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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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Lange M, Kramer S, Voll C, Corbacioglu S. Sturz vom Wickeltisch. Monatsschr Kinderheilkd 2023. [DOI: 10.1007/s00112-023-01712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Even KM, Hymel KP, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Liang M, Wang M. The association of subcortical brain injury and abusive head trauma. CHILD ABUSE & NEGLECT 2022; 134:105917. [PMID: 36308893 DOI: 10.1016/j.chiabu.2022.105917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) remains a major pediatric problem with diagnostic challenges. A small pilot study previously associated subcortical brain injury with AHT. OBJECTIVES To investigate the association of subcortical injury on neuroimaging with the diagnosis of AHT. PARTICIPANTS AND SETTING Children <3 years with acute TBI admitted to 18 PICUs between 2011 and 2021. METHODS Secondary analysis of existing, combined, de-identified, cross-sectional dataset. RESULTS Deepest location of visible injury was characterized as scalp/skull/epidural (n = 170), subarachnoid/subdural (n = 386), cortical brain (n = 170), or subcortical brain (n = 247) (total n = 973). Subcortical injury was significantly associated with AHT using both physicians' diagnostic impression (OR: 8.41 [95 % CI: 5.82-12.44]) and a priori definitional criteria (OR: 5.99 [95 % CI: 4.31-8.43]). Caregiver reports consistent with the child's gross motor skills and historically consistent with repetition decreased as deepest location of injury increased, p < 0.001. Patients with subcortical injuries were significantly more likely to have traumatic extracranial injuries such as rib fractures (OR 3.36, 95 % CI 2.30-4.92) or retinal hemorrhages (OR 5.97, 95 % CI 4.35-8.24), respiratory compromise (OR 12.12, 95 % CI 8.49-17.62), circulatory compromise (OR 6.71, 95 % CI 4.87-9.29), seizures (OR 3.18, 95 % CI 2.35-4.29), and acute encephalopathy (OR 12.44, 95 % CI 8.16-19.68). CONCLUSIONS Subcortical injury is associated with a diagnosis of AHT, historical inaccuracies concerning for abuse, traumatic extracranial injuries, and increased severity of illness including respiratory and circulatory compromise, seizures, and prolonged loss of consciousness. Presence of subcortical injury should be considered as one component of the complex AHT diagnostic process.
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Affiliation(s)
- Katelyn M Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Menglu Liang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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Caré MM. Parenchymal Insults in Abuse—A Potential Key to Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12040955. [PMID: 35454003 PMCID: PMC9029348 DOI: 10.3390/diagnostics12040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.
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Affiliation(s)
- Marguerite M. Caré
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology and Medical Imaging, University of Cincinnati, Cincinnati, OH 45267, USA
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Sheldrake E, Al-Hakeem H, Lam B, Goldstein BI, Wheeler AL, Burke M, Dunkley BT, Reed N, Scratch SE. Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review. Front Neurol 2022; 13:850590. [PMID: 35481264 PMCID: PMC9035995 DOI: 10.3389/fneur.2022.850590] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objective:Concussion is a common yet heterogenous injury. Approximately 15–30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.MethodOvid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.ResultsThere was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.DiscussionThis review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.
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Affiliation(s)
- Elena Sheldrake
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- *Correspondence: Elena Sheldrake
| | - Hiba Al-Hakeem
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Brendan Lam
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Benjamin I. Goldstein
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Anne L. Wheeler
- Neuroscience and Mental Health Program, Hospital for Sick Children, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Matthew Burke
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Benjamin T. Dunkley
- Neuroscience and Mental Health Program, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Nick Reed
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Shannon E. Scratch
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Alanazi FS, Saleheen H, Al-Eissa M, Alshamrani AA, Alhuwaymani AA, Jarwan WK, Hamaid MS. Epidemiology of Abusive Head Trauma Among Children in Saudi Arabia. Cureus 2021; 13:e19014. [PMID: 34824931 PMCID: PMC8610835 DOI: 10.7759/cureus.19014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To examine abusive head trauma (AHT) trends using data obtained from hospital-based child protection centers (CPCs) and the distribution of age in months among young children in Saudi Arabia. METHODS A retrospective study was conducted that includes data obtained from 58 hospital-based CPCs in all 13 regions of Saudi Arabia registered in the National Family Safety Registry from 2010 to 2020. AHT cases (n=106) were identified for inclusion in the registry by a daily review of the emergency department logbooks. RESULTS Over the 11-year period, there was a sharp increase in the number of cases, specifically after 2014, from seven cases per year in 2010 to 16 cases in 2020. AHT affects predominantly children aged 0-12 months (72.6%), followed by 13-24 months (17.9%), 25-36 months (3.8%), 37-48 months (3.8%), and 49-60 months (1.9%). Victims were characterized by a predominance of crying infants (23.6%), past history of abuse (13.2%), a child's chronic disease and disability (7.6%), and prematurity (2.8%). CONCLUSION Different training and educational programs need to be performed to raise awareness of AHT. Enacting the pediatrician's mandatory reporting law will improve the rate of reporting cases.
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Affiliation(s)
- Fahad S Alanazi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Hassan Saleheen
- Public Health, King Abdullah International Medical Research Center, Riyadh, SAU
- National Family Safety Program, King Abdulaziz Medical City Riyadh, Riyadh, SAU
| | - Majid Al-Eissa
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
- Department of Pediatrics, King Abdullah Specialized Children's Hospital, Riyadh, SAU
- National Family Safety Program, King Abdulaziz Medical City Riyadh, Riyadh, SAU
| | - Abdullah A Alshamrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Ahmed A Alhuwaymani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Waleed K Jarwan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Mohammed S Hamaid
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
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Boruah AP, Potter TO, Shammassian BH, Hills BB, Dingeldein MW, Tomei KL. Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review. J Neurosurg Pediatr 2021; 28:268-277. [PMID: 34171842 DOI: 10.3171/2021.2.peds20872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.
