MR Cranial Bone Imaging: Evaluation of Both Motion-Corrected and Automated Deep Learning Pseudo-CT Estimated MR Images.

BACKGROUND AND PURPOSE: CT imaging exposes patients to ionizing radiation. MR imaging is radiation free but previously has not been able to produce diagnostic-quality images of bone on a timeline suitable for clinical use. We developed automated motion correction and use deep learning to generate pseudo-CT images from MR images. We aim to evaluate whether motion-corrected pseudo-CT produces cranial images that have potential to be acceptable for clinical use. MATERIALS AND METHODS: Patients younger than age 18 who underwent CT imaging of the head for either trauma or evaluation of cranial suture patency were recruited. Subjects underwent a 5-minute golden-angle stack-of-stars radial volumetric interpolated breath-hold MR image. Motion correction was applied to the MR imaging followed by a deep learning-based method to generate pseudo-CT images. CT and pseudo-CT images were evaluated and, based on indication for imaging, either presence of skull fracture or cranial suture patency was first recorded while viewing the MR imaging-based pseudo-CT and then recorded while viewing the clinical CT. RESULTS: A total of 12 patients underwent CT and MR imaging to evaluate suture patency, and 60 patients underwent CT and MR imaging for evaluation of head trauma. For cranial suture patency, pseudo-CT had 100% specificity and 100% sensitivity for the identification of suture closure. For identification of skull fractures, pseudo-CT had 100% specificity and 90% sensitivity. CONCLUSIONS: Our early results show that automated motion-corrected and deep learning-generated pseudo-CT images of the pediatric skull have potential for clinical use and offer a high level of diagnostic accuracy when compared with standard CT scans.

Use of computed tomography to identify muscle quality subgroups, spatial mapping, and preliminary relationships to function in those with diabetic peripheral neuropathy.

BACKGROUND: Decreased muscle volume and increased muscle-associated adipose tissue (MAAT, sum of intra and inter-muscular adipose tissue) of the foot intrinsic muscle compartment are associated with deformity, decreased function, and increased risk of ulceration and amputation in those with diabetic peripheral neuropathy (DPN). RESEARCH QUESTION: What is the muscle quality (normal, abnormal muscle, and adipose volumes) of the DPN foot intrinsic compartment, how does it change over time, and is muscle quality related to gait and foot function? METHODS: Computed tomography was performed on the intrinsic foot muscle compartment of 45 subjects with DPN (mean age: 67.2 ± 6.4 years) at baseline and 3.6 years. Images were processed to obtain volumes of MAAT, highly abnormal, mildly abnormal, and normal muscle. For each category, annual rates of change were calculated. Paired t-tests compared baseline and follow-up. Foot function during gait was assessed using 3D motion analysis and the Foot and Ankle Ability Measure. Correlations between muscle compartment and foot function during gait were analyzed using Pearson's correlations. RESULTS: Total muscle volume decreased, driven by a loss of normal muscle and mildly abnormal muscle (p<0.05). MAAT and the adipose-muscle ratio increased. At baseline, 51.5% of the compartment was abnormal muscle or MAAT, increasing to 55.0% at follow-up. Decreased total muscle volume correlated with greater midfoot collapse during gait (r = -0.40, p = 0.02). Greater volumes of highly abnormal muscle correlated with a lower FAAM score (r = -0.33, p = 0.03). SIGNIFICANCE: Muscle volume loss may progress in parallel with MAAT accumulation, impacting contractile performance in individuals with DPN. Only 48.5% of the DPN intrinsic foot muscle compartment consists of normal muscle and greater abnormal muscle is associated with worse foot function. These changes identify an important target for rehabilitative intervention to slow or prevent muscle deterioration and poor foot outcomes.

Alzheimer Disease Pathology and Neurodegeneration in Midlife Obesity: A Pilot Study.

