Dating birth-related clavicular fractures: pediatric radiologists versus artificial intelligence.

BACKGROUND: Fracture dating from skeletal surveys is crucial in the diagnosis and investigation of infant abuse. However, this task is challenging because of the subjective nature of the radiologic interpretation and the lack of ground truth. Researchers have used birth-related clavicle fractures as a surrogate to study the radiographic pattern of healing; however, they did not elucidate the accuracy performance of the radiologists in dating fractures. OBJECTIVE: To determine the accuracy of radiologists in dating birth-related clavicle fractures and compare their performance to that achieved by computer algorithm. MATERIALS AND METHODS: We used a previously assembled birth-related clavicle fracture database consisting of 416 anteroposterior clavicle radiographs as the study cohort. The average and standard deviation of the fracture age within this database were 24 days and 18 days, respectively. Three blinded radiologists independently estimated the ages of the clavicle fractures depicted in the radiographs within the database. We compared these estimation results to those made by a recently published deep-learning (DL) model conducted with the identical infant cohort. We calculated standard error metrics to compare the accuracy performances of the radiologists and the computer model. RESULTS: The intra- and inter-reader agreements of the fracture age estimates by the radiologists were moderate to good. The radiologists estimated the fracture ages with a mean absolute error (MAE) of 6.1-7.1 days, and standard deviation of the absolute error of 6.3-8.3 days. The accuracy performances of the three radiologists were not significantly different from one another. In comparison, the DL model estimated the age of clavicle fractures with an MAE of 4.2 days, significantly lower than all of the radiologists (P < 0.001). CONCLUSION: Three experienced pediatric radiologists dated clavicular fractures with moderate-good intra- and inter-reader agreements. The correlations between the radiologists' estimates and the ground truth were moderate to good. The fracture ages assigned by the DL model showed superior correlation with the ground truth compared to radiologists' dating estimates.

Skeletal maturation and long-bone growth patterns of patients with progeria: a retrospective study.

BACKGROUND: Hutchinson-Gilford progeria syndrome (termed progeria in this Article) is a rare sporadic genetic disorder. One early clinical manifestation of progeria is abnormal skeletal growth, yet this growth has not been fully characterised. We aimed to characterise the skeletal maturation and long-bone growth patterns of patients with the clinical phenotype of progeria. METHODS: For this retrospective study, we reviewed skeletal surveys of patients (aged <20 years) with progeria obtained over a 9·5-year period. Most surveys included radiographs of the hands and long bones (humeri, radii, ulnas, tibias, and fibulas). Bone ages of these patients were estimated by the standards of Greulich and Pyle. Following the established methods for studying long-bone growth, the study cohort was separated into two overlapping age groups: longitudinal bone length measurements were made between physes for the childhood group (aged 12 years or younger) and from the upper margins of the proximal to the lower margin of the distal ossified epiphyses for the adolescent group (aged 10 years or older). Bone age estimates and bone length measurements were plotted against the chronological age of patients and compared with reference standards. Statistical analyses were based on mixed models. FINDINGS: 85 patients with progeria and 250 skeletal surveys were included in our study. For both sexes, bone age estimates showed a more advanced skeletal maturation rate throughout all chronological ages than the normal rate of 1 (p<0·0001), with the rate of maturation being 1·09 (SE 0·02) for boys and 1·14 (0·02) for girls. Longitudinal long-bone lengths began to deviate from normal standards by age 1-2 years. Growth curves for these long bones plateaued at about half the normal eventual bone length, and the half-life (the time taken to grow to half the eventual bone length) was also about half the time compared with normal standards. INTERPRETATION: Our study established growth curves that might serve as reference standards for skeletal maturation and long-bone growth of patients with the clinical phenotype of progeria. FUNDING: The Progeria Research Foundation, the US National Heart, Lung and Blood Institute, the Dana-Farber Cancer Institute Stop&Shop Pediatric Brain Tumor Program, the US National Center for Research Resources, US National Institutes of Health.