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Affiliation(s)
| | | | - Berje H Shammassian
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Byron B Hills
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Michael W Dingeldein
- 1Case Western Reserve University School of Medicine
- 3Surgery, University Hospitals Cleveland Medical Center
- and Divisions of4Pediatric Surgery and
| | - Krystal L Tomei
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
- 5Pediatric Neurosurgery, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Colombari M, Troakes C, Turrina S, Tagliaro F, De Leo D, Al-Sarraj S. Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT). Int J Legal Med 2021; 135:1481-1498. [PMID: 33619608 PMCID: PMC8205921 DOI: 10.1007/s00414-021-02526-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological "triad", a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216-223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44-48% when all the spinal cord levels are analysed as opposed to just 0-18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.
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Affiliation(s)
- Michela Colombari
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy.
| | - Claire Troakes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Stefania Turrina
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy
| | - Franco Tagliaro
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy
- Institute of Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Domenico De Leo
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy
| | - Safa Al-Sarraj
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Clinical Neuropathology, King's College Hospital NHS Foundation Trust, London, UK
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Porto L, Bartels MB, Zwaschka J, You SJ, Polkowski C, Luetkens J, Endler C, Kieslich M, Hattingen E. Abusive head trauma: experience improves diagnosis. Neuroradiology 2021; 63:417-430. [PMID: 33079214 PMCID: PMC7880981 DOI: 10.1007/s00234-020-02564-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/31/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE The diagnosis of abusive head trauma (AHT) is complex and neuroimaging plays a crucial role. Our goal was to determine whether non-neuroradiologists with standard neuroradiology knowledge perform as well as neuroradiologists with experience in pediatric neuroimaging in interpreting MRI in cases of presumptive AHT (pAHT). METHODS Twenty children were retrospectively evaluated. Patients had been diagnosed with pAHT (6 patients), non-abusive head trauma-NAHT (5 patients), metabolic diseases (3 patients), and benign enlargement of the subarachnoid spaces (BESS) (6 patients). The MRI was assessed blindly, i.e., no clinical history was given to the 3 non-neuroradiologists and 3 neuroradiologists from 2 different institutions. RESULTS Blindly, neuroradiologists demonstrated higher levels of sensitivity and positive predictive value in the diagnosis of pAHT (89%) than non-neuroradiologists (50%). Neuroradiologists chose correctly pAHT as the most probable diagnosis 16 out of 18 times; in contrast, non-neuroradiologists only chose 9 out of 18 times. In our series, the foremost important misdiagnosis for pAHT was NAHT (neuroradiologists twice and non-neuroradiologists 5 times). Only victims of motor vehicle accidents were blindly misdiagnosed as pAHT. No usual household NAHT was not misdiagnosed as pAHT. Neuroradiologists correctly ruled out pAHT in all cases of metabolic diseases and BESS. CONCLUSION MRI in cases of suspected AHT should be evaluated by neuroradiologists with experience in pediatric neuroimaging. Neuroradiologists looked beyond the subdural hemorrhage (SDH) and were more precise in the assessment of pAHT and its differential diagnosis than non-neuroradiologists were. It seems that non-neuroradiologists mainly assess whether or not a pAHT is present depending on the presence or absence of SDH.
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Affiliation(s)
- Luciana Porto
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany.
| | - Marco Baz Bartels
- Department of Paediatric Neurology, Hospital of Goethe University, Frankfurt am Main, Germany
| | - Jonas Zwaschka
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Se-Jong You
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Christoph Polkowski
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
| | - Julian Luetkens
- Institute of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Christoph Endler
- Institute of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Kieslich
- Department of Paediatric Neurology, Hospital of Goethe University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Hospital of Goethe University, University Hospital Frankfurt, Schleusenweg 2 - 16, 60528, Frankfurt am Main, Germany
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Syed S, Ashwick R, Schlosser M, Gonzalez-Izquierdo A, Li L, Gilbert R. Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis. Arch Dis Child 2021; 106:44-53. [PMID: 32788201 PMCID: PMC7788194 DOI: 10.1136/archdischild-2020-319027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic review and meta-analysis to evaluate the positive predictive values (PPVs) of coded indicators in EHRs for identifying intimate partner violence (IPV) and child maltreatment (CM), including prenatal neglect. METHODS We searched 18 electronic databases between January 1980 and May 2020 for studies comparing any coded indicator of IPV or CM including prenatal neglect defined as neonatal abstinence syndrome (NAS) or fetal alcohol syndrome (FAS), against an independent reference standard. We pooled PPVs for each indicator using random effects meta-analyses. RESULTS We included 88 studies (3 875 183 individuals) involving 15 indicators for identifying CM in the prenatal period and childhood (0-18 years) and five indicators for IPV among women of reproductive age (12-50 years). Based on the International Classification of Disease system, the pooled PPV was over 80% for NAS (16 studies) but lower for FAS (<40%; seven studies). For young children, primary diagnoses of CM, specific injury presentations (eg, rib fractures and retinal haemorrhages) and assaults showed a high PPV for CM (pooled PPVs: 55.9%-87.8%). Indicators of IPV in women had a high PPV, with primary diagnoses correctly identifying IPV in >85% of cases. CONCLUSIONS Coded indicators in EHRs have a high likelihood of correctly classifying types of CM and IPV across the life course, providing a useful tool for assessment, support and monitoring of high-risk groups in health services and research.
