 mm pixel pitch) (Eastman Kodak Company, Rochester, New York) and a 100 cm focused secondary radiation grid with 13:1 ratio and 78 lines/cm was used for exposures of the spine (see below). Images were presented using the default Image Tonescale processing facilities on the Kodak DirectView CR500 image processor and displayed on a 1700 HP L1702 LCD at panel monitor (HewlettePackard Development Company, USA) with 1280 1024 pixel resolution and a 0.26 mm pixel pitch. This secondary display

Point Source

Small Focal Spot

Large Focal Spot

Object

Penumbra

Image Receptor

Figure 1

Penumbra.

306
Table 1 Projection Ankle AP Knee AP Thoracic spine AP Lumbar spine HBL Technical parameters of the cadaver study. Film-to-focus distance (FFD) 100 cm 100 cm 100 cm 115 cm kVp 55 60 80 90 mAs 4 4 32 125

S. Gorham, P.C. Brennan

Collimation 24.2 16.9 cm 24.3 15 cm 16.1 39.4 cm 17.2 36 cm

monitor was calibrated to the DICOM Grey Scale Display Function (GSDF) standard using the VeriLUM 5.1 software and luminance pod (Image Smiths Inc., Maryland, USA) and displayed a minimum contrast ratio of 250:1. An ambient light at 30 cms from the monitor was maintained between 30 and 40 lux in line with previous recommendations,19 particularly for the type of images investigated in this study. The focal spot sizes were measured using test tool, RMI 112B (Gammex RMI, Middleton, Wisconsin, USA) and Kodak direct exposure dental lm. The ne and broad foci were measured to be 0.8 and 1.8 mm respectively, which was within the National Electrical Manufacturers Association standard of 50% from the nominal values.10 Routine quality assurance (QA) tests were performed throughout the work and these included verication of kVp and mAs output, beam alignment and collimation. All QA techniques and resultant measurements adhered to recent published standards.20

Each of the four examination types allowed the impact of varying foci to be tested on examinations where visibility of ne detail is required (lateral ankle and AP knee), large eld sizes along the cathodeeanode axis are evident (AP thoracic spine), which may be vulnerable to altered anode heel affect properties at different foci and anatomic regions already vulnerable to geometric unsharpness due to large object receptor distance (HBL lumbar spine). Ten images were produced for each category above e ve with a ne focus and ve with a broad focus and exposure parameters and positioning were kept constant for each projection, Table 1. Images were taken in a randomized order between the broad and ne foci and all images were conrmed as being of good diagnostic efcacy by a radiologist. All images were viewed at standard window levels and widths, Table 2.

Image production and assessment

A male cadaver, 59 years old at time of death, 1.88 m tall, of approximately 75 kg in weight was exposed throughout the work, with institutional approval granted prior to any exposures. Before the study took place, an anthropomorphic phantom was employed to ensure that both ne and broad focal spot size exposures were achievable for the examinations to be performed. A calibrated dose area product (DAP) meter recorded radiation doses. Four projections were chosen for the work. The CEC have presented 1.3 mm as an example of good radiographic practice for the lumbar spine (there are no recommended values for the other examinations).7 These projections are shown below along with image size in terms of actual dimensions and pixel number:  Medioelateral ankle, 12 12 cm, 696 696 pixels  Anteroeposterior (AP) knee, 12 14 cm, 696 812 pixels  AP thoracic spine 10 35 cm, 580x2030 pixels  Horizontal beam lateral (HBL) lumbar spine 15 30 cm 870 1740 pixels

Table 3 No. 1 2 3 4 5 6 7 8 9 10 11 12 13

Lateral ankle image criteria. Criteria Soft tissue detail visible posterior to the distal bula. Sharply dened tibioetalar joint space. Sharply dened naviculoetalar joint space. Lateral malleolus visible through the distal tibia and talus. Sharply dened cortical outlines of the distal tibia. Sharply dened cortical outlines of the distal bula. Sharply dened cortical outlines of the navicular bone. Sharply dened cortical outlines of the talus. Sharply dened cortical outlines of the calcaneum. Sharply dened cortical outlines of the fth metatarsal base. Sharply dened bony trabecular pattern of the distal tibia. Sharply dened bony trabecular pattern of the distal bula. Sharply dened bony trabecular pattern of the navicular bone. Sharply dened bony trabecular pattern of the talus. Sharply dened bony trabecular pattern of the calcaneum. Sharply dened bony trabecular pattern of the fth metatarsal base.

