Child Adult Relationship Enhancement in Primary Care (PriCARE) theory of change: A promising intervention to reduce child maltreatment

Child maltreatment (CM) is a pervasive public health problem and there is a critical need for brief, effective, scalable prevention programs. Because problematic parent-child relationships lie at the core of CM, interventions targeting this relationship hold promise as CM prevention strategies. Evidence-based positive parenting interventions, as discussed here, are manualized behavioral interventions that focus on teaching caregivers positive parenting skills and techniques to improve the effectiveness of their parenting and improve their relationship with their child. In this article, we describe one specific parenting intervention, Child Adult Relationship Enhancement in Primary Care (PriCARE)/Criando Niños con CARIÑO, and review the proposed mechanisms through which PriCARE may contribute to CM prevention. PriCARE is a 6-session group parenting intervention for parents of 2-to-6-year-old children. PriCARE was developed and iteratively adapted with input from racially and ethnically diverse families, including low-income families, and was designed specifically for implementation in primary care with inclusion of strategies to align with usual care workflow to increase uptake and retention. PriCARE has the potential to reduce risk of CM directly through improving parenting behaviors and indirectly through the impact of those changes in parenting behaviors on child behaviors. PriCARE has also been shown to reduce parenting-related stress. Finally, by strengthening and bringing warmth to the parent-child relationship, PriCARE may buffer against the negative health consequences associated with CM and childhood adversity.

Skills Training for Family Medicine Residents to Attenuate the Impact of Childhood Trauma: A Pilot Study

BACKGROUND AND OBJECTIVES

Toxic stress and trauma are prevalent in the pediatric population. The sequela can be significant, leading to disruptive behaviors in early childhood to chronic medical conditions in adulthood. Two factors that can mitigate negative outcomes of developmental traumatic stress include relational health care and healthy parental relationships. Family physicians are poised to play a significant role in both attenuating factors. Therefore, focused pediatric trauma-informed knowledge and skills training for family medicine residents is important.

METHODS

One family medicine residency program added a training module for residents, with two objectives: increase in-exam room trauma-informed interaction skills, and increase knowledge and skills for physicians to coach parents on strengthening the parent-child relationship. The training included didactics and skills training. Knowledge and skills were measured pre- and posttraining.

RESULTS

A total of 39 residents participated in the study over 3 years. The knowledge score increased by 4.49 points from pre- to posttraining. The number of trauma-informed interactional skills the residents demonstrated at posttraining had increased significantly. During the pilot, all participants moved from below mastery of skills to full mastery.

CONCLUSIONS

After being instructed in best practices in trauma-informed pediatric interactions, residents demonstrated an increased number of behaviors that cultivate pediatric relational health care. Residents demonstrated knowledge and skills gains that denoted their ability to interact with patients and coach parents in evidence-based ways that can mitigate the impact of childhood trauma exposure.

Autoantibody status, neuroradiological and clinical findings in children with acute cerebellitis

BACKGROUND

Acute cerebellitis (AC) in children and adolescents is an inflammatory disease of the cerebellum due to viral or bacterial infections but also autoimmune-mediated processes.

OBJECTIVE

To investigate the frequency of autoantibodies in serum and CSF as well as the neuroradiological features in children with AC.

MATERIAL AND METHODS

Children presenting with symptoms suggestive of AC defined as acute/subacute onset of cerebellar symptoms and MRI evidence of cerebellar inflammation or additional CSF pleocytosis, positive oligoclonal bands (OCBs), and/or presence of autoantibodies in case of negative cerebellar MRI. Children fulfilling the above-mentioned criteria and a complete data set including clinical presentation, CSF studies, testing for neuronal/cerebellar and MOG antibodies as well as MRI scans performed at disease onset were eligible for this retrospective multicenter study.

RESULTS

36 patients fulfilled the inclusion criteria for AC (f:m = 14:22, median age 5.5 years). Ataxia was the most common cerebellar symptom present in 30/36 (83 %) in addition to dysmetria (15/36) or dysarthria (13/36). A substantial number of children (21/36) also had signs of encephalitis such as somnolence or seizures. In 10/36 (28 %) children the following autoantibodies (abs) were found: MOG-abs (n = 5) in serum, GFAPα-abs (n = 1) in CSF, GlyR-abs (n = 1) in CSF, mGluR1-abs (n = 1) in CSF and serum. In two further children, antibodies were detected only in serum (GlyR-abs, n = 1; GFAPα-abs, n = 1). MRI signal alterations in cerebellum were found in 30/36 children (83 %). Additional supra- and/or infratentorial lesions were present in 12/36 children, including all five children with MOG-abs. Outcome after a median follow-up of 3 months (range: 1 a 75) was favorable with an mRS ≤2 in 24/36 (67 %) after therapy. Antibody (ab)-positive children were significantly more likely to have a better outcome than ab-negative children (p = .022).