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Affiliation(s)
- Shabeer Syed
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Rachel Ashwick
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Marco Schlosser
- Division of Psychiatry, University College London, London, UK
| | | | - Leah Li
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Institute of Health Informatics and Health Data Research UK, University College London, London, UK
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Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger. Pediatr Emerg Care 2020; 36:e428-e432. [PMID: 28953098 DOI: 10.1097/pec.0000000000001279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger. METHODS In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH. RESULTS Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]). CONCLUSIONS Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.
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Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, Agrawal A, Adeleye AO, Shrime MG, Rubiano AM, Rosenfeld JV, Park KB. Estimating the global incidence of traumatic brain injury. J Neurosurg 2019; 130:1080-1097. [PMID: 29701556 DOI: 10.3171/2017.10.jns17352] [Citation(s) in RCA: 1201] [Impact Index Per Article: 240.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/18/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups. METHODS Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group. RESULTS Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs. CONCLUSIONS Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 2Department of Neurological Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | | | - Ronnie E Baticulon
- 5University of the Philippines College of Medicine, Philippine General Hospital, Manila, Philippines
| | - Ya-Ching Hung
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
| | - Maria Punchak
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 6David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amit Agrawal
- 7Department of Neurosurgery, Narayana Medical College, Nellore, Andhra Pradesh, India
| | - Amos O Adeleye
- 8Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan
- 9Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Mark G Shrime
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
- 10Office of Global Surgery and Health, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Andrés M Rubiano
- 11Neurosciences Institute, Neurosurgery Service, El Bosque University, El Bosque Clinic, MEDITECH-INUB Research Group, Bogotá, Colombia
| | - Jeffrey V Rosenfeld
- 12Department of Neurosurgery, Alfred Hospital
- 13Department of Surgery, Monash University, Melbourne, Australia; and
- 14Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
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King D, Hume PA, Hardaker N, Pearce A, Cummins C, Clark T. Traumatic brain injuries in New Zealand: National Insurance (Accident Compensation Corporation) claims from 2012 to 2016. J Neurol Sci 2019; 399:61-68. [PMID: 30776729 DOI: 10.1016/j.jns.2019.01.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 11/25/2022]
Abstract
AIM To provide epidemiological data and related costs to the national health insurance scheme for traumatic brain injury (TBI) in New Zealand. METHOD A retrospective analytical review utilising detailed descriptive minor and moderate-to-severe epidemiological TBI data obtained from the Accident Compensation Corporation (ACC) for 2012-2016. Injuries were analysed by three levels of increasing severity: moderate, moderate-to-serious (MSC) and severe claims categories. RESULTS Over the January 2012 to December 2016 period there were 97,955 claims for TBI costing ACC $1,450,643,667 [equivalent to £$743,417,120]. Falls accounted for nearly half (41.7%, 8262), and over a quarter (39.9%; $67,626,000 [£34,662,176]) of the moderate claims for TBI. Motor vehicle accidents recorded the highest percentage (36.5%), total costs ($610,978,229 [£313,170,000]) and highest mean cost per-moderate claim per-year ($47,372 ± $2401 [£24,282 ± £1231]) for MSC TBI claims. This was similar for severe claims where motor vehicles accidents accounted for 56% of the total serious claims, 65.1% of the costs with a mean cost per-serious claim of $64,913 ± 4331 [£32,759 ± £2186] per-year. CONCLUSION There were 97,955 TBI injury claims lodged over the duration of the study with 36% (n = 35,304) classified as MSC. The incidence of total TBI in New Zealand was 432 per 100,000 population, and 155 per 100,000 for MSC TBI claims. Despite the growing number of studies reporting on the effects of sports-related TBI, there is a paucity of studies reporting on the longitudinal effects of TBI in falls, assaults and motor vehicle accidents. Further research is warranted into the assessment and management of intimate partner violence and child abuse victims for TBI's.
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Affiliation(s)
- Doug King
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand; School of Science and Technology, University of New England, Armidale, NSW, Australia.
| | - Patria A Hume
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand; National Institute of Stroke and Applied Neuroscience (NISAN), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
| | - Natalie Hardaker
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand; Accident Compensation Corporation, Wellington, New Zealand
| | - Alan Pearce
- Department of Rehabilitation, Nutrition and Sport, La Trobe University, Melbourne, Australia
| | - Cloe Cummins
- School of Science and Technology, University of New England, Armidale, NSW, Australia; Institute for Sport Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
| | - Trevor Clark
- Australian College of Physical Education, Department of Sport Performance, Sydney Olympic Park NSW, Australia
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Epidemiology of subdural haemorrhage during infancy: A population-based register study. PLoS One 2018; 13:e0206340. [PMID: 30379890 PMCID: PMC6209227 DOI: 10.1371/journal.pone.0206340] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022] Open
Abstract
Objectives To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse. Methods A Swedish population-based register study comprising infants born between 1997 and 2014, 0–1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0–6 and 7–365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis. Results Incidence of SDH was 16·5 per 100 000 infants (n = 306). Median age was 2·5 months. For infants older than one week, the median age was 3·5 months. Case fatality was 6·5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0–6 days, having a perinatal risk profile. For infants aged 7–365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age. Conclusions The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.