Table 2 Projection

Image window settings. Window centre 1494 1628 975 1169 Window width 1437 1419 801 546

14 15 16

Ankle AP Knee AP Thoracic spine AP Lumbar spine HBL

Impact of focal spot size on radiologic image quality

Table 4 No. 1 2 3 4 5 6 7 8 9 10 11 12 13 AP knee image criteria. Criteria Soft tissue detail visible lateral to the femorotibial joint space. Sharply dened cortical outlines of the patella. Sharply dened cortical outlines of the proximal bula. Sharply dened cortical outlines of the femorotibial joint. Sharply dened cortical outlines of the intercondylar eminence. Sharply dened cortical outlines of the proximal tibia. Sharply dened cortical outlines of the distal femur. Sharply dened bony trabecular patterns of the proximal bula. Sharply dened bony trabecular patterns of the medial femoral condyle. Sharply dened bony trabecular patterns of the lateral femoral condyle. Sharply dened bony trabecular patterns of the proximal tibia. Sharply dened bony trabecular patterns of the distal femur. Sharply dened bony trabecular patterns of the tibial plateau.

307 Image criteria for each projection were drawn up based on anatomical details. The starting point were the criteria issued by the Commission of the European Community (CEC) Quality Criteria for Diagnostic Radiographic Images, 1996,7 however, these have been developed by previous workers since the CEC publication and the criteria seen here reect this development.12e18 The criteria, reviewed and agreed by a radiologist, are shown in Tables 3e6. Images were presented alongside a projection-specic reference image, presented at full resolution, which was chosen on the basis that all criteria to be scored were demonstrated clearly. All images were presented on a LCD monitor at each viewing and for each test image, observers scored individual criteria as follows: 1. 2. 3. 4. Unacceptable. Acceptable, less clear than the reference image. Acceptable, equal to the reference image. Acceptable, more clear than the reference image.

Five clinicians, with a mean of 13 years experience in Diagnostic Imaging scored each image. Absolute scores for each criterion were provided and for each image these were summed to obtain a total image score. Criterion and total image scores were averaged over the 5 clinicians. Statistical analyses of the mean criteria and mean total image scores were undertaken using the non-parametric

Table 5 No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

AP thoracic spine image criteria.

Table 6 No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

HBL lumbar spine image criteria. Criteria Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened Sharply dened of L1 and L2. Sharply dened of L3 and L4. Sharply dened vertebral body. Sharply dened vertebral body. Sharply dened vertebral body. Sharply dened and L2. Sharply dened and L4. Sharply dened and S1. upper plate surface of L1. upper plate surface of L5. lower plate surface of L1. lower plate surface of L5. anterior vertebral edge of L1. anterior vertebral edge of L5. posterior vertebral edge of L1. posterior vertebral edge of L5. pedicles of L1. pedicles of L5. spinous process of L1. spinous process of L5. inter-vertebral foramen inter-vertebral foramen trabecular pattern of the L1 trabecular pattern of the L3 trabecular pattern of the L5 inter-vertebral joint space of L1 inter-vertebral joint space of L3 inter-vertebral joint space of L5

Criteria Sharply dened upper plate surface of T3. Sharply dened upper plate surface of T9. Sharply dened lower plate surface of T3. Sharply dened lower plate surface of T9. Sharply dened spinous process of T3. Sharply dened spinous process of T9. Sharply dened pedicles of T3. Sharply dened pedicles of T9. Sharply dened rst posterior rib. Sharply dened 12th posterior rib. Sharply dened trabecular pattern of the T3 vertebral body. Sharply dened trabecular pattern of the T9 vertebral body. Sharply dened right medial clavicle. Sharply dened left medial clavicle. Sharply dened transverse processes of T3. Sharply dened transverse processes of T9. Sharply dened inter-vertebral joint space of T1 and T2. Sharply dened inter-vertebral joint space of T5 and T6. Sharply dened inter-vertebral joint space of T11eT12. Sharply dened costo-vertebral articulations of T3. Sharply dened costo-vertebral articulations of T9.

