Olecranon bone age assessment in puberty using a lateral elbow radiograph and a deep-learning model.

OBJECTIVES: To improve pubertal bone age (BA) evaluation by developing a precise and practical elbow BA classification using the olecranon, and a deep-learning AI model. MATERIALS AND METHODS: Lateral elbow radiographs taken for BA evaluation in children under 18 years were collected from January 2020 to June 2022, retrospectively. A novel classification and the olecranon BA were established based on the morphological changes in the olecranon ossification process during puberty. The olecranon BA was compared with other elbow and hand BA methods, using intraclass correlation coefficients (ICCs), and a deep-learning AI model was developed. RESULTS: A total of 3508 lateral elbow radiographs (mean age 9.8 ± 1.8 years) were collected. The olecranon BA showed the highest applicability (100%) and interobserver agreement (ICC 0.993) among elbow BA methods. It showed excellent reliability with Sauvegrain (0.967 in girls, 0.969 in boys) and Dimeglio (0.978 in girls, 0.978 in boys) elbow BA methods, as well as Korean standard (KS) hand BA in boys (0.917), and good reliability with KS in girls (0.896) and Greulich-Pyle (GP)/Tanner-Whitehouse (TW)3 (0.835 in girls, 0.895 in boys) hand BA methods. The AI model for olecranon BA showed an accuracy of 0.96 and a specificity of 0.98 with EfficientDet-b4. External validation showed an accuracy of 0.86 and a specificity of 0.91. CONCLUSION: The olecranon BA evaluation for puberty, requiring only a lateral elbow radiograph, showed the highest applicability and interobserver agreement, and excellent reliability with other BA evaluation methods, along with a high performance of the AI model. CLINICAL RELEVANCE STATEMENT: This AI model uses a single lateral elbow radiograph to determine bone age for puberty from the olecranon ossification center and can improve pubertal bone age assessment with the highest applicability and excellent reliability compared to previous methods. KEY POINTS: Elbow bone age is valuable for pubertal bone age assessment, but conventional methods have limitations. Olecranon bone age and its AI model showed high performances for pubertal bone age assessment. Olecranon bone age system is practical and accurate while requiring only a single lateral elbow radiograph.

Achieving Functional Goals During a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries.

OBJECTIVES: The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals. METHODS: We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 ( N = 1,228,913). The admission Minimum Data Set was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance ( n = 371,801). RESULTS: For all self-care items, more than 70% of residents had a goal score of 1-6 points documented on the admission Minimum Data Set. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12 steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals. CONCLUSIONS: Assessing a resident's functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.

Addressing non-response data for standardized post-acute functional items.

BACKGROUND: The post-acute patient standardized functional items (Section GG) include non-response options such as refuse, not attempt and not applicable. We examined non-response patterns and compared four methods to address non-response functional data in Section GG at nation-wide inpatient rehabilitation facilities (IRF). METHODS: We characterized non-response patterns using 100% Medicare 2018 data. We applied four methods to generate imputed values for each non-response functional item of each patient: Monte Carlo Markov Chains multiple imputations (MCMC), Fully Conditional Specification multiple imputations (FCS), Pattern-mixture model (PMM) multiple imputations and the Centers for Medicare and Medicaid Services (CMS) approach. We compared changes of Spearman correlations and weighted kappa between Section GG and the site-specific functional items across impairments before and after applying four methods. RESULTS: One hundred fifty-nine thousand six hundred ninety-one Medicare fee-for-services beneficiaries admitted to IRFs with stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. At discharge, 3.9% (self-care) and 61.6% (mobility) of IRF patients had at least one non-response answer in Section GG. Patients tended to have non-response data due to refused at discharge than at admission. Patients with non-response data tended to have worse function, especially in mobility; also improved less functionally compared to patients without non-response data. Overall, patients coded as 'refused' were more functionally independent in self-care and patients coded as 'not applicable' were more functionally independent in transfer and mobility, compared to other non-response answers. Four methods showed similar changes in correlations and agreements between Section GG and the site-specific functional items, but variations exist across impairments between multiple imputations and the CMS approach. CONCLUSIONS: The different reasons for non-response answers are correlated with varied functional status. The high proportion of patients with non-response data for mobility items raised a concern of biased IRF quality reporting. Our findings have potential implications for improving patient care, outcomes, quality reporting, and payment across post-acute settings.

Decrease of Muscle Mass in Young Patients With Neuromuscular Disease: Assessment of Sarcopenia.