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Elinder G, Eriksson A, Hallberg B, Lynøe N, Sundgren PM, Rosén M, Engström I, Erlandsson BE. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr 2018; 107 Suppl 472:3-23. [PMID: 30146789 PMCID: PMC6585638 DOI: 10.1111/apa.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/30/2022]
Abstract
The Swedish Agency for Health Technology Assessment and Assesment of Social Services (SBU) is an independent national authority, tasked by the government with assessing methods used in health, medical and dental services and social service interventions from a broad perspective, covering medical, economic, ethical and social aspects. The language in SBU's reports are adjusted to a wide audience. SBU's Board of Directors has approved the conclusions in this report. The systematic review showed the following graded results: There is limited scientific evidence that the triad (Three components of a whole. The triad associated with SBS usually comprises subdural haematoma, retinal haemorrhages and encephalopathy.) and therefore, its components can be associated with traumatic shaking (low-quality evidence). There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). Limited scientific evidence (low-quality evidence) represents a combined assessment of studies of high or moderate quality which disclose factors that markedly weaken the evidence. It is important to note that limited scientific evidence for the reliability of a method or an effect does not imply complete lack of scientific support. Insufficient scientific evidence (very low-quality evidence) represents either a lack of studies or situations when available studies are of low quality or show contradictory results. Evaluation of the evidence was not based on formal grading of the evidence according to GRADE but on an evaluation of the total scientific basis.
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Affiliation(s)
- Göran Elinder
- Department of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation, Forensic Medicine, Umeå University, Umeå, Sweden
- The National Board of Forensic Medicine, Sweden
| | - Boubou Hallberg
- Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Niels Lynøe
- Medical Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Pia Maly Sundgren
- Diagnostic Radiology, Lund University, Lund, Sweden
- Department of Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Måns Rosén
- Health Technology Assessment, Karolinska Institutet, Stockholm, Sweden
| | - Ingemar Engström
- Child and Adolecent Psychiatry, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
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Affiliation(s)
- Arabinda Kumar Choudhary
- Department of Radiology, Nemours AI duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas L Slovis
- Department of Radiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Gary L Hedlund
- Department of Medical Imaging, Primary Children's Hospital, Intermountain Healthcare, Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sandeep K Narang
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Mark S Dias
- Departments of Neurosurgery and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Cindy W Christian
- Department of Pediatrics, Child Abuse and Neglect Prevention, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Marvin D Nelson
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Susan Palasis
- Pediatric Neuroradiology, Children's Healthcare of Atlanta, Scottish Rite Campus, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Andrea Rossi
- Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, Western Bank, University of Sheffield, Sheffield, UK
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SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations. Int J Legal Med 2018; 132:1719-1727. [PMID: 29982863 DOI: 10.1007/s00414-018-1889-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.
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Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. Insufficient evidence for 'shaken baby syndrome' - a systematic review. Acta Paediatr 2017; 106:1021-1027. [PMID: 28130787 DOI: 10.1111/apa.13760] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/24/2017] [Indexed: 01/08/2023]
Abstract
Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a meta-analysis impossible. None of the studies had a low risk of bias. CONCLUSION The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).
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Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Göran Elinder
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; and Karolinska University Hospital; Stockholm Sweden
| | - Måns Rosén
- Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Pia Sundgren
- Department of Diagnostic Radiology, Clinical Sciences; Lund University; Lund Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University Umeå Sweden
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Saunders D, Raissaki M, Servaes S, Adamsbaum C, Choudhary AK, Moreno JA, van Rijn RR, Offiah AC. Throwing the baby out with the bath water - response to the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) report on traumatic shaking. Pediatr Radiol 2017; 47:1386-1389. [PMID: 28785782 PMCID: PMC5608779 DOI: 10.1007/s00247-017-3932-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 11/23/2022]
Affiliation(s)
- Dawn Saunders
- 0000000121901201grid.83440.3bGreat Ormond Street Hospital NHS Trust for Children, Institute of Child Health, WC1N 3JH, London, UK
| | - Maria Raissaki
- grid.412481.aDepartment of Radiology, University Hospital of Heraklion, Iraklio, Greece ,0000 0004 0576 3437grid.8127.cUniversity of Crete, Heraklion, Crete, Greece
| | - Sabah Servaes
- 0000 0004 1936 8972grid.25879.31The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | - Catherine Adamsbaum
- 0000 0001 2171 2558grid.5842.bAP-HP, Bicêtre Hospital, Pediatric Imaging Department, Paris Sud University, Bicêtre, France
| | - Arabinda Kumar Choudhary
- 0000 0004 0458 9676grid.239281.3Department of Medical Imaging, Alfred I. duPont Hospital for Children, Wilmington, DE USA
| | | | - Rick R. van Rijn
- 0000000404654431grid.5650.6Department of Radiology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Amaka C. Offiah
- 0000 0004 1936 9262grid.11835.3eAcademic Unit of Child Health, Sheffield Childrens NHS Foundation Trust, University of Sheffield, Sheffield, UK
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Lyons TW, Stack AM, Monuteaux MC, Parver SL, Gordon CR, Gordon CD, Proctor MR, Nigrovic LE. A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures. Pediatrics 2016; 137:peds.2015-3370. [PMID: 27244848 PMCID: PMC4894255 DOI: 10.1542/peds.2015-3370] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures. METHODS We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database. RESULTS We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%. CONCLUSIONS We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.