308
fine 80 70 60 broad

S. Gorham, P.C. Brennan with ne and broad focus for each examination are shown in Figs. 3e10. The mean anatomic criteria scores along with the standard deviations for each projection are shown in Figs. 11e14. No statistical differences were noted between ne and broad focal spot size images for any single criterion for any of the examination types. The mean Kappa statistics values demonstrated that inter-observer agreement was excellent for the ankle and knee images for both broad and ne focus, moderate for the thoracic images for both foci and, fair and moderate for the lumbar images for ne and broad focus, respectively. No important differences between focus choice were seen for the dosimetric measurements, Table 7, with the maximum change being a 2.5% increase with the ne focus for the thoracic spine projection.

mean image score

50 40 30 20 10 0 ankle knee thoracic lumbar

projection

Figure 2 Mean total image scores for each projection at each focal spot size.

Discussion
A choice of focal spot sizes is available with nearly all conventional X-ray tubes and radiologic technologists or radiographers choose one size in a projection-specic way for each examination. Generally it is believed that for small body parts, particularly extremities, that ne focus is preferable so that ne details such as bony trabecular patterns are demonstrated maximally due to reduced geometric unsharpness. For larger exposures, which require greater tube loading the broad focus is normally chosen so that heat is dispersed over a greater area of the anode, but at the apparent expense of reduced radiographic quality. Evidence of this reduced quality with broad foci is currently unavailable and it was the aim of

ManneWhitney U test. A p-value of <0.05 was used to identify any statistical signicance and a Kappa analysis determined the level of agreement between observers.

Results
The mean total image scores and standard deviations for each projection are shown in Fig. 2. The maximum possible image score for the ankle, knee, thoracic spine and lumbar spine projections were 64, 52, 84 and 80, respectively. No statistically signicant differences between ne and broad focus were noted for total image scores. Images produced

Figure 3

An ankle image produced using the ne focal spot.

Figure 4 spot.

An ankle image produced using the broad focal

Impact of focal spot size on radiologic image quality

309

Figure 5

A knee image produced using the ne focal spot. Figure 7 A thoracic spine image produced using the ne focal spot.

this study to establish the level of detriment on visibility of normal anatomic parameters when using a broad focus for common clinical images compared with a smaller focal spot size.

The statistical analyses did between the two foci for anatomic features. Figs. 2, standard deviations exceeding

not reveal any differences the display of common 11e14 conrm this with any mean value variances,

Figure 6

A knee image produced using the broad focal spot.

Figure 8 A thoracic spine image produced using the broad focal spot.