Obesity and excess adiposity at midlife are risk factors for Alzheimer disease (AD). Visceral fat is known to be associated with insulin resistance and a pro-inflammatory state, the two mechanisms involved in AD pathology. We assessed the association of obesity, MRI-determined abdominal adipose tissue volumes, and insulin resistance with PET-determined amyloid and tau uptake in default mode network areas, and MRI-determined brain volume and cortical thickness in AD cortical signature in the cognitively normal midlife population. Thirty-two middle-aged (age: 51.27±6.12 years, 15 males, body mass index (BMI): 32.28±6.39 kg/m2) cognitively normal participants, underwent bloodwork, brain and abdominal MRI, and amyloid and tau PET scan. Visceral and subcutaneous adipose tissue (VAT, SAT) were semi-automatically segmented using VOXel Analysis Suite (Voxa). FreeSurfer was used to automatically segment brain regions using a probabilistic atlas. PET scans were acquired using [11C]PiB and AV-1451 tracers and were analyzed using PET unified pipeline. The association of brain volumes, cortical thicknesses, and PiB and AV-1451 standardized uptake value ratios (SUVRs) with BMI, VAT/SAT ratio, and insulin resistance were assessed using Spearman's partial correlation. VAT/SAT ratio was associated significantly with PiB SUVRs in the right precuneus cortex (p=0.034) overall, controlling for sex. This association was significant only in males (p=0.044), not females (p=0.166). Higher VAT/SAT ratio and PiB SUVRs in the right precuneus cortex were associated with lower cortical thickness in AD-signature areas predominantly including bilateral temporal cortices, parahippocampal, medial orbitofrontal, and cingulate cortices, with age and sex as covariates. Also, higher BMI and insulin resistance were associated with lower cortical thickness in bilateral temporal poles. In midlife cognitively normal adults, we demonstrated higher amyloid pathology in the right precuneus cortex in individuals with a higher VAT/SAT ratio, a marker of visceral obesity, along with a lower cortical thickness in AD-signature areas associated with higher visceral obesity, insulin resistance, and amyloid pathology.

Cardiac imaging and biomarkers for assessing myocardial fibrosis in children with hypertrophic cardiomyopathy.

BACKGROUND: Myocardial fibrosis, as diagnosed on cardiac magnetic resonance imaging (cMRI) by late gadolinium enhancement (LGE), is associated with adverse outcomes in adults with hypertrophic cardiomyopathy (HCM), but its prevalence and magnitude in children with HCM have not been established. We investigated: (1) the prevalence and extent of myocardial fibrosis as detected by LGE cMRI; (2) the agreement between echocardiographic and cMRI measurements of cardiac structure; and (3) whether serum concentrations of N-terminal pro hormone B-type natriuretic peptide (NT-proBNP) and cardiac troponin-T are associated with cMRI measurements. METHODS: A cross-section of children with HCM from 9 tertiary-care pediatric heart centers in the U.S. and Canada were enrolled in this prospective NHLBI study of cardiac biomarkers in pediatric cardiomyopathy (ClinicalTrials.gov Identifier: NCT01873976). The median age of the 67 participants was 13.8 years (range 1-18 years). Core laboratories analyzed echocardiographic and cMRI measurements, and serum biomarker concentrations. RESULTS: In 52 children with non-obstructive HCM undergoing cMRI, overall low levels of myocardial fibrosis with LGE >2% of left ventricular (LV) mass were detected in 37 (71%) (median %LGE, 9.0%; IQR: 6.0%, 13.0%; range, 0% to 57%). Echocardiographic and cMRI measurements of LV dimensions, LV mass, and interventricular septal thickness showed good agreement using the Bland-Altman method. NT-proBNP concentrations were strongly and positively associated with LV mass and interventricular septal thickness (P < .001), but not LGE. CONCLUSIONS: Low levels of myocardial fibrosis are common in pediatric patients with HCM seen at referral centers. Longitudinal studies of myocardial fibrosis and serum biomarkers are warranted to determine their predictive value for adverse outcomes in pediatric patients with HCM.

Rate of tarsal and metatarsal bone mineral density change in adults with diabetes mellitus and peripheral neuropathy: a longitudinal study.