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Affiliation(s)
| | | | | | | | | | | | - Mark R. Proctor
- Department of Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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Yagmur F, Celik S, Yener Z, Koral F, Yaman T, Sezer Y, Kandemir E. Head Trauma–Related Deaths Among Preschool Children in Istanbul, Turkey. Am J Forensic Med Pathol 2016; 37:35-9. [DOI: 10.1097/paf.0000000000000213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hanlon LA, Huh JW, Raghupathi R. Minocycline Transiently Reduces Microglia/Macrophage Activation but Exacerbates Cognitive Deficits Following Repetitive Traumatic Brain Injury in the Neonatal Rat. J Neuropathol Exp Neurol 2016; 75:214-26. [PMID: 26825312 DOI: 10.1093/jnen/nlv021] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Elevated microglial/macrophage-associated biomarkers in the cerebrospinal fluid of infant victims of abusive head trauma (AHT) suggest that these cells play a role in the pathophysiology of the injury. In a model of AHT in 11-day-old rats, 3 impacts (24 hours apart) resulted in spatial learning and memory deficits and increased brain microglial/macrophage reactivity, traumatic axonal injury, neuronal degeneration, and cortical and white-matter atrophy. The antibiotic minocycline has been effective in decreasing injury-induced microglial/macrophage activation while simultaneously attenuating cellular and functional deficits in models of neonatal hypoxic ischemia, but the potential for this compound to rescue deficits after impact-based trauma to the immature brain remains unexplored. Acute minocycline administration in this model of AHT decreased microglial/macrophage reactivity in the corpus callosum of brain-injured animals at 3 days postinjury, but this effect was lost by 7 days postinjury. Additionally, minocycline treatment had no effect on traumatic axonal injury, neurodegeneration, tissue atrophy, or spatial learning deficits. Interestingly, minocycline-treated animals demonstrated exacerbated injury-induced spatial memory deficits. These results contrast with previous findings in other models of brain injury and suggest that minocycline is ineffective in reducing microglial/macrophage activation and ameliorating injury-induced deficits following repetitive neonatal traumatic brain injury.
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Affiliation(s)
- Lauren A Hanlon
- From the Program in Neuroscience, Drexel University College of Medicine, Philadelphia, Pennsylvania (LAH, RR); Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia Pennsylvania (JWH); and Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania (RR)
| | - Jimmy W Huh
- From the Program in Neuroscience, Drexel University College of Medicine, Philadelphia, Pennsylvania (LAH, RR); Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia Pennsylvania (JWH); and Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania (RR)
| | - Ramesh Raghupathi
- From the Program in Neuroscience, Drexel University College of Medicine, Philadelphia, Pennsylvania (LAH, RR); Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia Pennsylvania (JWH); and Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania (RR).
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Kelly P, John S, Vincent AL, Reed P. Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team. Arch Dis Child 2015; 100:1123-30. [PMID: 26130384 PMCID: PMC4680201 DOI: 10.1136/archdischild-2014-306960] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 05/28/2015] [Indexed: 12/05/2022]
Abstract
AIM To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand. METHODS Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010. RESULTS Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%). CONCLUSIONS The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death.
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Affiliation(s)
- Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand,Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Simon John
- Department of Neurosurgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrea L Vincent
- Department of Ophthalmology, Auckland District Health Board, Auckland, New Zealand,Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Reed
- Children's Research Centre, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
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Wood JN, French B, Song L, Feudtner C. Evaluation for Occult Fractures in Injured Children. Pediatrics 2015; 136:232-40. [PMID: 26169425 PMCID: PMC4516941 DOI: 10.1542/peds.2014-3977] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine variation across US hospitals in evaluation for occult fractures in (1) children <2 years old diagnosed with physical abuse and (2) infants <1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation. METHODS We performed a retrospective study in children <2 years old with a diagnosis of physical abuse and in infants <1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child- and hospital-level factors associated with evaluation for occult fractures. RESULTS Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P < .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P < .001). CONCLUSIONS Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.
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Affiliation(s)
- Joanne N. Wood
- Division of General Pediatrics and,PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Departments of Pediatrics, and
| | - Benjamin French
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lihai Song
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Chris Feudtner
- Division of General Pediatrics and,Departments of Pediatrics, and
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25
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Nnadi MON, Bankole OB, Fente BG. Epidemiology and treatment outcome of head injury in children: A prospective study. J Pediatr Neurosci 2015; 9:237-41. [PMID: 25624926 PMCID: PMC4302543 DOI: 10.4103/1817-1745.147577] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Summary: Head injury in children is a major concern all over the world. The increasing level of poverty in the world is exposing more children to trauma situations. The future consequences of trauma in these children are enormous, hence prevention they say, is better than cure. Aim of the Study: The study was designed to determine the etiological pattern, age group affectation and treatment outcome in children managed for head injury in our center. Methods: It was a prospective, descriptive and cross-sectional study of children with head injuries managed in our center from July 2010 to December 2013. Data were collected using structured proforma that was part of our prospective Data Bank approved by our hospital Research and Ethics Committee. Data were collected in accident and emergency unit, Intensive Care Unit, wards and out-patient clinic. The data was analyzed using Epi Info 7 software. Results: Total of 76 children managed by the unit and followed-up to a minimum of 3 months qualified for the study. There were 42 males. The age ranged from 7 months to 18 years with a mean of 8.66 years. There were 30 adolescent/teenagers. Road traffic accident formed 63.15%. Pedestrian accident was more among preschool and school children. Thirty-seven patients had mild head injury. Sixty-six patients were managed conservatively. The commonest posttraumatic effect was seizure (15.79%). Good functional outcome (≥4) was seen in 92.1%. Mode of accident and severity of injury affected the outcome. Conclusions: The etiologies of traumatic brain injury, from our study, were age dependent with falls commonest in toddlers and pedestrian accident commonest in pre-school and school ages. The outcome of treatment was related to severity of injury.