310

S. Gorham, P.C. Brennan providing multiple foci, and the expectation that these should be available for at least the examinations used here, needs to be reconsidered. On closer examination of the data, however, an interesting observation is noted: for the smallest body part, i.e., the ankle, the higher mean scores were distributed evenly between the two foci, but as the body part thickness increased the smaller focus had higher scores in 77% (n Z 10), 71% (n Z 15) and 90% (n Z 18) of criteria compared with broad focus for the knee, thoracic spine and lumbar spine, respectively. Certainly for the lateral lumbar spine, but to a lesser extent the thoracic spine and knee images, this is most likely due to the smaller focal spot size offsetting some of the increased penumbra due to the relatively large distance between the object of interest and the receptor plate, but it is worth noting that this potential subtle improvement in image quality with a smaller focus is not evident in the ankle examination where one would expect the employment of a ne focus to visualize minute trabecular detail. It is acknowledged that only a limited number of examinations were chosen for this study, but the results shown for this range of projections, should represent to some extent the impact of varying focal spot sizes on a number of other examination types, an obvious exception being the visualization of microcalcications within breast images. A legitimate concern is that the display monitor employed in this study does not have the specications of a primary workstation and whilst the adherence of the monitor to the GSDF standard and its contrast ratio may allay fears about contrast resolution, spatial resolution remains an issue. It may be argued that if a primary workstation display was used a greater difference in scores between the two foci may have been demonstrated. However, if one considers spatial resolution characteristics of the two examinations that would normally require a ne focus, the ankle and knee, it can be observed that the native resolution was below the total available with the display so a 1:1 image pixel to display pixel was evident, thus resulting in no loss of detail. This was not the case with the spine examinations where up to a 45% reduction in image size is evident, and it is possible that any ne focus benet is under-represented for these two examinations. Nonetheless, the conclusion that ne focus selection may not be necessary for those examinations where it is normally selected, e.g. the ankle and knee, remains valid. The current study employed a visual grading analysis (VGA). This is a well proven method of analyzing the visualization of normal anatomic features12e18 and has shown a good ability to discriminate between test variables such as varying beam energy,21 novel radiographic techniques22,23 and rare-earth lters.14 It is acknowledged, however, that unlike a receiver operating characteristic (ROC) investigation, VGA testing does not assess diagnostic efcacy and, therefore, at this stage the impact of different focal spot sizes on the ability to detect abnormal lesions cannot be commented upon with condence. Nonetheless it is reasonable to propose that, following the ndings of this work, the impact of different foci on abnormal image features is not likely to be substantial.

Figure 9 spot.

A lumbar spine image produced using the ne focal

the latter generally being very small. This initial conclusion would suggest that choosing a broad rather than a ne focus to reduce tube loading does not impact on image quality and that the long-held tradition of

Figure 10 focal spot.

A lumbar spine image produced using the broad

Impact of focal spot size on radiologic image quality

fine 4 3.5 3 broad

311

mean score

2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

criteria no.

Figure 11

Mean anatomic criteria scores for ankle images at each focal spot size. Error bars represent standard deviations.

fine 3.5 3 2.5

broad

mean score

2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 criteria no. 9 10 11 12 13

Figure 12

Mean anatomic criteria scores for knee images at each focal spot size. Error bars represent standard deviations.

fine 3.5 3 2.5

broad

mean score

2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

criteria no.

Figure 13 deviations.

Mean anatomic criteria scores for thoracic spine images at each focal spot size. Error bars represent standard

312
fine 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 criteria no. 13 14 15 16 17 18 19 20 broad

S. Gorham, P.C. Brennan

Figure 14 deviations.

Mean anatomic criteria scores for lumbar spine images at each focal spot size. Error bars represent standard

mean score

Table 7 Projection

Dose measurements (dGycm2). Fine 2.713 2.032 1.424 0.879 Broad 2.711 2.000 1.439 0.857

Pelvis AP Lumbar spine AP Abdomen AP Thoracic spine AP

Conclusion
This investigation demonstrates that the impact of focal spot size choice for a number of examination types is limited, and there appears to be little support for using ne focus for at least some projections where it would have traditionally been employed. Whilst the authors at this preliminary stage do not propose that multi-foci X-ray tubes have no future role in radiology departments, the advantages of a single broad focus X-ray tube in terms of lower manufacturing costs, reduced customer service and replacement expenses and the ability to set shorter times to minimize movement unsharpness cannot be dismissed.

Conict of interest statement

The authors have no conicts of interest.

References
1. Ammann E, Kutschera W. X-ray tubesdcontinuous innovative technology. The British Journal of Radiology 1997;70:S1eS9. 2. Hames SM, Flynn MJ, Reimann DA. Measurement of very small (1e10 micron) X-ray focal spot intensity distributions. Nuclear Science Symposium and Medical Imaging Conference, Conference Record of the 1992 IEEE, 1993; vol. 2, p. 1331e3. 3. Cunningham IA, Fenster A. A method for modulation transfer function determination from edge proles with correction for nite-element differentiation. Medical Physics 1987;14: 533e7.