BACKGROUND: Sarcopenia can be associated with the disease etiologies other than degenerative processes, such as neurologic disease including cerebral palsy, myelomeningocele, or Duchenne muscular dystrophy, even in children. Although the relationship between neurologic disease and scoliosis or ambulatory function is known, the mediators affecting scoliosis or gait function in these patients are unclear, an example might be sarcopenia. This study aimed to assess the degree of sarcopenia in young patients with neurologic diseases using computed tomography (CT), and analyze the correlation between sarcopenia and scoliosis or ambulatory function. METHODS: Pediatric and young adult patients (≤ 25 years old) who underwent whole-spine or lower-extremity CT were retrospectively included. From bilateral psoas muscle areas (PMAs) at the L3 level, the psoas muscle z-score (PMz) and psoas muscle index [PMI = PMA/(L3 height)²] were calculated. The t-test, Fisher's exact test, and logistic regression analyses were performed. RESULTS: A total of 121 patients (56 men, mean age 12.2 ± 3.7 years) were included with 79 neurologic and 42 non-neurologic diseases. Patients with neurologic diseases had lower PMz (P = 0.013) and PMI (P = 0.026) than patients without. In neurologic disease patients, severe scoliosis patients showed lower PMz (P < 0.001) and PMI (P = 0.001). Non-ambulatory patients (n = 42) showed lower BMI (ß = 0.727, P < 0.001) and PMz (ß = 0.547, P = 0.025). In non-ambulatory patients, patients with severe scoliosis also showed lower PMz (P < 0.001) and PMI (P = 0.004). CONCLUSION: Patients with neurologic diseases could have sarcopenia even in young age. Psoas muscle volume was also associated with ambulatory function in these patients. Sarcopenia was more severe in severe scoliosis patients in the non-ambulatory subgroup.

Increase in the Initial Outpatient Rehabilitation Utilization for Patients With Total Knee Arthroplasty.

OBJECTIVES: The objective of this study was to examine the patient characteristics and features associated with the initial rehabilitation utilization with a particular emphasis on outpatient rehabilitation after total knee arthroplasty (TKA) among 2016-2018 Texas Medicare enrollees. DESIGN: This is a retrospective cohort study. We used chi-square tests to examine the variability in patient demographic and clinical characteristics across the different post-acute rehabilitation settings after TKA. A Cochran-Armitage trend test was used to investigate the yearly trend of outpatient rehabilitation utilization after TKA. SETTING: Post-acute rehabilitation settings after TKA. PARTICIPANTS: The target population was Medicare beneficiaries aged ≥65 with an initial TKA in 2016-2018 and complete demographic and residential information (N=44,313). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We identified whether patients first used (1) outpatient rehabilitation, (2) home health, (3) self-care, (4) inpatient rehabilitation, (5) skilled nursing, or (6) other setting within the 3 months after TKA. RESULTS: Our results demonstrated an increasing use of the initial outpatient rehabilitation and home health, while the use of skilled nursing and inpatient rehabilitation facilities decreased from 2016 to 2018. The increase in outpatient utilization was significant in 2018 compared with 2016 controlling for distance to the TKA facilities, comorbid conditions, sex, race/ethnicity groups (White, Black, Hispanic, and Others), lower income (Medicaid eligible), Medicare entitlement types, age groups, and rurality (OR 1.23, 95% CI 1.12-1.34). However, the overall utilization rate of the initial outpatient rehabilitation after TKA remained low, increasing from 7.36% in 2016 to 8.60% in 2018. CONCLUSION: Despite the growing use of the initial outpatient rehabilitation after TKA, the overall rate of outpatient rehabilitation utilization remained low. Our findings raise an important question as to whether certain patient demographics and clinical groups might have limited access to outpatient rehabilitation after TKA.

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay.

OBJECTIVES: Older adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults' independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay. DESIGN: Retrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019. SETTINGS AND PARTICIPANTS: The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31, 2019. METHODS: The admission Minimum Data Set (MDS) was used to determine residents' prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge. RESULTS: Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively). CONCLUSIONS AND IMPLICATIONS: Our findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.

Image quality assessment of pediatric chest and abdomen CT by deep learning reconstruction.