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Affiliation(s)
- M O N Nnadi
- Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - O B Bankole
- Neurosurgical Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - B G Fente
- General Surgery Unit, Department of Surgery, Niger Delta University Teaching Hospital, Okolobri, Bayelsa State, Nigeria
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Abstract
In the decades since Dr. John Caffey described a series of children with chronic subdural hematoma and long bone fractures, there has been a substantial increase in the medical recognition of various forms child abuse. In the United States, the term shaken baby syndrome was coined to explain a constellation of injuries assumed to be the result of violent shaking of infants. After improved understanding of the variety of mechanisms that occur when children are abused, abusive head trauma (AHT) has become the recommended terminology. AHT is a more comprehensive term that reflects the brain injuries that children suffer as the result of abuse. AHT continues to include shaking as a mechanism of injury as well as shaking with impact, impact alone, crushing injuries or combinations of several mechanisms. The medical community in the United States has led the way in developing new terminology and research to describe this unique and devastating form of abuse. The globalization of medicine and rapid information transfer has resulted in AHT becoming well-recognized internationally as a form of serious and fatal child abuse. This paper will review the historical basis in the United States for the diagnosis of AHT. We will also review some of the current international issue in epidemiology, diagnosis, legal processes and outcomes in selected countries/regions where child abuse physicians are actively involved in the evaluation of AHT.
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Vaghani G, Singh PK, Gupta DK, Agrawal D, Sinha S, Satyarthee G, Sharma BS, Mahapatra AK. Outcome of patients with traumatic head injury in infants: An institutional experience at level 1 trauma center. J Pediatr Neurosci 2013; 8:104-7. [PMID: 24082924 PMCID: PMC3783713 DOI: 10.4103/1817-1745.117836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Traumatic head injury is a common cause of mortality and acquired disability in infants and children. However, patterns and outcome of head injury in infants are different from other age groups. Aims and Objectives: Aim of our study was to find out epidemiological factors, characteristics of injury, and outcome in infants with traumatic brain injury. Materials and Methods: This is a retrospective study from March 2009 through Feb 2012, at JPNATC, AIIMS, New Delhi. The clinical records of all patients, admitted with head injury were evaluated. Twenty-nine infants with traumatic brain injury were followed up and outcome was analyzed. Results: Twenty-nine infants with traumatic brain injury were included in the study. Of these 17 (59%) were boys and 12 (41%) were girls. Fall from height was recorded in 27 (93%) patients and road traffic accident was the mode of injury in 2 (7%). Mild head injury (GCS 14-15) was found in 18 (62%) patients, moderate in 4 (14%) patients (GCS 9-13), severe (GCS 3-8) in 7 (24%) patients. SDH was the most common injury in 8 (27%) patients. Out of these 4 (14%) were immediately operated, 25 (86%) were managed conservatively. Overall mortality was 11% (3 patients). Glasgow Outcome Scale was 5 in 20 (69%) patients and 3 (10.3%) patients each had GOS 3 or 4. Conclusion: Infants suffered significant brain injury due to fall. Traumatic brain injury in infants generally carries good outcome. Severe head injury was observed to be a predictor of poor outcome.
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Affiliation(s)
- Gaurang Vaghani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Abstract
OBJECTIVE The objectives of this study were to provide population-based incidence estimate of abusive head trauma (AHT) in children aged 0 to 5 years from inpatient and emergency department (ED) and identify risk characteristics for recognizing high-risk children to improve public health surveillance. METHODS This was a retrospective cohort study based on children's first encounter in ED or hospital admission with a diagnosis of head trauma (HT), 2000-2010. The relationship between clinical markers and AHT was examined controlling for covariables in the model using Cox hazards regression. Kaplan-Meier incidence probability was plotted, and the number of weeks elapsing from date of birth to the first encounter with HT established the survival time (T). RESULTS Twenty-six thousand six hundred eighty-one children had HT, 502 (1.8%) resulted from abuse; 42.4% was captured from ED. Incidence varied from 28.9 (95% confidence interval [CI], 27.9-37.4) in infants to 4.1 (95% CI, 2.4-5.7) in 5-year-olds per 100,000 per year. Adjusted hazard ratio was 20.3 (95% CI, 10.9-38.0) for intracranial bleeding and 11.4 (95% CI, 8.57-15.21) for retinal hemorrhage. CONCLUSIONS Incidence estimates of AHT are incomplete without including ED. Intracranial bleeding is a cardinal feature of AHT to be considered in case ascertainment to improve public health surveillance.
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30
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Halvorsen S, Killén K, Grøgaard J. Hvorfor overser vi barnemishandling? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:16-7. [DOI: 10.4045/tidsskr.12.0801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Crowe LM, Catroppa C, Anderson V, Babl FE. Head injuries in children under 3 years. Injury 2012; 43:2141-5. [PMID: 22921385 DOI: 10.1016/j.injury.2012.07.195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 07/24/2012] [Accepted: 07/27/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND A significant number of children under 3 years sustain a head injury every year. Despite this few studies have provided detailed information about these injuries. METHODS A retrospective review of the medical files all children aged 0-3 years who attended a paediatric emergency department for treatment over a 2-year period. RESULTS Children aged 0-6 months had the highest rate of moderate head injury. Children under 12 months were at the greatest risk of injury. Falls were the most common cause of injury including falls from caregiver's arms. CONCLUSIONS Children under 12 months are at significant risk of head injury, many of these injuries could be prevented by increased parental supervision or improved home safety.
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Affiliation(s)
- Louise M Crowe
- Psychological Science, University of Melbourne, Melbourne, Australia.