BACKGROUND: In people with diabetes (DM) and peripheral neuropathy (PN), loss of bone mineral density (BMD) in the tarsals and metatarsals contribute to foot complications; however, changes in BMD of the calcaneal bone is most commonly reported. This study reports rate of change in BMD of all the individual bones in the foot, in participants with DM and PN. Our aim was to investigate whether the rate of BMD change is similar across all the bones of the foot. METHODS: Participants with DM and PN (n = 60) were included in this longitudinal cohort study. Rate of BMD change of individual bones was monitored using computed tomography at baseline and 6 months, 18 months, and 3-4 years from baseline. Personal factors (age, sex, medication use, step count, sedentary time, and PN severity) were assessed. A random coefficient model estimated rate of change of BMD in all bones and Pearson correlation tested relationships between personal factor variables and rate of BMD change. RESULTS: Mean and calcaneal BMD decreased over the study period (p < 0.05). Individual tarsal and metatarsal bones present a range of rate of BMD change (-0.3 to -0.9%/year) but were not significantly different than calcaneal BMD change. Only age showed significant correlation with BMD and rate of BMD change. CONCLUSION: The rate of BMD change did not significantly differ across different foot bones at the group level in people with DM and PN without foot deformity. Asymmetric BMD loss between individual bones of the foot and aging may be indicators of pathologic changes and require further investigation. TRIAL REGISTRATION: Metatarsal Phalangeal Joint Deformity Progression-R01. Registered 25 November 2015, https://clinicaltrials.gov/ct2/show/NCT02616263.

Deep-learning synthesized pseudo-CT for MR high-resolution pediatric cranial bone imaging (MR-HiPCB).

PURPOSE: CT is routinely used to detect cranial abnormalities in pediatric patients with head trauma or craniosynostosis. This study aimed to develop a deep learning method to synthesize pseudo-CT (pCT) images for MR high-resolution pediatric cranial bone imaging to eliminating ionizing radiation from CT. METHODS: 3D golden-angle stack-of-stars MRI were obtained from 44 pediatric participants. Two patch-based residual UNets were trained using paired MR and CT patches randomly selected from the whole head (NetWH) or in the vicinity of bone, fractures/sutures, or air (NetBA) to synthesize pCT. A third residual UNet was trained to generate a binary brain mask using only MRI. The pCT images from NetWH (pCTNetWH ) in the brain area and NetBA (pCTNetBA ) in the nonbrain area were combined to generate pCTCom . A manual processing method using inverted MR images was also employed for comparison. RESULTS: pCTCom (68.01 ± 14.83 HU) had significantly smaller mean absolute errors (MAEs) than pCTNetWH (82.58 ± 16.98 HU, P < 0.0001) and pCTNetBA (91.32 ± 17.2 HU, P < 0.0001) in the whole head. Within cranial bone, the MAE of pCTCom (227.92 ± 46.88 HU) was significantly lower than pCTNetWH (287.85 ± 59.46 HU, P < 0.0001) but similar to pCTNetBA (230.20 ± 46.17 HU). Dice similarity coefficient of the segmented bone was significantly higher in pCTCom (0.90 ± 0.02) than in pCTNetWH (0.86 ± 0.04, P < 0.0001), pCTNetBA (0.88 ± 0.03, P < 0.0001), and inverted MR (0.71 ± 0.09, P < 0.0001). Dice similarity coefficient from pCTCom demonstrated significantly reduced age dependence than inverted MRI. Furthermore, pCTCom provided excellent suture and fracture visibility comparable to CT. CONCLUSION: MR high-resolution pediatric cranial bone imaging may facilitate the clinical translation of a radiation-free MR cranial bone imaging method for pediatric patients.

Cranial vault imaging for pediatric head trauma using a radial VIBE MRI sequence.

OBJECTIVE: Head trauma is the most common indication for a CT scan. In this pilot study, the authors assess the feasibility of a 5-minute high-resolution 3D golden-angle (GA) stack-of-stars radial volumetric interpolated breath-hold examination (VIBE) MRI sequence (GA-VIBE) to obtain clinically acceptable cranial bone images and identify cranial vault fractures compared to CT. METHODS: Patients younger than 18 years of age presenting after head trauma were eligible for the study. Three clinicians reviewed and assessed 1) slice-by-slice volumetric CT and inverted MR images, and 2) 3D reconstructions obtained from inverted MR images and the gold standard (CT). For each image set, reviewers noted on 5-point Likert scales whether they recommended that a repeat scan be performed and the presence or absence of cranial vault fractures. RESULTS: Thirty-one patients completed MRI after a clinical head CT scan was performed. Based on CT imaging, 8 of 31 patients had cranial fractures. Two of 31 patients were sedated as part of their clinical MRI scan. In 30 (97%) of 31 MRI reviews, clinicians agreed (or strongly agreed) that the image quality was acceptable for clinical diagnosis. Overall, comparing MRI to acceptable gold-standard CT, sensitivity and specificity of fracture detection were 100%. Furthermore, there were no discrepancies between CT and MRI in classification of fracture type or location. CONCLUSIONS: When compared with the gold standard (CT), the volumetric and 3D reconstructed images using the GA-VIBE sequence were able to produce clinically acceptable cranial images with excellent ability to detect cranial vault fractures.

