The automated Greulich and Pyle: a coming-of-age for segmental methods?

The well-known Greulich and Pyle (GP) method of bone age assessment (BAA) relies on comparing a hand X-ray against templates of discrete maturity classes collected in an atlas. Automated methods have recently shown great success with BAA, especially using deep learning. In this perspective, we first review the success and limitations of various automated BAA methods. We then offer a novel hypothesis: When networks predict bone age that is not aligned with a GP reference class, it is not simply statistical error (although there is that as well); they are picking up nuances in the hand X-ray that lie "outside that class." In other words, trained networks predict distributions around classes. This raises a natural question: How can we further understand the reasons for a prediction to deviate from the nominal class age? We claim that segmental aging, that is, ratings based on characteristic bone groups can be used to qualify predictions. This so-called segmental GP method has excellent properties: It can not only help identify differential maturity in the hand but also provide a systematic way to extend the use of the current GP atlas to various other populations.

Pilot Study on Gut Microbiota Profile in Indian Children with Type 1 Diabetes.

Background: Non-genetic factors like microbial dysbiosis may be contributing to the increasing incidence/progression of type 1 diabetes mellitus (T1DM). Objectives: To analyse the gut microbiota profile in Indian children with T1DM and its effect on glycaemic control. Methodology: Faecal samples of 29 children with T1DM were collected and faecal microbial DNA was extracted and subjected to 16S rRNA (ribosomal RNA) sequencing and further analysis. Results: The dominant phyla in children with T1DM were Firmicutes and Bacteroidetes. Butyrate-producing bacteria Blautia and Ruminococcus showed a significant negative correlation with the glycosylated haemoglobin (HbA1C) levels (p < 0.05). Coprococcus and Propionibacterium were important negative predictors of glycaemic control (p < 0.05). Conclusion: Our study suggests that Indian children with T1DM have a distinct gut microbiome taxonomic composition and that short-chain fatty acid-producing bacteria like Ruminococcus and Blautia (butyrate-producing) may play an important role in the glycaemic control of subjects with T1DM.

Adiponectin-leptin ratio as a marker of cardio-metabolic risk in Indian children and youth with type 1 diabetes.

OBJECTIVES: Adiponectin/leptin ratio (ALR) is a promising novel marker of cardio-metabolic risk in patients with metabolic syndrome. Our aim was to study the association of adiponectin-leptin ratio with markers of obesity and adiposity and also to assess its usefulness as a marker of increased cardiometabolic risk (CMR) in Indian children and youth with type 1 diabetes mellitus. METHODS: This observational study included 79 children and youth with type 1 diabetes (T1DM) (10-21 years) having disease duration>6 months. Demographic data and laboratory findings were obtained from patients' records. Patients with ALR<1 were categorised as having increased CMR and those with ALR>1 were categorised as having no CMR. RESULTS: ALR showed a significant negative correlation with body mass index (BMI), waist and hip circumference and body fat percentage (p<0.05). Body fat percentage was the single most important predictor of ALR. Children and youth with increased CMR had higher weight, BMI, waist and hip circumferences and body fat percentage as compared to those with no CMR (p<0.05). In T1DM children with dyslipidemia, ALR was significantly lower as compared to those without dyslipidemia (p<0.05). CONCLUSIONS: ALR may be a useful marker for adiposity and increased cardiometabolic risk in Indian children and youth with type 1 diabetes mellitus.

Contribution of Vitamin D Metabolites to Vitamin D Concentrations of Families Residing in Pune City.

The objective was to explore the patterns of contribution from vitamin D metabolites (D2 and D3) to total vitamin D concentrations in Indian families. This cross-sectional study was carried out in slum-dwelling families residing in Pune city. Data on demography, socio-economic status, sunlight exposure, anthropometry, and biochemical parameters (serum 25OHD2, 25OHD3) via the liquid chromatography-tandem mass spectrometry method were collected. The results are presented for 437 participants (5 to 80 years). One-third were vitamin-D-deficient. Intake of foods containing vitamin D2 or D3 was rarely reported. Irrespective of gender, age, and vitamin D status, the contribution of D3 to total 25OHD concentrations far exceeded that of D2 (p < 0.05). The contribution of D2 ranged from 8% to 33% while that of D3 to 25OHD concentrations ranged from 67% to 92%. 25OHD3 is a major contributor to overall vitamin D concentrations, and the contribution of 25OHD2 was found to be negligible. This implies that sunlight and not diet is currently the major source of vitamin D. Considering that lifestyle and cultural practices may lead to insufficient sunlight exposure for large sections of the society, especially women, dietary contribution to vitamin D concentrations through fortification may play an important role in improving the vitamin D status of Indians.