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32
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Wood JN, Feudtner C, Medina SP, Luan X, Localio R, Rubin DM. Variation in occult injury screening for children with suspected abuse in selected US children's hospitals. Pediatrics 2012; 130:853-60. [PMID: 23071208 PMCID: PMC4074645 DOI: 10.1542/peds.2012-0244] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To describe variation across selected US children's hospitals in screening for occult fractures in children <2 years old diagnosed with physical abuse and in infants <1 year old who have injuries associated with a high likelihood of physical abuse. METHODS We performed a retrospective study of children <2 years old with a diagnosis of physical abuse and infants <1 year old with non-motor vehicle crash-associated traumatic brain injuries or femur fractures admitted to 40 hospitals within the Pediatric Hospital Information System database from January 1, 1999, to December 31, 2009. We examined variation among the hospitals in the performance of screening for occult fractures as defined by receipt of skeletal survey or radionuclide bone scan. Marginal standardization implemented with logistic regression analysis was used to examine hospital variation after adjusting for patient demographic characteristics, injury severity, and year of admission. RESULTS Screening for occult fractures was performed in 83% of the 10,170 children <2 years old with a diagnosis of physical abuse, 68% of the 9942 infants who had a traumatic brain injury, and 77% of the 2975 infants who had femur fractures. After adjustment for patient characteristics, injury severity, and year of admission, hospitals varied significantly in use of screening for occult fractures in all 3 groups of children. CONCLUSIONS The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.
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Affiliation(s)
- Joanne N. Wood
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Departments of Pediatrics, and
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Departments of Pediatrics, and
| | - Sheyla P. Medina
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Xianqun Luan
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Russell Localio
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M. Rubin
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Departments of Pediatrics, and
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Piteau SJ, Ward MGK, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics 2012; 130:315-23. [PMID: 22778309 DOI: 10.1542/peds.2011-1545] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children. METHODS We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT. RESULTS Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma. CONCLUSIONS Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.
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Affiliation(s)
- Shalea J Piteau
- Department of Pediatrics, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario, Canada K7L 2V7.
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Rosema S, Crowe L, Anderson V. Social function in children and adolescents after traumatic brain injury: a systematic review 1989-2011. J Neurotrauma 2012; 29:1277-91. [PMID: 22260408 DOI: 10.1089/neu.2011.2144] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical reports and case studies suggest that traumatic brain injury (TBI) can have significant social consequences, with social dysfunction reported to be the most debilitating problem for child and adolescent survivors. From a social neuroscience perspective, evidence suggests that social skills are not localized to a specific brain region, but are mediated by an integrated neural network. Many components of this network are susceptible to disruption in the context of TBI. In early development, a brain injury can disrupt this neural network while it is in the process of being established, resulting in social dysfunction. In order to clarify the prevalence and nature of social dysfunction after child TBI, studies of social outcomes in children and adolescents after TBI over the last 23 years have been reviewed. Despite casting a wide net initially, only 28 articles met review criteria. These studies were characterized by methodological weaknesses, including variations in definitions of TBI, limited assessment tools, reliance on parent reports, small sample sizes, and absent control groups. Despite these limitations, the weight of evidence confirmed an elevated risk of social impairment in the context of moderate and severe injury. While rarely examined, younger age at insult, pathology to frontal regions and the corpus callosum, and social disadvantage and family dysfunction may also increase the likelihood of social difficulties. More research is needed to obtain an accurate picture of social outcomes post-brain injury.
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Affiliation(s)
- Stefanie Rosema
- Child Neuropsychology, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
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Inoue H, Nakagawa Y, Ikemura M, Shinone K, Okada K, Nata M. A subacute epidural haematoma extending over the occipital region and posterior cranial fossa due to a laceration in the transverse sinus. Int J Legal Med 2011; 126:467-71. [PMID: 22008787 DOI: 10.1007/s00414-011-0635-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 10/07/2011] [Indexed: 01/07/2023]
Abstract
A 6-year-old male was found dead on his stomach with massive reddish vomiting from his mouth and nose. Postmortem cranial CT revealed an epidural haematoma in the left occipital region, but the cause and origin of the haematoma were unclear. An autopsy revealed that the epidural haematoma expanded over the left temporal region and the left side of the occipital region and posterior cranial fossa, and its origin was a laceration in the left transverse sinus induced by diastases in the left lambdoidal and occipitomastoid sutures. A pathohistological examination revealed that one portion of the haematoma was an early-stage hemorrhage, while the other portion extended approximately 1 week after the hemorrhage. Moreover, approximately 1 week elapsed after the laceration of the transverse sinus. Thus, we believe that the primary haematoma was induced by the laceration in the transverse sinus approximately 1 week before death, but the haematoma ceased to enlarge due to hemostasis. However, later, the size of the haematoma rapidly increased again due to rebleeding from the laceration, which led to intracranial hypertension. Consequently, we diagnosed the direct cause of death as choking due to vomit aspiration that resulted from intracranial hypertension induced by a subacute epidural haematoma.
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Affiliation(s)
- Hiromasa Inoue
- Department of Forensic Medicine and Sciences, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
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Ursachen des Schädel-Hirn-Traumas im Kindesalter. Rechtsmedizin (Berl) 2011. [DOI: 10.1007/s00194-011-0751-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gean AD, Fischbein NJ, Purcell DD, Aiken AH, Manley GT, Stiver SI. Benign Anterior Temporal Epidural Hematoma: Indolent Lesion with a Characteristic CT Imaging Appearance after Blunt Head Trauma. Radiology 2010; 257:212-8. [DOI: 10.1148/radiol.10092075] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wood JN, Hall M, Schilling S, Keren R, Mitra N, Rubin DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics 2010; 126:408-14. [PMID: 20713477 DOI: 10.1542/peds.2010-0031] [Citation(s) in RCA: 157] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. METHODS We conducted a retrospective study of infants with non-motor vehicle-associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. RESULTS After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P=.022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P=.009). CONCLUSIONS National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).