Body mass index and maximum available midfoot motion are associated with midfoot angle at peak heel rise in people with type 2 diabetes mellitus and peripheral neuropathy.

PURPOSE: Midfoot movement dysfunction, as measured by heel rise performance, is associated with midfoot deformity in people with diabetes and peripheral neuropathy. Understanding contributors of midfoot movement dysfunction may help clinicians understand deformity progression. The purpose of this study was to determine the factors associated with midfoot angle at peak heel rise. METHODS: The outcomes of fifty-eight participants with type 2 diabetes mellitus and peripheral neuropathy were analyzed. Midfoot (forefoot on hindfoot) sagittal kinematics during unilateral heel rise task were measured using 3-dimensional motion analysis. A multivariate linear regression model was used to predict midfoot sagittal movements at peak heel rise. Independent variables that were entered in the model were (in order of entry): age, body mass index, intrinsic foot muscle volume, and maximum available midfoot plantarflexion range of motion. Intrinsic foot muscle volume was obtained from magnetic resonance imaging and maximum available midfoot motion was measured during non-weightbearing plantarflexion using 3-dimensional motion analysis. RESULTS: Body mass index (R2 = 30.5%, p < 0.001) and maximum available midfoot plantarflexion range of motion (R2 = 10.9%, p = 0.001) were significant factors that accounted for 41.4% of variance of midfoot angle at peak heel rise, while age and intrinsic foot muscle volume were not significant predictors. CONCLUSIONS: Greater body mass index and less available midfoot plantarflexion range of motion were associated with greater midfoot movement dysfunction. These two significant predictors are potentially modifiable, suggesting possible improvements in midfoot movements with reduction in body weight and increasing midfoot plantarflexion range of motion. Health care professionals should consider patient's weight and joint motion when prescribing foot exercise(s) to prevent excessive midfoot collapse during weightbearing tasks.

Computed Tomography and Magnetic Resonance Correlation and Agreement for Foot Muscle and Adipose Tissue Measurements.

BACKGROUND: Volumetric measures of intrinsic foot muscle and intermuscular adipose tissue (IMAT) infiltration are important in understanding foot injury and disease. We questioned whether measures of muscle and fat derived from computed tomography (CT) and magnetic resonance (MR) would be comparable. METHODS: This study determined the correlation and level of agreement between CT and MR measurements of foot muscle and IMAT from 32 subjects with diabetes and peripheral neuropathy. Volumetric CT and DIXON 3T MR scans were obtained. Intermuscular adipose tissue and muscle volumes used to create the IMAT to muscle ratio were obtained by segmenting the forefoot muscle compartment from each modality. RESULTS: Computed tomography IMAT ratios were significantly correlated (r = 0.85, P < 0.0001) with MR IMAT ratios. Computed tomography and MR IMAT ratio mean difference between CT and MR was small (0.044 unit, Bland-Altman plots). CONCLUSIONS: The CT and MR IMAT ratio measurements were highly correlated, indicating both modalities represent tissue quantification similarly.Level of Evidence: 2Technical Efficacy: 1.

Comparison between movement pattern training and strengthening on muscle volume, muscle fat, and strength in patients with hip-related groin pain: An exploratory analysis.

The purpose of this exploratory analysis was to compare the impact of movement pattern training (MoveTrain) and standard strength and flexibility training (Standard) on muscle volume, strength and fatty infiltration in patients with hip-related groin pain (HRGP). We completed a secondary analysis of data collected during an assessor-blinded randomized control trial. Data were used from 27 patients with HRGP, 15-40 years, who were randomized into MoveTrain or Standard groups. Both groups participated in their training protocol (MoveTrain, n = 14 or Standard, n = 13) which included 10 supervised sessions over 12 weeks and a daily home exercise program. Outcome measures were collected at baseline and immediately after treatment. Magnetic resonance images data were used to determine muscle fat index (MFI) and muscle volume. A hand-held dynamometer was used to assess isometric hip abductor and extensor strength. The Standard group demonstrated a significant posttreatment increase in gluteus medius muscle volume compared to the MoveTrain group. Both groups demonstrated an increase in hip abductor strength and reduction in gluteus minimus and gluteus maximus MFI. The magnitude of change for all outcomes were modest. Statement of Clinical Significance: Movement pattern training or a program of strength/flexibility training may be effective at improving hipabductor strength and reducing fatty infiltration in the gluteal musculature among those with HRGP. Further research is needed to betterunderstand etiology of strength changes and impact of muscle volume and MFI in HRGP and the effect of exercise on muscle structure andfunction.