CONCLUSION

In nearly 30 % of children in our study with AC, a range of abs was found, underscoring that autoantibody testing in serum and CSF should be included in the work-up of a child with suspected AC. The detection of MOG-abs in AC does expand the MOGAD spectrum.

Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic

Importance

Information about the trend in illicit substance ingestions among young children during the pandemic is limited.

Objectives

To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies.

Design, Setting, and Participants

Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023.

Exposure

Absence or presence of the COVID-19 pandemic.

Main Outcome(s) and Measure(s)

The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances.

Results

Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters.

Conclusions and Relevance

In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Parental Perspectives on the Impact of the COVID-19 Pandemic on Infant, Child, and Adolescent Development

OBJECTIVE

The purpose of this study is to understand how families from diverse sociodemographic backgrounds perceived the impact of the pandemic on the development of their children.

METHODS

We used a multimethod approach guided by Bronfenbrenner's Ecological Systems Theory, which identifies 5 developmental systems (micro, meso, exo, macro, and chrono). Semistructured interviews were conducted in English or Spanish with parents living in 5 geographic regions of the United States between July and September 2021. Participants also completed the COVID-19 Exposure and Family Impact Survey.

RESULTS

Forty-eight families participated, half of whose preferred language was Spanish, with a total of 99 children ages newborn to 19 years. Most qualitative themes pertained to developmental effects of the microsystem and macrosystem. Although many families described negative effects of the pandemic on development, others described positive or no perceived effects. Some families reported inadequate government support in response to the pandemic as causes of stress and potential negative influences on child development. As context for their infant's development, families reported a variety of economic hardships on the COVID-19 Exposure and Family Impact Survey, such as having to move out of their homes and experiencing decreased income.

CONCLUSION

In addition to negative impacts, many parents perceived positive pandemic-attributed effects on their child's development, mainly from increased time for parent-child interaction. Families described economic hardships that were exacerbated by the pandemic and that potentially affect child development and insufficient government responses to these hardships. These findings hold important lessons for leaders who wish to design innovative solutions that address inequities in maternal, family, and child health.

Child Adult Relationship Enhancement in Primary Care (PriCARE): study design/protocol for a randomized trial of a primary care-based group parenting intervention to prevent child maltreatment

BACKGROUND

Child maltreatment (CM) is a pervasive public health problem and there is a critical need for brief, effective, scalable prevention programs. Problematic parent-child relationships lie at the heart of CM. Parents who maltreat their children are more likely to have punitive parenting styles characterized by high rates of negative interaction and ineffective discipline strategies with over-reliance on punishment. Thus, parenting interventions that strengthen parent-child relationships, teach positive discipline techniques, decrease harsh parenting, and decrease child behavioral problems hold promise as CM prevention strategies. Challenges in engaging parents, particularly low-income and minority parents, and a lack of knowledge regarding effective implementation strategies, however, have greatly limited the reach and impact of parenting interventions. Child Adult Relationship Enhancement in Primary Care (PriCARE)/Criando Niños con CARIÑO is a 6-session group parenting intervention that holds promise in addressing these challenges because PriCARE/CARIÑO was (1) developed and iteratively adapted with input from racially and ethnically diverse families, including low-income families and (2) designed specifically for implementation in primary care with inclusion of strategies to align with usual care workflow to increase uptake and retention.

METHODS

This study is a multicenter randomized controlled trial with two parallel arms. Children, 2-6 years old with Medicaid/CHIP/no insurance, and their English- and Spanish-speaking caregivers recruited from pediatric primary care clinics in Philadelphia and North Carolina will be enrolled. Caregivers assigned to the intervention regimen will attend PriCARE/CARIÑO and receive usual care. Caregivers assigned to the control regimen will receive usual care only. The primary outcome is occurrence of an investigation for CM by child protective services during the 48 months following completion of the intervention. In addition, scores for CM risk, child behavior problems, harsh and neglectful parenting behaviors, caregiver stress, and caregiver-child interactions will be assessed as secondary outcome measures and for investigation of possible mechanisms of intervention-induced change. We will also identify PriCARE/CARIÑO implementation factors that may be barriers and facilitators to intervention referrals, enrollment, and attendance.

