Performance of a Severity Score on Admission Chest Radiography in Predicting Clinical Outcomes in Hospitalized Patients With Coronavirus Disease (COVID-19).

BACKGROUND. Chest radiographs (CXRs) are typically obtained early in patients admitted with coronavirus disease (COVID-19) and may help guide prognosis and initial management decisions. OBJECTIVE. The purpose of this study was to assess the performance of an admission CXR severity scoring system in predicting hospital outcomes in patients admitted with COVID-19. METHODS. This retrospective study included 240 patients (142 men, 98 women; median age, 65 [range, 50-80] years) admitted to the hospital from March 16 to April 13, 2020, with COVID-19 confirmed by real-time reverse-transcriptase polymerase chain reaction who underwent chest radiography within 24 hours of admission. Three attending chest radiologists and three radiology residents independently scored patients' admission CXRs using a 0- to 24-point composite scale (sum of scores that range from 0 to 3 for extent and severity of disease in upper and lower zones of left and right lungs). Interrater reliability of the score was assessed using the Kendall W coefficient. The mean score was obtained from the six readers' scores for further analyses. Demographic variables, clinical characteristics, and admission laboratory values were collected from electronic medical records. ROC analysis was performed to assess the association between CXR severity and mortality. Additional univariable and multivariable logistic regression models incorporating patient characteristics and laboratory values were tested for associations between CXR severity and clinical outcomes. RESULTS. Interrater reliability of CXR scores ranged from 0.687 to 0.737 for attending radiologists, from 0.653 to 0.762 for residents, and from 0.575 to 0.666 for all readers. A composite CXR score of 10 or higher on admission achieved 53.0% (35/66) sensitivity and 75.3% (131/174) specificity for predicting hospital mortality. Hospital mortality occurred in 44.9% (35/78) of patients with a high-risk admission CXR score (≥ 10) versus 19.1% (31/162) of patients with a low-risk CXR score (< 10) (p < .001). Admission composite CXR score was an independent predictor of death (odds ratio [OR], 1.17; 95% CI, 1.10-1.24; p < .001). composite CXR score was a univariable predictor of intubation (OR, 1.23; 95% CI, 1.12-1.34; p < .001) and continuous renal replacement therapy (CRRT) (OR, 1.15; 95% CI, 1.04-1.27; p = .007) but was not associated with these in multivariable models (p > .05). CONCLUSION. For patients admitted with COVID-19, an admission CXR severity score may help predict hospital mortality, intubation, and CRRT. CLINICAL IMPACT. CXR may assist risk assessment and clinical decision-making early in the course of COVID-19.

Geometric calibration and correction for a lens-coupled detector in x-ray phase-contrast imaging.

A lens-coupled x-ray camera with a tilted phosphor collects light emission from the x-ray illuminated (front) side of phosphor. Experimentally, it has been shown to double x-ray photon capture efficiency and triple the spatial resolution along the phosphor tilt direction relative to the same detector at normal phosphor incidence. These characteristics benefit grating-based phase-contrast methods, where linear interference fringes need to be clearly resolved. However, both the shallow incident angle on the phosphor and lens aberrations of the camera cause geometric distortions. When tiling multiple images of limited vertical view into a full-field image, geometric distortion causes blurring due to image misregistration. Here, we report a procedure of geometric correction based on global polynomial transformation of image coordinates. The corrected image is equivalent to one obtained with a single full-field flat panel detector placed at the sample plane. In a separate evaluation scan, the position deviations in the horizontal and vertical directions were reduced from 0.76 and 0.028 mm, respectively, to 0.006 and 0.009 mm, respectively, by the correction procedure, which were below the 0.028-mm pixel size of the imaging system. In a demonstration of a phase-contrast imaging experiment, the correction reduced blurring of small structures.

A Universal Moiré Effect and Application in X-Ray Phase-Contrast Imaging.

A moiré pattern is created by superimposing two black-and-white or gray-scale patterns of regular geometry, such as two sets of evenly spaced lines. We observed an analogous effect between two transparent phase masks in a light beam which occurs at a distance. This phase moiré effect and the classic moiré effect are shown to be the two ends of a continuous spectrum. The phase moiré effect allows the detection of sub-resolution intensity or phase patterns with a transparent screen. When applied to x-ray imaging, it enables a polychromatic far-field interferometer (PFI) without absorption gratings. X-ray interferometry can non-invasively detect refractive index variations inside an object1-10. Current bench-top interferometers operate in the near field with limitations in sensitivity and x-ray dose efficiency2, 5, 7-10. The universal moiré effect helps overcome these limitations and obviates the need to make hard x-ray absorption gratings of sub-micron periods.

Enhancing Tabletop X-Ray Phase Contrast Imaging with Nano-Fabrication.

X-ray phase-contrast imaging is a promising approach for improving soft-tissue contrast and lowering radiation dose in biomedical applications. While current tabletop imaging systems adapt to common x-ray tubes and large-area detectors by employing absorptive elements such as absorption gratings or monolithic crystals to filter the beam, we developed nanometric phase gratings which enable tabletop x-ray far-field interferometry with only phase-shifting elements, leading to a substantial enhancement in the performance of phase contrast imaging. In a general sense the method transfers the demands on the spatial coherence of the x-ray source and the detector resolution to the feature size of x-ray phase masks. We demonstrate its capabilities in hard x-ray imaging experiments at a fraction of clinical dose levels and present comparisons with the existing Talbot-Lau interferometer and with conventional digital radiography.

Motionless electromagnetic phase stepping versus mechanical phase stepping in x-ray phase-contrast imaging with a compact source.