A limited number of slices yields comparable results to all slices in foot intrinsic muscle deterioration ratio on computed tomography and magnetic resonance imaging.

Diagnostic imaging modalities, like computed tomography (CT) and magnetic resonance imaging (MRI), can be used to assess in vivo muscle quality. Quantitative assessment using these techniques is time-intensive and costly due in part to extensive post-processing needs. The purpose of this study was to identify whether a subset of slices on CT and MRI would yield comparable results to the full number of slices for a measure of muscle quality (muscle deterioration ratio = fat volume/muscle volume) in the foot intrinsic muscles of people with diabetes and peripheral neuropathy. CT (0.6 mm slice thickness) and MRI (3.5 mm slice thickness) scans were obtained using previously described methods. The total number of slices acquired during the scan was compared to several conditions using a portion of slices. Bland-Altman plots and Lin's concordance correlation coefficient were used to test agreement. Any condition using at least three slices yielded substantial to almost perfect agreement with the total number of slices on both CT and MRI (Range of Lin's concordance correlation coefficient: 0.947-0.999). Using a single slice in the middle of the region of interest demonstrated poor to moderate agreement with the total number of slices. The findings of this study suggest that using a limited number of slices to quantify muscle deterioration ratio on CT or MRI is a viable way to balance the combined need for measurement accuracy with feasibility in research and clinical settings.

Extracorporeal photopheresis to attenuate decline in lung function due to refractory obstructive allograft dysfunction.

BACKGROUND: This study was designed to prospectively evaluate the efficacy of extracorporeal photopheresis (ECP) to attenuate the rate of decline of FEV1 in lung transplant recipients with refractory bronchiolitis obliterans. Due to an observed higher than expected early mortality, a preliminary analysis was performed. STUDY DESIGN AND METHODS: Subjects from 10 lung transplant centres were assigned to ECP treatment or to observation based on spirometric criteria, with potential crossover for those under observation. The primary endpoint of this study was to assess response to ECP (i.e., greater than a 50% decrease in the rate of FEV1 decline) before and 6 months after initiation of ECP. Mortality was also evaluated 6 and 12 months after enrolment as a secondary endpoint. RESULTS: Of 44 enrolled subjects, 31 were assigned to ECP treatment while 13 were initially assigned to observation on a non-random basis using specific spirometric inclusion criteria (seven of the observation patients subsequently crossed over to receive ECP). Of evaluable patients, 95% of patients initially assigned to treatment responded to ECP with rates of FEV1 decline that were reduced by 93% in evaluable ECP-treated patients. Mortality rates (percentages) at 6 and 12 months after enrolment was 32% and 41%, respectively. The most common (92%) primary cause of death was respiratory or graft failure. Significantly (p = 0.002) higher rates of FEV1 decline were observed in the non-survivors (-212 ± 177 ml/month) when compared to the survivors (-95 ± 117 ml/month) 12 months after enrolment. In addition, 18 patients with bronchiolitis obliterans syndrome (BOS) diagnosis within 6 months of enrolment had lost 38% of their baseline lung function at BOS diagnosis and 50% of their lung function at enrolment. CONCLUSIONS: These analyses suggest that earlier detection and treatment of BOS should be considered to appreciate improved outcomes with ECP.

Qualitative study of musculoskeletal tissues and their radiographic correlates in diabetic neuropathic foot deformity.