DISCUSSION

By evaluating proximal outcomes in addition to the distal outcome of CM, this study, the largest CM prevention trial with individual randomization, will help elucidate mechanisms of change and advance the science of CM prevention. This study will also gather critical information on factors influencing successful implementation and how to optimize intervention referrals, enrollment, and attendance to inform future dissemination and practical applications.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05233150) on February 1, 2022, prior to enrolling subjects.

COVID-19 vaccine hesitancy among low-income, racially and ethnically diverse US parents

OBJECTIVE

Examine factors impacting U.S. parents' intention to vaccinate their children against COVID-19.

METHODS

Data were collected February-May 2021 from parents living in six geographically diverse locations. The COVID-19 Exposure and Family Impact Survey assessed perceived susceptibility and severity to adverse outcomes from the pandemic. Semi-structured interviews assessed perceptions about benefits and risks of vaccinating children.

RESULTS

Fifty parents of 106 children (newborn-17 years) were included; half were Spanish-speaking and half English-speaking. 62% were hesitant about vaccinating their children against COVID-19. Efficacy and safety were the main themes that emerged: some parents perceived them as benefits while others perceived them as risks to vaccination. Parent hesitancy often relied on social media, and was influenced by narrative accounts of vaccination experiences. Many cited the lower risk of negative outcomes from COVID-19 among children, when compared with adults. Some also cited inaccurate and constantly changing information about COVID-19 vaccines.

CONCLUSION

Main drivers of parent hesitancy regarding child COVID-19 vaccination include perceived safety and efficacy of the vaccines and lower severity of illness in children.

PRACTICE IMPLICATIONS

Many vaccine-hesitant parents may be open to vaccination in the future and welcome additional discussion and data.

Criando Niños Con Cariño : Primary Care-Based Group Parenting Program Adaptation and Pilot

OBJECTIVE

This study culturally adapted and piloted a primary care-based group parenting program (Child-Adult Relationship Enhancement in Primary Care, PriCARE) for Spanish-speaking, Hispanic parents of 2- to 6-year-old children.

METHODS

The process was informed by the cultural adaptation literature, expert consultation, and focus group data from 18 previous PriCARE, eligible Cariño , and initial Cariño test participants. As adaptations were made, an implementation framework was applied to systematically record all changes. Finally, parents of children aged 2 to 6 years participated in the Cariño pilot study (n = 32). Enrollment and attendance data were used to examine feasibility, and the Therapy Attitude Inventory (TAI) was administered postintervention to measure acceptability.

RESULTS

Most adaptations were minor changes to make the adapted program, Criando Niños con Cariño , more appropriate, applicable, or acceptable. Some changes required reframing Cariño concepts (e.g., child-led play) or incorporating new concepts (e.g., respeto , armonía , and educación ) to better align Cariño goals with parents' values. Among the 121 dyads invited to participate in the Cariño pilot study, 52 (43%) enrolled. Among the 52 enrolled, 32 (62%) attended at least 4 of the 6 sessions and reported high satisfaction on the TAI (mean 47/50, range 33-50).

CONCLUSION

Cariño is the result of a rigorous adaption process and incorporates multiple changes to ensure the translation reflects the intended meaning and to reframe the program goals and concepts in a culturally congruent manner. Pilot data suggest Cariño is feasible and acceptable to parents.

High-alert medications for hospitalised paediatric patients - a two-step survey among paediatric clinical expert pharmacists in Germany