BACKGROUND: Efforts to reduce the radiation dose have continued steadily, with new reconstruction techniques. Recently, image denoising algorithms using artificial neural networks, termed deep learning reconstruction (DLR), have been applied to CT image reconstruction to overcome the drawbacks of iterative reconstruction (IR). The purpose of our study was to compare the objective and subjective image quality of DLR and IR on pediatric abdomen and chest CT images. METHODS: This retrospective study included pediatric body CT images from February 2020 to October 2020, performed on 51 patients (34 boys and 17 girls; age 1-18 years). Non-contrast chest CT (n = 16), contrast-enhanced chest CT (n = 12), and contrast-enhanced abdomen CT (n = 23) images were included. Standard 50% adaptive statistical iterative reconstruction V (ASIR-V) images were compared to images with 100% ASIR-V and DLR at medium and high strengths. Attenuation, noise, contrast to noise ratio (CNR), and signal to noise (SNR) measurements were performed. Overall image quality, artifacts, and noise were subjectively assessed by two radiologists using a four-point scale (superior, average, suboptimal, and unacceptable). A phantom scan was performed including the dose range of the clinical images used in our study, and the noise power spectrum (NPS) was calculated. Quantitative and qualitative parameters were compared using repeated-measures analysis of variance (ANOVA) with Bonferroni correction and Wilcoxon signed-rank tests. RESULTS: DLR had better CNR and SNR than 50% ASIR-V in both pediatric chest and abdomen CT images. When compared with 50% ASIR-V, high strength DLR was associated with noise reduction in non-contrast chest CT (33.0%), contrast-enhanced chest CT (39.6%), and contrast-enhanced abdomen CT (38.7%) with increases in CNR at 149.1%, 105.8%, and 53.1% respectively. The subjective assessment of overall image quality and the noise was also better on DLR images (p < 0.001). However, there was no significant difference in artifacts between reconstruction methods. From NPS analysis, DLR methods showed a pattern of reducing the magnitude of noise while maintaining the texture. CONCLUSION: Compared with 50% ASIR-V, DLR improved pediatric body CT images with significant noise reduction. However, artifacts were not improved by DLR, regardless of strength.

Quantitative MRI Assessment of Pancreatic Steatosis Using Proton Density Fat Fraction in Pediatric Obesity.

OBJECTIVE: To assess the feasibility of quantitatively assessing pancreatic steatosis using magnetic resonance imaging (MRI) and its correlation with obesity and metabolic risk factors in pediatric patients. MATERIALS AND METHODS: Pediatric patients (≤ 18 years) who underwent liver fat quantification MRI between January 2016 and June 2019 were retrospectively included and divided into the obesity and control groups. Pancreatic proton density fat fraction (P-PDFF) was measured as the average value for three circular regions of interest (ROIs) drawn in the pancreatic head, body, and tail. Age, weight, laboratory results, and mean liver MRI values including liver PDFF (L-PDFF), stiffness on MR elastography, and T2* values were assessed for their correlation with P-PDFF using linear regression analysis. The associations between P-PDFF and metabolic risk factors, including obesity, hypertension, diabetes mellitus (DM), and dyslipidemia, were assessed using logistic regression analysis. RESULTS: A total of 172 patients (male:female = 125:47; mean ± standard deviation [SD], 13.2 ± 3.1 years) were included. The mean P-PDFF was significantly higher in the obesity group than in the control group (mean ± SD, 4.2 ± 2.5% vs. 3.4 ± 2.4%; p = 0.037). L-PDFF and liver stiffness values showed no significant correlation with P-PDFF (p = 0.235 and p = 0.567, respectively). P-PDFF was significantly associated with obesity (odds ratio 1.146, 95% confidence interval 1.006-1.307, p = 0.041), but there was no significant association with hypertension, DM, and dyslipidemia. CONCLUSION: MRI can be used to quantitatively measure pancreatic steatosis in children. P-PDFF is significantly associated with obesity in pediatric patients.

Quick assessment with controlled attenuation parameter for hepatic steatosis in children based on MRI-PDFF as the gold standard.

