Very flexible and did a good job writing DICOM files "from scratch", rather than as modifications of existing files. Useful utilities for taking apart files as well, can be used to write tests. C# interface is not perfect, reference counted C++ objects that you create from C# are not always properly managed across the interface, you really need to try to get all the objects you want created on the C++ side. (Eg. using ImageWriter.GetImage rather than creating an image and putting it into the ImageWriter). Also the clever byte packing/unpacking doesn't work smoothly from C#, you have to do it "yourself" a lot with C# encoders. Overall, feels like quite a 'low level' toolkit - very flexible, but lacking explicit modelling of IODs or modules at a higher level. Support via mailing list was excellent.