Paediatric patients are more vulnerable to be harmed by medication errors compared to adults due to pharmacokinetic and pharmacodynamic changes in their development, individual dosing calculations, and manipulation of ready to-use products intended for adult patients. According to the Institute of Safe Medication Practices, there are some "drugs that bear a heightened risk of causing significant patient harm when they are used in error"; these drugs are called high-alert medications (HAM). The two-step survey among paediatric clinical expert pharmacists presented here aimed to compile a nation-wide HAM list. To provide detailed guidance, this survey followed a drugbased approach, resulting in specific potential drug related problems (DRPs) and associated recommendations for prevention. In contrast to this approach, in the first round of the survey two drug classes were included that both were rated as HAM (i.e.chemotherapy and parenteral nutrition). Twenty single drugs were identified as HAM, 65% of which were cardiovascular or neurological drugs. The paediatric expert pharmacists mentioned in total 216 potential DRPs; in particular, they identified potential administration-related problems (28% of all DRPs), dosing-related problems (26%), and drug-choice-related problems (18%, e.g.drug confusion and drug monitoring). Moreover, they suggested 275 potential interventions to address these DRPs. Two thirds of all interventions dealt with the preparation by the hospital pharmacy, standardisation of processes (e.g.labelling), and education or training. In conclusion, this survey provided a German paediatric high-alert medication list from a paediatric pharmacist point of view. Moreover, the experts mentioned for the first time specific potential DRPs and associated interventions to guide a local multidisciplinary approach for preventing medication-related harm in children.

Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed.

Plain Language Summary

There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals

IMPORTANCE

Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement.

OBJECTIVE

To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022.

EXPOSURES

Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital.

MAIN OUTCOMES AND MEASURES

Use of neuroimaging by CT or MRI.

RESULTS

Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001).

CONCLUSIONS AND RELEVANCE

This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.

Cultural Adaptation of Group Parenting Programs: Review of the Literature and Recommendations for Best Practices

Group parenting programs based on cognitive-behavioral and social learning principles are effective in improving child behavior problems and positive parenting. However, most programs target non-Hispanic, White, English-speaking families and are largely inaccessible to a growing Hispanic and non-White population in the United States. We sought to examine the extent to which researchers have culturally adapted group parenting programs by conducting a systematic review of the literature. We identified 41 articles on 23 distinct culturally adapted programs. Most cultural adaptations focused on language translation and staffing, with less focus on modification of concepts and methods, and on optimizing the fit between the target cultural group and the program goals. Only one of the adapted programs engaged a framework to systematically record and publish the adaptation process. Fewer than half of the culturally adapted programs were rigorously evaluated. Additional investment in cultural adaptation and subsequent evaluation of parenting programs is critical to meet the needs of all US families.

Improving Child Behaviors and Parental Stress: A Randomized Trial of Child Adult Relationship Enhancement in Primary Care

BACKGROUND

Prior single-site evaluations of Child Adult Relationship Enhancement in Primary Care (PriCARE), a 6-session group parent training, demonstrated reductions in child behavioral problems and improvements in positive parenting attitudes.

OBJECTIVE

To measure the impact of PriCARE on disruptive child behaviors, parenting stress, and parenting attitudes in a multisite study.

METHODS

Caregivers of children 2- to 6-year-old with behavior concerns recruited from 4 pediatric primary care practices were randomized 2:1 to PriCARE intervention (n = 119) or waitlist control (n = 55). Seventy-nine percent of caregivers identified as Black and 59% had annual household incomes under $22,000. Child behavior, parenting stress, and parenting attitudes were measured at baseline and 2 to 3 months after intervention using the Eyberg Child Behavior Inventory, Parenting Stress Index, and Adult-Adolescent Parenting Inventory-2. Marginal standardization implemented in a linear regression compared mean change scores from baseline to follow-up by treatment arm while accounting for clustering by site.

RESULTS

Mean change scores from baseline to follow-up demonstrated greater improvements (decreases) in Eyberg Child Behavior Inventory problem scores but not intensity scores in the PriCARE arm compared to control, (problem: -4.4 [-7.5, -1.2] vs -1.8 [-4.1, 0.4], P= .004; intensity: -17.6 [-28.3, -6.9] vs -10.4 [-18.1, -2.6], P= .255). Decreases in parenting stress were greater in the PriCARE arm compared to control (-3.3 [-4.3, -2.3] vs 0 [-2.5, 2.5], P= .025). Parenting attitudes showed no significant changes (all P> .10).

CONCLUSIONS

PriCARE showed promise in improving parental perceptions of the severity of child behaviors and decreasing parenting stress but did not have an observed impact on parenting attitudes.