BACKGROUND: Diabetes mellitus (DM) with peripheral neuropathy (PN) results in foot deformity increasing ulceration, joint dislocation, and amputation risk. This study describes the frequency and severity of foot and ankle musculoskeletal abnormalities and their relationship to radiographic alignment in people with DMPN with (DMPN + MCD) and without (DMPN - MCD) medial column deformity (MCD) compared to age- and body mass index-matched controls without DMPN or MDC. METHODS: DMPN + MCD (n = 11), DMPN - MCD (n = 12), and controls (n = 12) were studied. A radiologist scored foot and ankle magnetic resonance images (MRI) for abnormalities in tendons/fascia, ligaments, muscles, joints, and bones. Higher scores represent greater abnormalities. Foot alignment was measured from lateral weightbearing radiographs. Frequency of abnormalities between groups and relationships between abnormalities and foot alignment in the combined group (n = 35) were examined. RESULTS: DMPN + MCD had higher total muscle, joint, and bone scores compared to controls and higher total joint scores than DMPN - MCD. DMPN - MCD had higher total muscle scores than controls. DMPN + MCD higher bone and joint scores were driven by increased frequency of osteophytes, cartilage damage, focal bone marrow edema, new bone formation, and subchondral cysts. Significant correlations included cuboid height and total bone and joint scores (ρ = -0.37 and ρ = -0.40, respectively) and talar declination angle and total joint score (ρ = 0.38). CONCLUSION: High contrast resolution MRI allowed identification of structural lesions of the foot affecting the cartilage surfaces, bone marrow, and soft tissue supports in patients with DMPN + MCD. As expected, the presence of bone and joint lesions on MRI were strongly associated with DMPN + MCD; surprisingly, although the sample is small, lesions of the soft tissue supports were not associated with MCD. While MRI is not done routinely to investigate MCD, opportunistic use of the information from MRI done for the common clinical indications may allow early identification of the structural lesions associated with MCD and facilitate early, aggressive therapy. LEVEL OF EVIDENCE: III.

Association of toe-extension movement pattern magnitude and variability during three functional tasks with diabetic foot complications.

BACKGROUND: A toe-extension movement pattern may contribute to metatarsophalangeal joint deformity and ulceration in people with diabetes. We sought to quantify the relationship between toe extension magnitude and variability during three functional tasks (ankle range of motion, sit to stand, walking) with metatarsophalangeal joint deformity, and identify potential mechanisms associated with a toe-extension movement pattern. METHODS: Individuals with diabetes and peripheral neuropathy were included (n = 60). Metatarsophalangeal joint deformity was assessed using computed tomography (CT). Toe-extension movement was quantified using 3-dimensional motion capture. Linear regression was used to investigate the role of toe-extension movement pattern on metatarsophalangeal joint deformity. Regression analysis was used to identify mechanisms (neuropathy severity, foot intrinsic muscle deterioration ratio, ankle dorsiflexion range of motion) contributing to toe-extension movement pattern. FINDINGS: Toe extension with each functional task as well as the mean and coefficient of variation across all tasks were significantly related to metatarsophalangeal joint deformity (range of correlation coefficients = (-0.386, 0.692), p ≤ 0.001). Ankle dorsiflexion range of motion was associated with mean toe extension across all tasks (rsp = -0.282, p = 0.029). Neuropathy severity and foot intrinsic muscle deterioration ratio were associated with toe extension variability (rsp = -0.373, p = 0.003 and rsp = -0.266, p = 0.043; respectively). INTERPRETATION: Greater magnitude and lower variability of a toe-extension movement pattern was found to be associated with metatarsophalangeal joint deformity. These findings may support clinical assessment and treatment of movement across more than one task.

3D pediatric cranial bone imaging using high-resolution MRI for visualizing cranial sutures: a pilot study.

OBJECTIVE: There is an unmet need to perform imaging in young children and obtain CT-equivalent cranial bone images without subjecting the patients to radiation. In this study, the authors propose using a high-resolution fast low-angle shot golden-angle 3D stack-of-stars radial volumetric interpolated breath-hold examination (GA-VIBE) MRI sequence that is intrinsically robust to motion and has enhanced bone versus soft-tissue contrast. METHODS: Patients younger than 11 years of age, who underwent clinical head CT scanning for craniosynostosis or other cranial malformations, were eligible for the study. 3D reconstructed images created from the GA-VIBE MRI sequence and the gold-standard CT scan were randomized and presented to 3 blinded reviewers. For all image sets, each reviewer noted the presence or absence of the 6 primary cranial sutures and recorded on 5-point Likert scales whether they recommended a second scan be performed. RESULTS: Eleven patients (median age 1.8 years) underwent MRI after clinical head CT scanning was performed. Five of the 11 patients were sedated. Three clinicians reviewed the images, and there were no cases, either with CT scans or MR images, in which a reviewer agreed a repeat scan was required for diagnosis or surgical planning. The reviewers reported clear imaging of the regions of interest on 99% of the CT reviews and 96% of the MRI reviews. With CT as the standard, the sensitivity and specificity of the GA-VIBE MRI sequence to detect suture closure were 97% and 96%, respectively (n = 198 sutures read). CONCLUSIONS: The 3D reconstructed images using the GA-VIBE sequence in comparison to the CT scans created clinically acceptable cranial images capable of detecting cranial sutures. Future directions include reducing the scan time, improving motion correction, and automating postprocessing for clinical utility.