Management Strategies in the Intensive Care Unit to Improve Psychosocial Outcomes.

Critical care nurses work in challenging environments that are often sterile, impersonal, noisy, and frightening to patients and their families. Nurses act as liaisons between medical professionals and patients and their families in multiple specialty intensive care units. Critical care nursing practice, guided by the American Nurses Association Code of Ethics, respects patients' religious, spiritual, and cultural beliefs, contributing to holistic care delivery. Therapeutic psychosocial outcomes of holistic care delivery and patient advocacy are explored. Personalized psychosocial care through treating patients holistically will support and maintain positive psychosocial outcomes in intensive care units across the country.

Management of Chronic Stable Angina.

Chronic stable angina (CSA) is a symptomatic problem that is precipitated by ischemic heart disease. CSA is diagnosed when symptoms are present for at least 2 months without changes in severity, character, or triggering circumstances. This article is a summary of current treatment strategies aimed to prevent progression of atherosclerosis, and medication therapies to control angina symptoms and improve quality of life for the individual.

Development of a Standardized Kalamazoo Communication Skills Assessment Tool for Radiologists: Validation, Multisource Reliability, and Lessons Learned.

OBJECTIVE: The purpose of this study was to develop and test a standardized communication skills assessment instrument for radiology. MATERIALS AND METHODS: The Delphi method was used to validate the Kalamazoo Communication Skills Assessment instrument for radiology by revising and achieving consensus on the 43 items of the preexisting instrument among an interdisciplinary team of experts consisting of five radiologists and four nonradiologists (two men, seven women). Reviewers assessed the applicability of the instrument to evaluation of conversations between radiology trainees and trained actors portraying concerned parents in enactments about bad news, radiation risks, and diagnostic errors that were video recorded during a communication workshop. Interrater reliability was assessed by use of the revised instrument to rate a series of enactments between trainees and actors video recorded in a hospital-based simulator center. Eight raters evaluated each of seven different video-recorded interactions between physicians and parent-actors. RESULTS: The final instrument contained 43 items. After three review rounds, 42 of 43 (98%) items had an average rating of relevant or very relevant for bad news conversations. All items were rated as relevant or very relevant for conversations about error disclosure and radiation risk. Reliability and rater agreement measures were moderate. The intraclass correlation coefficient range was 0.07-0.58; mean, 0.30; SD, 0.13; and median, 0.30. The range of weighted kappa values was 0.03-0.47; mean, 0.23; SD, 0.12; and median, 0.22. Ratings varied significantly among conversations (χ26 = 1186; p < 0.0001) and varied significantly by viewing order, rater type, and rater sex. CONCLUSION: The adapted communication skills assessment instrument is highly relevant for radiology, having moderate interrater reliability. These findings have important implications for assessing the relational competencies of radiology trainees.

Prevalence of Capitellar Osteochondritis Dissecans in Children With Chronic Radial Head Subluxation and Dislocation.