Relationship Between Parental Locus of Control and Childhood Injury

Although pediatricians routinely counsel parents about preventing childhood injuries, we know little about parents' locus of control (LOC) in regards to preventing their children from being injured. We performed an observational analysis of sociodemographic differences in LOC for injury prevention, as measured by four items adapted from the Parental Health Beliefs Scales, in English- and Spanish-speaking parents of infants participating in the treatment arm of an obesity prevention study. First, we examined associations of parental LOC for injury prevention at the time their children were 2 months old with parents' age, race/ethnicity, income, and education. Next, we analyzed time trends for repeated LOC measures when the children were 2, 6, 9, 12, and 24 months old. Last, we examined the association between injury-related LOC items and children's injury (yes/no) at each time point. Of 452 parents, those with lower incomes had both lower internal and higher external LOC. Lower educational achievement was associated with higher external LOC. Both internal and external LOC scores decreased over time. Injuries were more common in children whose parents endorsed low internal and high external LOC. Future studies should examine whether primary care-based interventions can increase parents' sense of control over their children's safety and whether that, in turn, is associated with lower injury rates.Clinical Trial Registration: NCT01040897.

Symptom Burden and Profiles in Concussed Children with and without Prolonged Recovery

Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10–18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included; 80.3% white, 60.0% male, and 44.0% aged 13–15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p < 0.001 and p < 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p < 0.001), ocular (p < 0.001), cognitive/fatigue (p < 0.001), migraine (p < 0.001) and anxiety (p < 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.

Rachitic change and vitamin D status in young children with fractures

OBJECTIVE

To examine the association between rachitic changes and vitamin D levels in children less than 2 years old with fractures.

METHODS

Children less than 2 years old who were admitted to a large children's hospital for a fracture and underwent a skeletal survey were included. Two pediatric radiologists blinded to the children's vitamin D levels independently reviewed the skeletal surveys for the following rachitic findings: demineralization, widened sutures, rachitic rosary, Looser zones, and metaphyseal changes. Kappa coefficients were calculated to assess inter-rater agreement. Logistic regression was used to test the association between vitamin D level and rachitic findings.

RESULTS

There were 79 subjects (40 female and 39 male) with a median age of 4 months. Vitamin D levels ranged from 11.6 to 88.9 ng/ml and were low in 27. Questionable demineralization was noted in seven subjects; mild to moderate demineralization was observed in four subjects. Widened sutures were noted in seven subjects, many also with concurrent intracranial hemorrhage. Lower vitamin D levels were associated with increased odds of demineralization after adjusting for age, gender, and prematurity (P < 0.015). An association was not found between the vitamin D level and suture widening (P = 0.07). None of the cases demonstrated Looser zones, rachitic rosary, or metaphyseal changes of rickets.

CONCLUSIONS

Infants and toddlers with fractures frequently have suboptimal vitamin D levels, but radiographic evidence of rickets is uncommon in these children.

Screening for Social Determinants of Health in Pediatric Resident Continuity Clinic

OBJECTIVE

Describe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET).

METHODS

CORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH, including the screen source, timing of screening, process of administering the screen, and personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition.

RESULTS

Clinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Barriers to screening included lack of time (63%), resources (50%), and training (46%).

CONCLUSIONS

Screening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered.

Health Status of Children Enrolled in a Family Navigator Program to Eliminate Intergenerational Poverty

In 2014, Family Success Alliance (FSA) was formed as a place-based initiative to build a pipeline of programs to reduce the impact of poverty on outcomes for children living in Orange County, North Carolina. In this study, FSA parents' perception of child health, parent and child adverse childhood experiences (ACEs), and resilience were obtained by parent interview. Receipt of recommended health services were abstracted from primary care medical records of FSA children. Correlation coefficients investigated relationships among health, ACEs, and resilience. Among 87 parent-child dyads, 65% were Spanish speaking. At least 1 of the 7 ACEs measured was reported in 37% of children and 70% of parents. Parent perceptions of child health were lower than national averages. Routine preventive services included the following: autism screening at 18 months (15%) and 24 months (31%); ≥4 fluoride varnish applications (10%); lead screening (66%); and receipt of immunizations (94%). Parent perception of child health was moderately correlated with resilience.

Understanding patient-reported outcome measures in Huntington disease: at what point is cognitive impairment related to poor measurement reliability?

PURPOSE

Symptom progression in Huntington disease (HD) is associated with cognitive decline which may interfere with the self-report of symptoms. Unfortunately, data to support or refute the psychometric reliability of patient-reported outcomes (PROs) as HD progresses are limited. This is problematic given that PROs are increasingly recognized as important measures of efficacy for new treatments.