Multi-System Factors Associated with Metatarsophalangeal Joint Deformity in Individuals with Type 2 Diabetes.

The underlying factors contributing to metatarsophalangeal joint deformity, a known precursor to skin breakdown in individuals with diabetes mellitus (DM), is likely to involve multiple body systems. The purpose of this cross-sectional study was to identify multi-system factors associated with metatarsophalangeal joint deformity in individuals with type 2 DM and peripheral neuropathy (n = 60). Metatarsophalangeal joint deformity was quantified with a computed tomography (CT) scan. System biomarkers included the musculoskeletal system (foot intrinsic muscle deterioration, tarsal/metatarsal bone mineral density, ankle dorsiflexion, metatarsophalangeal extension movement during a sit to stand task); the vascular system (ankle-brachial index); and the endocrine/immune systems (high sensitivity C-reactive protein, skin intrinsic fluorescence, and hemoglobin A1C). Muscle deterioration (r = 0.27), bone density (r = -0.35), metatarsophalangeal extension movement (r = 0.50), maximum dorsiflexion (r = -0.31), and ankle-brachial index (r = 0.33) were related to metatarsophalangeal joint deformity (p < 0.05). Bone mineral density and metatarsophalangeal extension movement were retained in a regression model relating to deformity (R2 = 0.34). All musculoskeletal system biomarkers and the ankle-brachial index demonstrated weak to moderate relationships to metatarsophalangeal joint deformity. Bone mineral density of the tarsal/metatarsal bones and extending the toes during a sit to stand task were the two strongest factors associated with metatarsophalangeal joint deformity. Evaluation and management of foot bone mineral density and toe extension movement pattern could reduce metatarsophalangeal joint deformity and the risk of skin breakdown and subsequent amputation.

Hip Kinematics During Single-Leg Tasks in People With and Without Hip-Related Groin Pain and the Association Among Kinematics, Hip Muscle Strength, and Bony Morphology.

OBJECTIVE: To compare 3-D hip kinematics during the single-leg squat and step-down in patients with hip-related groin pain to those in asymptomatic participants, and to assess relationships among hip kinematics, muscle strength, and bony morphology. DESIGN: Controlled laboratory cross-sectional study. METHODS: Forty patients with hip-related groin pain and 40 matched, asymptomatic participants between 18 and 40 years of age participated. A handheld dynamometer was used to assess hip abductor and external rotator strength. An 8-camera motion-analysis system was used to quantify 3-D kinematics during the single-leg squat and step-down. Magnetic resonance imaging was used to quantify bony morphology. The independent t test and Mann-Whitney U test were used to assess between-group differences. Pearson coefficient correlations were used to assess relationships. RESULTS: Patients with hip-related groin pain had smaller peak hip flexion angles, smaller knee flexion angles, and lesser squat depth compared to asymptomatic participants during the single-leg squat. Among patients with hip-related groin pain, smaller hip flexion angles during the single-leg squat were associated with hip abductor weakness (r = 0.47, P≤.01). Among asymptomatic participants, smaller peak hip flexion angles during the single-leg squat were associated with less acetabular coverage (r = 0.33, P = .04) and shallow squat depth (r = 0.48, P≤.01); a smaller hip internal rotation angle during the step-down was associated with larger femoral neck shaft angle (r = -0.43, P<.01). CONCLUSION: Compared to asymptomatic participants, patients with hip-related groin pain had smaller hip and knee flexion angles and shallower squat depth during the single-leg squat. Smaller hip flexion angles were associated with hip abductor weakness among those with hip-related groin pain. J Orthop Sports Phys Ther 2020;50(5):243-251. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9150.

Clinical tests to determine femoral version category in people with chronic hip joint pain and asymptomatic controls.