OBJECTIVE: An abnormal radiocapitellar articulation may play a role in the development of capitellar osteochondritis dissecans (OCD). The objective of this study is to determine the prevalence of capitellar OCD in pediatric patients with chronic radial head subluxation (RHS) or radial head dislocation (RHD). MATERIALS AND METHODS: We searched the radiology reports generated at a large pediatric hospital between 2004 and 2012, to identify patients 8-18 years old with chronic RHS or RHD. Patients with underlying bony abnormalities that could obscure, be confused with, or increase the risk of OCD of the elbow were excluded. Two pediatric radiologists assessed images of the elbow, grading radiocapitellar alignment as follows: normal, subluxed, dislocated, or intermittently subluxed and dislocated. Readers also reviewed images to detect capitellar OCD. The differences in the prevalence of OCD noted in elbows in each category of radiocapitellar alignment were assessed. RESULTS: A total of 118 cases of chronic RHS, RHD, or both were detected in 100 patients. The radiocapitellar alignment of these cases was defined as follows: 53-58% were dislocated, 26-31% were subluxed, 14-15% were intermittently subluxed and dislocated, and less than 1% had normal alignment. There were 14 cases of capitellar OCD (11.9%). One elbow with OCD was categorized by both readers as dislocated, with the remaining 13 elbows (93%) deemed by the two readers to be either subluxed or intermittently subluxed and dislocated. The percentage of elbows with RHS that were found to have capitellar OCD was 32.3-33.3%, compared with 1.4-1.6% of elbows with RHD. CONCLUSION: The prevalence of capitellar OCD is greater in elbows with RHS than in those with RHD. This finding suggests that abnormal radiocapitellar mechanics are a factor in the development of OCD. In children with RHS and new or worsening pain, capitellar OCD should be considered, and imaging strategies should be directed toward early identification of this important and treatable condition.

Management of Travel-Related Illness Acquired in Haiti.

Management of travel-related diseases acquired in Haiti begins with the identification of tropical diseases that are prevalent in the region. Knowledge of various tropical disease incubation periods and presenting symptoms is crucial to ensure rapid triage and management of care.

Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse.

BACKGROUND: Dating fractures is critical in cases of suspected infant abuse. There are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. OBJECTIVE: Since birth-related clavicular fractures are not immobilized and their age is known, we propose that an assessment of these injuries may serve as a guide for dating inflicted fractures in young infants, acknowledging that patterns observed in the clavicle may not be entirely generalizable to other bones injured in the setting of abuse. MATERIALS AND METHODS: One hundred thirty-one radiographs of presumed birth-related clavicular fractures in infants between 0 and 3 months of age were reviewed by two pediatric radiologists with 30 and 15 years' experience. Readers were asked to evaluate images based on several parameters of fracture healing, with a focus on subperiosteal new bone formation (SPNBF) and callus formation. SPNBF and callus were each evaluated with regard to presence, thickness and character. Responses were correlated with known fracture ages. RESULTS: SPNBF was rarely seen in fractures less than 7 days old and was most often present by 10 days. Callus formation was rarely seen in fractures less than 9 days old and was most often present by 15 days. SPNBF thickness increased with fracture age and the character of SPNBF evolved from single-layered to solid/multilayered. Callus thickness decreased with fracture age and callus matrix evolved from soft to intermediate to hard in character. CONCLUSION: There is an evolution in clavicular fracture healing in young infants that follows a predictable pattern. These findings afford the prospect that predictable patterns of infant clavicular fracture healing can provide an evidence base that may be applicable in cases of suspected infant abuse.

Comparative evaluation of the resolution of hydronephrosis in children who underwent open and robotic-assisted laparoscopic pyeloplasty.

OBJECTIVES: To assess long-term postoperative ultrasonographic outcomes of robotic-assisted laparoscopic pyeloplasty (RALP) and of conventional open pyeloplasty (COP) in pediatric patients with ureteropelvic junction obstruction. METHODS: Retrospective review of 312 patients who underwent RALP or COP in a single institution. Preoperative and postoperative ultrasounds were used to determine the grade of hydronephrosis. Postoperative assessment included 3 ultrasounds at 0-6, 6-12 and >12 months intervals. Patients were matched by age, etiology of obstruction, grade of preoperative hydronephrosis and gender for case-matched analysis. RESULTS: We identified 212 pyeloplasties that met inclusion criteria, being 58 RALP and 154 COP. Groups were different in age, gender and etiology, but similar in severity of hydronephrosis and follow-up time. At the end of follow-up, complete resolution and success rates were 62% and 74% in RALP and 45% and 70% in COP, respectively. Matching included 105 patients. Complete resolution was higher in RALP (p = 0.004), while median time before improvement was lower (12.3 months RALP vs 29.9 months COP). There was no difference in success rate at the end of follow-up between the groups. CONCLUSION: RALP shows satisfactory long-term outcomes, comparable to COP. In our cohort, patients who underwent robotic pyeloplasty showed faster resolution of hydronephrosis on ultrasound.