BACKGROUND: Controlled attenuation parameter (CAP) is a recently introduced, non-invasive and quantitative method to evaluate hepatic steatosis demonstrated in adults, but limited in obesity and not well evaluated in children. The aim of this study was to investigate the diagnostic performance for assessing hepatic steatosis grades using CAP in children based on MR proton density fat fraction (PDFF). METHODS: Children evaluated for non-alcoholic fatty liver disease (NAFLD) who were assessed for PDFF and CAP were enrolled retrospectively. Hepatic steatosis grades 0-3 were classified according to PDFF using cutoff values of 6, 17.5, and 23.3%. Subgroup analyses were performed in non-obese and obese groups using the 95th percentile body mass index (BMI) as a cutoff and BMI30 group when BMI > 30 kg/m2. Pearson's correlations between variables were also analyzed. RESULTS: In a total of 86 children, there were 53 in the obese group including 17 of the BMI30 group. CAP demonstrated 98.7% sensitivity and 80% specificity for diagnosing grades 1-3 vs. grade 0 using a cutoff value of 241 dB/m (area under the curve = 0.941, p < 0.001). The diagnostic performance for higher steatosis grades was suboptimal. CAP correlated with abdominal wall thickness in both obese (r = 0.549, p = 0.001) and non-obese (r = 0.386, p = 0.004) groups and did not correlate with PDFF in BMI30 group. CONCLUSION: In children with NAFLD, CAP showed excellent diagnostic performance for differentiating presence and absence of hepatic steatosis using a cutoff value of 241 dB/m. However, CAP was limited in evaluating grades of steatosis, especially in children with BMI > 30 kg/m2.

Evaluating Korean Personal Assistance Services Classification System.

OBJECTIVE: To evaluate the utility of using the Personal Assistance Services classification system (PAS-CS) that examines individuals with disabilities for services and government funding. To this end, this study also tests for significant differences in PAS-CS scores across disability grades and disability types. METHODS: A retrospective analysis was conducted using the 2014 National Survey on People with Disabilities (NSPD) data set. We selected patients with three types of disabilities (physical disabilities, brain lesions, and visual impairments). We compared the average PAS-CS scores of patients with different disability types and grades using general linear models with multiple comparisons. RESULTS: A total of 4,810 patients were included in the analysis. Patients with brain lesions had the highest average PAS-CS scores in activities of daily living (ADL) and instrumental activities of daily living (IADL) domains. Patients with visual impairments had the highest average scores in 'Disease-specific disability' and 'Social-environment' domains. For patients with physical disabilities and visual impairments, no PAS-CS domains were significantly different between patients with disability grade III and those with disability grade IV (p>0.05). CONCLUSION: The PAS-CS scores of disability grades were not equivalent among individuals with different disability types. The Korean Ministry of Health and Welfare currently only considers certain disability grades for PAS preeligibility, as a result disregarding the characteristics of different disability types. Thus, the current PAS-CS requires modifications.

Liver intravoxel incoherent motion diffusion-weighted imaging for the assessment of hepatic steatosis and fibrosis in children.

AIM: To evaluate the correlation between intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) parameters and the degree of hepatic steatosis and fibrosis in children. METHODS: This retrospective study was approved by the institutional review board. The children (≤ 18 years) who underwent liver IVIM DWI with 8 b-values under the suspicion of hepatic steatosis or fibrosis from February 2013 to November 2016 were included. Subjects were divided into normal, fatty liver (FAT), and fibrotic liver (FIB) groups. The slow diffusion coefficient (D), fast diffusion coefficient (D*), perfusion fraction (f), and apparent diffusion coefficient (ADC) were measured. MR proton density fat fraction (PDFF), MR elastography (MRE), and IVIM values were compared. RESULTS: A total of 123 children (median age of 12 years old, range: 6-18 years) were included, with 8 in the normal group, 93 in the FAT group, and 22 in the FIB group. The D* values were lower in the FIB group compared with those of the normal (P = 0.015) and FAT (P = 0.003) groups. The f values were lower in the FIB group compared with the FAT group (P = 0.001). In multivariate analyses, PDFF value was positively correlated with f value (ß = 3.194, P < 0.001), and MRE value was negatively correlated with D* value (ß = -7.031, P = 0.032). The D and ADC values were not influenced by PDFF or MRE value. CONCLUSION: In liver IVIM DWI with multiple b-values in children, there was a positive correlation between hepatic fat and blood volume, and a negative correlation between hepatic stiffness and endovascular blood flow velocity, while diffusion-related parameters were not affected.

MRI-based decision tree model for diagnosis of biliary atresia.