STUDY DESIGN: Controlled laboratory cross-sectional. OBJECTIVES: To investigate the relationship between femoral version (FV), measured by MRI (FVMRI), Craig's test and hip rotation range of motion (ROM). To determine rotation ROM values associated with FVMRI categories: excessive anteversion, normal version and retroversion. BACKGROUND: Abnormal FV values are associated with hip disorders, such as osteoarthritis, structural instability, acetabular labral tears and femoroacetabular impingement. Clinical assessment of FV may allow clinician to identify the effect of bony abnormalities on hip rotation ROM to guide clinical decisions. METHODS: Thirty-eight participants with chronic hip joint pain (CHJP) and 38 matched controls participated. MRI was used to determine FVMRI. A digital inclinometer was used to assess Craig's test, hip internal rotation (IR) and external rotation (ER) with hip flexed to 90° (90°), and hip IR/ER with hip in neutral flexion/extension (0°). ROM differences (ROMdif) were determined by subtracting ER from IR. Pearson correlation coefficients were used to assess the relationship between FVMRI and clinical variables. One-way analysis of variance (ANOVA) was used to compare rotation ROM among FVMRI categories. RESULTS: There were no differences between CHJP and control groups in demographics, FVMRI, Craig's test or ROM. ROMdif0° showed the highest correlation (r = 0.63) with FVMRI, then IR90° (r = 0.61) and Craig's test (r = 0.61). Differences were noted among FVMRI categories for rotation ROM except hip ER90°. CONCLUSION: Hip rotation ROM and Craig's test may be used for screening when imaging is not indicated. A 20° difference between hip IR and ER ROM would be suggestive of abnormal FV.

The efficacy of extracorporeal photopheresis to arrest bronchiolitis obliterans in lung allograft recipients was compared between two automated photopheresis instruments.

BACKGROUND: The most common instruments used for extracorporeal photopheresis (ECP) treatment in the United States are the UVAR XTS and the CELLEX devices (Therakos, West Chester, PA). When compared to the UVAR XTS instrument, the efficacy of the CELLEX instrument to arrest the decline in lung function in patients with chronic lung allograft dysfunction (CLAD) related to bronchiolitis obliterans (BOS) has not been previously evaluated. METHODS: The relative efficacy of the CELLEX vs UVAR XTS ECP instruments was assessed by comparing the difference in rates of FEV1 decline before and after ECP treatment and survival in two series of lung allograft recipients with BOS who had been treated with these instruments. RESULTS: Similar Slope Difference values for change in rate of decline (6 months Post ECP - Pre ECP) were observed between the two cohorts (UVAR XTS: 85 ± 109 mL/month vs CELLEX: 76 ± 128 mL/month, p=0.72). A similar percentage of patients responded to ECP (UVAR XTS: 77% vs CELLEX: 89%; p=0.36) i.e., as defined as a positive difference in slope between the rate of decline of FEV1 before and 6 months after ECP. Survival at either 6 (p=0.89) or 12 (p=0.8) months after the start of ECP was not associated with instrument used despite a trend in higher early mortality (34% vs 17%, p=0.054) in the patients who were predominately treated with the CELLEX. CONCLUSIONS: Our data support the use of the CELLEX for prospective studies designed to evaluate the merits of ECP in this population.

Effect of Protein Supplementation During Diet-Induced Weight Loss on Muscle Mass and Strength: A Randomized Controlled Study.

OBJECTIVE: High protein (particularly leucine-rich whey protein) intake is recommended to mitigate the adverse effect of weight loss on muscle mass. The effectiveness of this approach is unknown. METHODS: Seventy middle-aged (50-65 years old) postmenopausal women with obesity were randomized to (1) weight maintenance (WM), (2) weight loss and the recommended daily allowance for protein (0.8 g/kg/d) (WL group), or (3) weight loss plus whey protein supplementation (total protein: 1.2 g/kg/d) (WL-PS group). Thigh muscle volume and strength were assessed at baseline and after 5% and 10% weight loss in the weight-loss groups and after matched time periods (∼3 and 6 months, respectively) in the WM group. RESULTS: A 5% weight loss caused a greater decrease in thigh muscle volume in the WL group than the WL-PS group (4.7% ± 0.7% vs. 2.8% ± 0.8%, respectively; P < 0.05). After 10% weight loss, there was no statistically significant difference in muscle mass loss in the two groups, and the total loss was small in both groups (5.5% ± 0.8% and 4.5% ± 0.7%, respectively). The dietary interventions did not affect muscle strength. CONCLUSIONS: Whey protein supplementation during diet-induced weight loss does not have clinically important therapeutic effects on muscle mass or strength in middle-aged postmenopausal women with obesity.