The feasibility and utility of grocery receipt analyses for dietary assessment.

OBJECTIVE: To establish the feasibility and utility of a simple data collection methodology for dietary assessment. DESIGN: Using a cross-sectional design, trained data collectors approached adults (approximately 20 - 40 years of age) at local grocery stores and asked whether they would volunteer their grocery receipts and answer a few questions for a small stipend (dollar 1). METHODS: The grocery data were divided into 3 categories: "fats, oils, and sweets," "processed foods," and "low-fat/low-calorie substitutions" as a percentage of the total food purchase price. The questions assessed the shopper's general eating habits (eg, fast-food consumption) and a few demographic characteristics and health aspects (eg, perception of body size). Statistical Analyses Performed. Descriptive and analytic analyses using non-parametric tests were conducted in SAS. RESULTS: Forty-eight receipts and questionnaires were collected. Nearly every respondent reported eating fast food at least once per month; 27% ate out once or twice a day. Frequency of fast-food consumption was positively related to perceived body size of the respondent (p = 0.02). Overall, 30% of the food purchase price was for fats, oils, sweets, 10% was for processed foods, and almost 6% was for low-fat/low-calorie substitutions. Households where no one was perceived to be overweight spent a smaller proportion of their food budget on fats, oils, and sweets than did households where at least one person was perceived to be overweight (p = 0.10); household where the spouse was not perceived to be overweight spent less on fats, oils, and sweets (p = 0.02) and more on low-fat/low-calorie substitutions (p = 0.09) than did households where the spouse was perceived to be overweight; and, respondents who perceived themselves to be overweight spent more on processed foods than did respondents who did not perceive themselves to be overweight (p = 0.06). CONCLUSION: This simple dietary assessment method, although global in nature, may be a useful indicator of dietary practices as evidenced by its association with perceived weight status.

Effects of fire and fire intensity on the germination and establishment of Acacia karroo, Acacia nilotica, Acacia luederitzii and Dichrostachys cinerea in the field.

BACKGROUND: While fire has been used in some instances to control the increase of woody plants, it has also been reported that fire may cause an increase in certain fire-tolerant Acacia tree species. This study investigated germination of Acacia karroo, A. luederitzii and Dichrostachys cinerea, thought to be increasing in density, as well as the historically successful encroaching woody species, A. nilotica, in savanna grassland, Hluhluwe-iMfolozi Park, South Africa. A. karroo is thought to be replacing A. nilotica as the dominant microphyllous species in the park. We tested the hypothesis that observed increases in certain woody plants in a savanna were related to seed germination and seedling establishment. Germination is compared among species for burnt and unburnt seeds on burnt and unburnt plots at three different locations for both hot and cool fires. RESULTS: Acacia karroo showed higher germination (A. karroo 5.1%, A. nilotica 1.5% and A. luederitzii 5.0%) levels and better establishment (A. karroo 4.9%, A. nilotica 0.4% and A. luederitzii 0.4%). Seeds of the shrub Dichrostachys cinerea did not germinate in the field after fire and it is thought that some other germination cue is needed. On average, burning of A. karroo, A. nilotica and A. luederitzii seeds did not affect germination. There was a significant difference in the germination of burnt seeds on burnt sites (4.5%) and burnt seeds on unburnt plots (2.5%). Similarly, unburnt seeds on unburnt sites germinated better (4.9%) than unburnt seeds on burnt sites (2.8%). CONCLUSION: We conclude that a combination of factors may be responsible for the success of A. karroo and that fires may not be hot enough or may occur at the wrong time of year to control A. karroo establishment in HiP. Although germination and establishment of A. karroo was higher than for A. nilotica a competitive advantage after fire could not be shown.