4. Doi K, Loo LN, Chan HP. X-ray tube focal spot sizes: comprehensive studies of their measurement and effect of measured size in angiography. Radiology 1982;144:383e93. 5. Letang JM, Peix G. On-line X-ray focal spot assessment based on deconvolution using standard imaging devices. NDT & E International 2003;36:303e17. 6. Ball J, Price T. Chesneys radiographic imaging. 6th ed. Oxford: Blackwell Scientic; 1995. 7. Carmichael JHE, Maccia C, Moores BM, Oestmann JW, Schibilla H, Teunen D, et al. European guidelines on quality criteria for diagnostic radiographic images. Luxembourg: Ofce for Ofcial Publications of the European Communities; 1996. 8. Muntz EP, Logan WW. Focal spot size and scatter suppression in magnication mammography. American Journal of Roentgenology 1979;133:453e9. 9. Katz MC, Nickoloff EL. Radiographic detail and variation of the nominal focal spot size: the "focal effect. Radiographics 1992; 12:753e61. 10. Platin E, Mauriello S, Ludlow JB. Effects of focal spot size on caries diagnosis with D and E speed images. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1996;81:235e9. 11. Hart D, Wall BF. Radiation exposure of the UK population from medical and dental X-ray examinations. United Kingdom: National Radiological Protection Board; 2002. W4. 12. Mansson LG. Methods for the evaluation of image quality: a review. Radiation Protection Dosimetry 90:89e99. 13. Peters SE, Brennan PC. Digital radiography: are the manufacturers settings too high? Optimisation of the Kodak digital radiography system with aid of the computed radiography dose index. European Radiology 2002;12:2381e7. 14. Doyle CA, Brennan PC. Erbium ltration: a cost effective, dosereducing lter which maintains abdominal image quality. European Radiology 1999;9:1923e5. 15. Grondin Y, Matthews K, McEntee M, Rainford L, Casey M, Tonra M, et al. Dose-reducing strategies in combination offers substantial potential benets to females requiring X-ray examination. Radiation Protection Dosimetry 2004;108:123e32. 16. Tingberg A, Bath M, Hakansson M, Medin J, Besjakov J, Sandborg M, et al. Evaluation of image quality of lumbar spine images: a comparison between FFE and VGA. Radiation Protection Dosimetry 2005;114:53e61. 17. Sandborg M, Tingberg A, Ullman G, Dance DR, Alm Carlsson G. Comparison of clinical and physical measures of image quality

Impact of focal spot size on radiologic image quality

in chest and pelvis computed radiography at different tube voltages. Medical Physics 2006;33:4169e75. 18. Sund P, Bath M, Kheddache S, Mansson LG. Comparison of visual grading analysis and determination of detective quantum efciency for evaluating system performance in digital chest radiography. European Radiology 2004;14: 48e58. 19. Brennan PC, McEntee M, Evantoff M, Philips P, OConnor WT, Manning DJ. Ambient lighting: effect of illumination on softcopy viewing of radiographs of the wrist. American Journal of Roentgenology 2007;188:W177eW180.

313
20. Finch A, Bury R, Davies G, Fife I, Hufton A, Workman A. Assurance of quality in the diagnostic imaging department. 2nd ed. London: The British Institute of Radiology; 2001. 21. Doherty P, OLeary D, Brennan PC. Do CEC guidelines underutilise the full potential of increasing kVp as a dose-reducing tool? European Radiology 2003;13:1992e9. 22. Brennan PC, Nash M. Increasing FFD: an effective dosereducing tool for lateral lumbar spine investigations. Radiography 1998;4:251e9. 23. Nic an Ghearr FA, Brennan PC. The PA projection of the abdomen: a dose reducing technique. Radiography 1998;4:195e203.