OBJECTIVES: To evaluate MRI findings and to generate a decision tree model for diagnosis of biliary atresia (BA) in infants with jaundice. METHODS: We retrospectively reviewed features of MRI and ultrasonography (US) performed in infants with jaundice between January 2009 and June 2016 under approval of the institutional review board, including the maximum diameter of periportal signal change on MRI (MR triangular cord thickness, MR-TCT) or US (US-TCT), visibility of common bile duct (CBD) and abnormality of gallbladder (GB). Hepatic subcapsular flow was reviewed on Doppler US. We performed conditional inference tree analysis using MRI findings to generate a decision tree model. RESULTS: A total of 208 infants were included, 112 in the BA group and 96 in the non-BA group. Mean age at the time of MRI was 58.7 ± 36.6 days. Visibility of CBD, abnormality of GB and MR-TCT were good discriminators for the diagnosis of BA and the MRI-based decision tree using these findings with MR-TCT cut-off 5.1 mm showed 97.3 % sensitivity, 94.8 % specificity and 96.2 % accuracy. CONCLUSIONS: MRI-based decision tree model reliably differentiates BA in infants with jaundice. MRI can be an objective imaging modality for the diagnosis of BA. KEY POINTS: • MRI-based decision tree model reliably differentiates biliary atresia in neonatal cholestasis. • Common bile duct, gallbladder and periportal signal changes are the discriminators. • MRI has comparable performance to ultrasonography for diagnosis of biliary atresia.

Change of Nutritional Status Assessed Using Subjective Global Assessment Is Associated With All-Cause Mortality in Incident Dialysis Patients.

Subjective global assessment (SGA) is associated with mortality in end-stage renal disease (ESRD) patients. However, little is known whether improvement or deterioration of nutritional status after dialysis initiation influences the clinical outcome. We aimed to elucidate the association between changes in nutritional status determined by SGA during the first year of dialysis and all-cause mortality in incident ESRD patients. This was a multicenter, prospective cohort study. Incident dialysis patients with available SGA data at both baseline and 12 months after dialysis commencement (n = 914) were analyzed. Nutritional status was defined as well nourished (WN, SGA A) or malnourished (MN, SGA B or C). The patients were divided into 4 groups according to the change in nutritional status between baseline and 12 months after dialysis commencement: group 1, WN to WN; group 2, MN to WN; group 3, WN to MN; and group 4, MN to MN. Cox proportional hazard analysis was performed to clarify the association between changes in nutritional status and mortality. Being in the MN group at 12 months after dialysis initiation, but not at baseline, was a significant risk factor for mortality. There was a significant difference in the 3-year survival rates among the groups (group 1, 92.2%; group 2, 86.0%; group 3, 78.2%; and group 4, 63.5%; log-rank test, P < 0.001). Multivariate Cox regression analysis revealed that the mortality risk was significantly higher in group 3 than in group 1 (hazard ratio [HR] 2.77, 95% confidence interval [CI] 1.27-6.03, P = 0.01) whereas the mortality risk was significantly lower in group 2 compared with group 4 (HR 0.35, 95% CI 0.17-0.71, P < 0.01) even after adjustment for confounding factors. Moreover, mortality risk of group 3 was significantly higher than in group 2 (HR 2.89, 95% CI 1.22-6.81, P = 0.02); there was no significant difference between groups 1 and 2. The changes in nutritional status assessed by SGA during the first year of dialysis were associated with all-cause mortality in incident ESRD patients.

Quantitative computed tomography assessment of graft-versus-host disease-related bronchiolitis obliterans in children: A pilot feasibility study.

OBJECTIVE: To suggest a simple method that can quantify air trapping from chest CT in children with graft-versus-host disease (GVHD)-related bronchiolitis obliterans (BO). METHODS: This institutional review board-approved retrospective study included eight GVHD-related BO patients (age, 6 - 17 years) who underwent both 31 CTs of variable settings and pulmonary function tests (PFT). The attenuation values of lung parenchyma in normal (An) and air trapping (Aa) areas were obtained. Individualized threshold [(An + Aa)/2] and fixed threshold of -950 HU were set for air trapping quantification. Spearman correlation analysis and generalized linear mixed models were used for statistical analysis. RESULTS: The mean value of individualized threshold was -830.2 ± 48.3 HU. The mean air trapping lung volume percentage with individualized threshold and -950 HU were 45.4 ± 18.9% and 1.4 ± 1.9%, respectively. The air trapping lung volume percentage with individualized threshold showed a significant negative correlation with the PFT of FEV1/FVC% in all data (γ = -0.795, P < .001) and in the correction of repetition (γ = -0.837, P = .010). CONCLUSIONS: We suggest a simple and individualized threshold attenuation setting method for air trapping quantification insusceptible to CT imaging protocols or respiratory phase control in children with GVHD-related BO. KEY POINTS: • Simple and individualized threshold attenuation setting for air trapping quantification is possible. • Individualized threshold attenuation setting is insusceptible to CT imaging protocols or respiratory phase control. • CT air trapping quantification correlates with PFT of pulmonary obstruction.