X-ray phase contrast imaging based on grating interferometers detects the refractive index distribution of an object without relying on radiation attenuation, thereby having the potential for reduced radiation absorption. These techniques belong to the broader category of optical wavefront measurement, which requires stepping the phase of the interference pattern to obtain a pixel-wise map of the phase distortion of the wavefront. While phase stepping traditionally involves mechanical scanning of a grating or mirror, we developed electromagnetic phase stepping (EPS) for imaging with compact sources to obviate the need for mechanical movement. In EPS a solenoid coil is placed outside the x-ray tube to shift its focal spot with a magnetic field, causing a relative movement between the projection of the sample and the interference pattern in the image. Here we present two embodiments of this method. We verified experimentally that electromagnetic and mechanical phase stepping give the same results and attain the same signal-to-noise ratios under the same radiation dose. We found that the relative changes of interference fringe visibility were within 3.0% when the x-ray focal spot was shifted by up to 1.0 mm in either direction. We conclude that when using x-ray tube sources, EPS is an effective means of phase stepping without the need for mechanical movement.

Fabrication of 200 nm period hard X-ray phase gratings.

Far field X-ray grating interferometry achieves extraordinary phase sensitivity in imaging weakly absorbing samples, provided that the grating period is within the transverse coherence length of the X-ray source. Here we describe a cost-efficient process to fabricate large area, 100 nm half-pitch hard X-ray phase gratings with an aspect ratio of 32. The nanometric gratings are suitable for ordinary compact X-ray sources having low spatial coherence, as demonstrated by X-ray diffraction experiments.

Efficient decoding of 2D structured illumination with linear phase stepping in X-ray phase contrast and dark-field imaging.

The ability to map the phase distribution and lateral coherence of an x-ray wavefront offers the potential for imaging the human body through phase contrast, without the need to deposit significant radiation energy. The classic means to achieve this goal is structured illumination, in which a periodic intensity modulation is introduced into the image, and changes in the phase distribution of the wavefront are detected as distortions of the modulation pattern. Two-dimensional periodic patterns are needed to fully characterize a transverse wavefront. Traditionally, the information in a 2D pattern is retrieved at high resolution by acquiring multiple images while shifting the pattern over a 2D matrix of positions. Here we describe a method to decode 2D periodic patterns with single-axis phase stepping, without either a loss of information or increasing the number of sampling steps. The method is created to reduce the instrumentation complexity of high-resolution 2D wavefront sensing in general. It is demonstrated with motionless electromagnetic phase stepping and a flexible processing algorithm in x-ray dark-field and phase contrast imaging.

Boosting phase contrast with a grating Bonse-Hart interferometer of 200 nanometre grating period.

We report on a grating Bonse-Hart interferometer for phase-contrast imaging with hard X-rays. The method overcomes limitations in the level of sensitivity that can be achieved with the well-known Talbot grating interferometer, and without the stringent spectral filtering at any given incident angle imposed by the classic Bonse-Hart interferometer. The device operates in the far-field regime, where an incident beam is split by a diffraction grating into two widely separated beams, which are redirected by a second diffraction grating to merge at a third grating, where they coherently interfere. The wide separation of the interfering beams results in large phase contrast, and in some cases absolute phase images are obtained. Imaging experiments were performed using diffraction gratings of 200 nm period, at 22.5 keV and 1.5% spectral bandwidth on a bending-magnetic beamline. Novel design and fabrication process were used to achieve the small grating period. Using a slitted incident beam, we acquired absolute and differential phase images of lightly absorbing samples. An advantage of this method is that it uses only phase modulating gratings, which are easier to fabricate than absorption gratings of the same periods.

Motionless phase stepping in X-ray phase contrast imaging with a compact source.

X-ray phase contrast imaging offers a way to visualize the internal structures of an object without the need to deposit significant radiation, and thereby alleviate the main concern in X-ray diagnostic imaging procedures today. Grating-based differential phase contrast imaging techniques are compatible with compact X-ray sources, which is a key requirement for the majority of clinical X-ray modalities. However, these methods are substantially limited by the need for mechanical phase stepping. We describe an electromagnetic phase-stepping method that eliminates mechanical motion, thus removing the constraints in speed, accuracy, and flexibility. The method is broadly applicable to both projection and tomography imaging modes. The transition from mechanical to electromagnetic scanning should greatly facilitate the translation of X-ray phase contrast techniques into mainstream applications.

Subnanoradian X-ray phase-contrast imaging using a far-field interferometer of nanometric phase gratings.

Hard X-ray phase-contrast imaging characterizes the electron density distribution in an object without the need for radiation absorption. The power of phase contrast to resolve subtle changes, such as those in soft tissue structures, lies in its ability to detect minute refractive bending of X-rays. Here we report a far-field, two-arm interferometer based on the new nanometric phase gratings, which can detect X-ray refraction with subnanoradian sensitivity, and at the same time overcomes the fundamental limitation of ultra-narrow bandwidths (Δλ/λ~10⁻4) of the current, most sensitive methods based on crystal interferometers. On a 1.5% bandwidth synchrotron source, we demonstrate clear visualization of blood vessels in unstained mouse organs in simple projection views, with over an order-of-magnitude higher phase contrast than current near-field grating interferometers.

Interferometric hard x-ray phase contrast imaging at 204 nm grating period.

We report on hard x-ray phase contrast imaging experiments using a grating interferometer of approximately 1/10th the grating period achieved in previous studies. We designed the gratings as a staircase array of multilayer stacks which are fabricated in a single thin film deposition process. We performed the experiments at 19 keV x-ray energy and 0.8 µm pixel resolution. The small grating period resulted in clear separation of different diffraction orders and multiple images on the detector. A slitted beam was used to remove overlap of the images from the different diffraction orders. The phase contrast images showed detailed features as small as 10 µm, and demonstrated the feasibility of high resolution x-ray phase contrast imaging with nanometer scale gratings.