A comparison of bone age assessments using automated and manual methods in children of Indian ethnicity.

BACKGROUND: Bone age is useful for pediatric endocrinologists in evaluating various disorders related to growth and puberty. Traditional methods of bone age assessment, namely Greulich and Pyle (GP) and Tanner-Whitehouse (TW), have intra- and interobserver variations. Use of computer-automated methods like BoneXpert might overcome these subjective variations. OBJECTIVE: The aim of our study was to assess the validity of BoneXpert in comparison to manual GP and TW methods for assessing bone age in children of Asian Indian ethnicity. MATERIALS AND METHODS: We extracted from a previous study the deidentified left hand radiographs of 920 healthy children aged 2-19 years. We compared bone age as determined by four well-trained manual raters using GP and TW methods with the BoneXpert ratings. We computed accuracy using root mean square error (RMSE) to assess how close the bone age estimated by BoneXpert was to the reference rating. RESULTS: The standard deviations (SDs) of rating among the four manual raters were 0.52 years, 0.52 years and 0.47 years for GP, TW2 and TW3 methods, respectively. The RMSEs between the automated bone age estimates and the true ratings were 0.39 years, 0.41 years and 0.36 years, respectively, for the same methods. The RMSE values were significantly lower in girls than in boys (0.53, 0.5 and 0.47 vs. 0.39, 0.47 and 0.4) by all the methods; however, no such difference was noted in classification by body mass index. The best agreement between BoneXpert and manual rating was obtained by using 50% weight on carpals (GP50). The carpal bone age was retarded in Indian children, more so in boys. CONCLUSION: BoneXpert was accurate and performed well in estimating bone age by both GP and TW methods in healthy Asian Indian children; the error was larger in boys. The GP50 establishes "backward compatibility" with manual rating.

Impact of decreased physical activity due to COVID restrictions on cardio-metabolic risk parameters in Indian children and youth with type 1 diabetes.

BACKGROUND AND AIMS: Implementation of COVID restrictions following lockdown led to changes in routines of subjects with type 1 diabetes due to closure of schools and outdoor activities. The aim of this study was to assess the impact of decreased physical activity due to COVID restrictions on cardio-metabolic risk parameters (waist circumference, laboratory and body composition parameters) in Indian children and youth with T1D. METHODS: This observational study included 312 participants (2-21 years) with T1DM having disease duration of ≥6 months. Demographic, anthropometric, body composition data and investigations were recorded at two time points (during COVID restrictions when children came for follow up, pre COVID restriction data from medical and electronic records). RESULTS: Glycemic control improved during COVID restrictions (Hba1c: 9.8 ± 2.0%) as compared to pre COVID restrictions (Hba1C: 10.0 ± 1.9%) (p < 0.05). However, due to significant reduction in physical activity (p < 0.05) there was significant increase in waist circumference z-scores (-0.9 ± 1.1 vs -1.6 ± 1.1), body fat percentage z-scores (-0.2 ± 1.0 vs -0.3 ± 0.9) and lipid parameters like cholesterol, low density lipid cholesterol and triglyceride concentrations (p < 0.05) without any significant change in body mass index z-scores (p > 0.05). CONCLUSIONS: Prolonged COVID restrictions, although led to modest improvement in glycemic control, there was worsening of cardio-metabolic risk factors or indices of adiposity like waist circumference, body fat percentage and lipid parameters which could be attributed to decreased time spent in physical activity.

Prevalence of metabolic syndrome and predictors of metabolic risk in Indian children, adolescents and youth with type 1 diabetes mellitus.

INTRODUCTION: Children with type 1 diabetes (T1D) are at the same risk of developing metabolic syndrome (MS) as the general population. Several environmental factors such as lifestyle, exogenous insulin therapy (over-insulinization) and genetic/familial factors are thought to underlie the phenotype of 'double diabetes' (co-existence of MS components in patients with T1D). OBJECTIVES: To determine the prevalence of overweight/obesity and MS and to identify its predictors in Indian children, adolescents and young adults with T1D. METHODS: This cross-sectional study included 355 children and youth aged 6-23 years with T1D. Demographic data were obtained from patients using questionnaires. Anthropometry, blood pressure, sexual maturity rating, biochemical measurements and body composition measurements were performed using standard protocols. Insulin resistance (IR) was calculated using estimated glucose disposal rate (eGDR) and MS was diagnosed using the international diabetes federation (IDF) consensus definition 2017. RESULTS: The prevalence of overweight/obesity and MS in our study was 15.5% and 4.5%, respectively. Abnormal HDL-cholesterol was the most common component of MS (55.6%) among children with T1D. Age, gender, body mass index (BMI) and eGDR were identified as significant predictors of the likelihood of MS. CONCLUSIONS: We found a similar prevalence of MS in children with T1D as compared to other healthy children, which emphasises the need for monitoring of eGDR to determine IR in these children.