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Affiliation(s)
- Joanne N Wood
- General Pediatrics, Children's Hospital of Philadelphia, Department of Biostatistics, University of Pennsylvania School of Medicine, 3535 Market Street, Room 1517, Philadelphia, PA 19104, USA.
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Ashton R. Practitioner review: beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury? J Child Psychol Psychiatry 2010; 51:967-80. [PMID: 20524940 DOI: 10.1111/j.1469-7610.2010.02272.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) in infancy is relatively common, and is likely to lead to poorer outcomes than injuries sustained later in childhood. While the headlines have been grabbed by infant TBI caused by abuse, often known as shaken baby syndrome, the evidence base for how to support children following TBI in infancy is thin. These children are likely to benefit from ongoing assessment and intervention, because brain injuries sustained in the first year of life can influence development in different ways over many years. METHODS A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence-based studies specifically looking at children who have sustained a TBI in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury. RESULTS This paper outlines the issues around measuring outcomes for children following TBI in the first year of life. An explanation of outcomes which are more likely for children following TBI in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre-morbid situation; genetics; family factors and interventions. CONCLUSIONS Practitioners need to take a long-term, developmental view when assessing, understanding and supporting children who have sustained a TBI in their first year of life. The literature suggests some interventions which may be useful in prevention, acute care and longer-term rehabilitation, and further research is needed to assess their effectiveness.
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Kristiansen T, Søreide K, Ringdal KG, Rehn M, Krüger AJ, Reite A, Meling T, Naess PA, Lossius HM. Trauma systems and early management of severe injuries in Scandinavia: review of the current state. Injury 2010; 41:444-52. [PMID: 19540486 DOI: 10.1016/j.injury.2009.05.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 05/26/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development. METHODS An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included. RESULTS The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management. CONCLUSION Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.
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Affiliation(s)
- Thomas Kristiansen
- Norwegian Air Ambulance Foundation, Department of Research, Drøbak, Norway.
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Hymel KP, Stoiko MA, Herman BE, Combs A, Harper NS, Lowen D, Deye KP, Homa K, Blackman JA. Head injury depth as an indicator of causes and mechanisms. Pediatrics 2010; 125:712-20. [PMID: 20351004 DOI: 10.1542/peds.2009-2133] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children <36 months of age with varying "greatest depths" of acute cranial injury. METHODS Children <36 months of age who were hospitalized with acute head trauma were recruited at multiple sites. Clinical and imaging data were collected, and caregivers underwent scripted interviews. Neurodevelopmental evaluations were completed 6 months after injury. Head trauma causes were categorized independently, and subject groups with varying greatest depths of injury were compared. RESULTS Fifty-four subjects were enrolled at 9 sites. Twenty-seven subjects underwent follow-up neurodevelopmental assessments 6 months after injury. Greatest depth of visible injury was categorized as scalp, skull, or epidural for 20 subjects, subarachnoid or subdural for 13, cortical for 10, and subcortical for 11. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < .001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury. CONCLUSION For children <3 years of age, head injury depth is a useful indicator of injury causes and mechanisms.
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Affiliation(s)
- Kent P Hymel
- Dartmouth-Hitchcock Medical Center, Department of Pediatrics, One Medical Center Dr, Lebanon, NH 03756-0001, USA.
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Scott D, Tonmyr L, Fraser J, Walker S, McKenzie K. The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature. CHILD ABUSE & NEGLECT 2009; 33:791-808. [PMID: 19853915 DOI: 10.1016/j.chiabu.2009.08.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 08/13/2009] [Accepted: 08/13/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE The objectives of this article are to explore the extent to which the International Statistical Classification of Diseases and Related Health Problems (ICD) has been used in child abuse research, to describe how the ICD system has been applied, and to assess factors affecting the reliability of ICD coded data in child abuse research. METHODS PubMed, CINAHL, PsychInfo and Google Scholar were searched for peer reviewed articles written since 1989 that used ICD as the classification system to identify cases and research child abuse using health databases. Snowballing strategies were also employed by searching the bibliographies of retrieved references to identify relevant associated articles. The papers identified through the search were independently screened by two authors for inclusion, resulting in 47 studies selected for the review. Due to heterogeneity of studies meta-analysis was not performed. RESULTS This paper highlights both utility and limitations of ICD coded data. ICD codes have been widely used to conduct research into child maltreatment in health data systems. The codes appear to be used primarily to determine child maltreatment patterns within identified diagnoses or to identify child maltreatment cases for research. CONCLUSIONS A significant impediment to the use of ICD codes in child maltreatment research is the under ascertainment of child maltreatment by using coded data alone. This is most clearly identified and, to some degree, quantified, in research where data linkage is used. PRACTICE IMPLICATIONS The importance of improved child maltreatment identification will assist in identifying risk factors and creating programs that can prevent and treat child maltreatment and assist in meeting reporting obligations under the CRC.
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Affiliation(s)
- Debbie Scott
- National Centre for Health Information Research and Training, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove 4059, Brisbane, Queensland, Australia
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Long-term outcome of the shaken baby syndrome and medicolegal consequences: A case report. Ann Phys Rehabil Med 2009; 52:436-47. [DOI: 10.1016/j.rehab.2009.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 03/20/2009] [Indexed: 11/23/2022]
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Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics 2009; 123:e247-52. [PMID: 19171576 DOI: 10.1542/peds.2008-2467] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury. METHODS A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non-motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services. RESULTS Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse. CONCLUSION Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.
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Affiliation(s)
- Joanne N Wood
- Department of General Pediatrics and Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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