Impact of lockdown for COVID-19 pandemic in Indian children and youth with type 1 diabetes from different socio-economic classes.

OBJECTIVES: In March 2020, lockdown was imposed in India to combat spread of Coronavirus, which was extended till 31st May. Implementation of lockdown and limited outdoor activities resulted in changes in routines of children with diabetes. The aim of this study was to assess the impact of lockdown on glycemic control, weight and body mass index (BMI) patterns of children with type 1 diabetes (T1DM) from different socio-economic (SE) classes. METHODS: This observational study included 77 children and youth (5-20 years) with T1DM having disease duration of ≥6 months. Demographic data and investigations were recorded at two time points (post lockdown when the children came for follow up, pre lockdown data from medical records). RESULTS: Glycemic control improved (pre lockdown HbA1C 79.4±19.2 vs. post lockdown Hba1C 74.5±16.9 mmol/mol, p<0.05) and there was weight gain post lockdown (pre lockdown weight z-score -0.4±0.8 vs. post lockdown weight z-score -0.2±0.8, p<0.05) without any significant change in BMI and insulin requirements. Improved glycemic was seen in the lower SE group control post lockdown (p<0.05), whereas in higher SE group, it remained unchanged. Children whose parents were at home during lockdown showed an improved glycemic control (p<0.05) as compared to children whose parents continued to work during lockdown (p>0.01). CONCLUSIONS: During coronavirus lockdown, glycemic control was adequately maintained in children with T1DM, highlighting importance of stronger family support system leading to more steady daily routine.

Random Blood Glucose Concentrations and their Association with Body Mass Index in Indian School Children.

OBJECTIVE AND AIMS: Overweight/obese children are at risk of developing type 2 diabetes mellitus. Random glucose elevations provide early warning signs of glycemic dysregulation. To assess random blood glucose (RBG) concentrations and risk factors associated with prediabetes in children aged 3-18 years from six Indian regions. METHOD: Multicenter, cross sectional, observational school-based study; multi-stage stratified random sampling was carried out. Height and weight measured; body mass index (BMI) was computed. RBG measured using a glucometer. National sample survey was used for dietary patterns. Data were analyzed using SPSS 25.0 for Windows. SETTING: Study centers were from Maharashtra, Gujarat, Chhattisgarh, Assam, Tamil Nadu and Punjab from 40 selected schools. PARTICIPANT: Children aged 3-18 years were measured. RESULTS: Data on 14339 subjects (7413 boys) were analyzed. Prevalence of obesity was 5.8% and overweight-10.6%. Overall, 1% had low (<3 mmol/L), 93.7% in reference range (3.9-7.2 mmol/L) and 5.3% had elevated RBG (>7.2 mmol/L). With increasing mean BMI, there was increase in RBG concentrations. Children from Tamil Nadu were more likely to have RBG outside reference range compared to other regions (P < 0.05). Assam and Punjab had highest prevalence of RBG and BMI within reference range. Energy intake partly explained regional variations. Multivariate analysis showed male gender, urban residency, age >10 yrs (girls) and 13 yrs (boys), and overweight or obesity were predictive of prediabetes. CONCLUSION: Increased prevalence of overweight, obesity and prediabetes in Indian children are a matter of concern. Regional differences suggest that strategies to prevent obesity and combat perturbations in blood sugar may have to be customized.

Sitting height percentiles in 3-17-year-old Indian children: a multicentre study.

Background: Sitting height (StH) percentiles are not described for the Indian paediatric population.Aim: To generate multicentre StH percentile values for Indian children.Subjects and methods: A total of 7961 apparently healthy children (3-17 years old, Boys: 4328) randomly selected from 10 schools from six states of India were measured for height (ht), StH and weight during July 2016-October 2017.Results: The StH:Ht ratio was 0.52 (0.02) and was similar between boys and girls (p > 0.1). The ratio decreased in boys until the age of 14 years and then slightly increased; the lowest ratio was observed during 13-15 years. In girls, however, the StH:Ht ratio decreased until the age of 9 years and then plateaued until 15 years of age with a slight increase at 16 years; the lowest ratio was observed at the age of 12-13 years. Sitting height percentiles (3rd, 10th, 25th, 50th, 75th, 90th and 97th) were computed using LMS chartmaker.Conclusions: The results indicate that, during the pubertal years, the lower limb growth is more predominant than trunk growth. Further, this study provides smoothened percentile curves for sitting height in Indian children for the first time.