METHODS

We examined PRO data from the HDQLIFE Measurement System (Speech Difficulties; Swallowing Difficulties; Chorea) in 509 individuals with premanifest, early-stage, or late-stage HD. Clinician-administered assessments of motor functioning (items from the UHDRS) and standardized objective assessments of cognition (Stroop, Symbol Digit Modalities) were also collected. We examined item bias using differential item functioning (DIF) across HD stage (premanifest, early-, late-) and relative to cognitive performance. We also examined the correlations between self-report and clinician ratings. Regression models that considered total cognitive ability were utilized to determine psychometric reliability of the PROs.

RESULTS

Most PRO items were free from DIF for both staging and cognition. There were modest correlations between PROs and clinician report (ranged from - 0.40 to - 0.60). Modeling analyses indicated that psychometric reliability breaks down with poorer cognition and more progressed disease stage; split-half reliability was compromised (i.e., split-half reliability < 0.80) when scores were < 136 for Chorea, < 109 for Speech Difficulties, and < 179 for Swallowing Difficulties.

CONCLUSIONS

Results indicate that the psychometric reliability of PROs can be compromised as HD symptoms progress and cognition declines. Clinicians should consider PROs in conjunction with other types of assessments when total cognition scores exceed critical thresholds.

Dimerization leads to changes in APP (amyloid precursor protein) trafficking mediated by LRP1 and SorLA

Proteolytic cleavage of the amyloid precursor protein (APP) by α-, β- and γ-secretases is a determining factor in Alzheimer's disease (AD). Imbalances in the activity of all three enzymes can result in alterations towards pathogenic Aβ production. Proteolysis of APP is strongly linked to its subcellular localization as the secretases involved are distributed in different cellular compartments. APP has been shown to dimerize in cis-orientation, affecting Aβ production. This might be explained by different substrate properties defined by the APP oligomerization state or alternatively by altered APP monomer/dimer localization. We investigated the latter hypothesis using two different APP dimerization systems in HeLa cells. Dimerization caused a decreased localization of APP to the Golgi and at the plasma membrane, whereas the levels in the ER and in endosomes were increased. Furthermore, we observed via live cell imaging and biochemical analyses that APP dimerization affects its interaction with LRP1 and SorLA, suggesting that APP dimerization modulates its interplay with sorting molecules and in turn its localization and processing. Thus, pharmacological approaches targeting APP oligomerization properties might open novel strategies for treatment of AD.

[Two synchronous malignancies in a single nephrectomy specimen]

We report a case of a 65-year-old man examined for hematuria and neurologic symptoms. Radiologically a tumour of the kidney was suspected, with metastatic involvement of the brain and both lungs. The urologists then performed a cytoreductive nephrectomy.In histopathological examination of the nephrectomy specimen a clear cell renal cell carcinoma (clear cell RCC) was found. However, an additional focus of a high-grade adenocarcinoma was discovered that turned out to be a metastasis of a poor differentiated lung adenocarcinoma. This diagnosis was supported by positive TTF1 and napsin-A as well as good clinical correlations.The article summarizes the differential diagnostic considerations of poor differentiated adenocarcinoma of the kidney, aimed at gross and microscopic morphology, immunohistochemistry and clinical-pathological correlation. A review of literature about a tumour-in-tumour metastasis is included.

Improving HIV post-exposure prophylaxis rates after pediatric acute sexual assault

The purpose of our study was to increase the rate of children with appropriate HIV-PEP regimens among those diagnosed with sexual assault in The Children's Hospital of Philadelphia Emergency Department (ED). The outcome measure was the percent of patients receiving correct HIV-PEP. We retrospectively reviewed 97 charts over 31 months to define the baseline rate of children receiving appropriate HIV-PEP regimens (pre QI-implementation period: 2/2012-8/2014). Among children in which HIV-PEP was indicated following sexual assault, 40% received the recommended 28-day course. Root cause analysis indicated prescribing errors accounted for 87% of patients not receiving appropriate HIV-PEP. Process drivers included standardizing care coordination follow-up calls to elicit specific information about HIV-PEP, ED educational initiatives targeted at HIV-PEP prescribing, revision of the clinical pathway to specify indicated duration of HIV-PEP, and revision of the order set to auto-populate the number of days for the HIV-PEP prescription. During the QI-implementation period (9/2014-4/2015), the rate of appropriate HIV-PEP increased to 64% (median 60%) and the average number of days between incorrect HIV-PEP regimens was 24.5. Post QI-implementation (5/2015-3/2016), the rate of appropriate HIV-PEP increased to 84% (median 100%) and the average number of days between incorrect HIV-PEP regimens increased to 78.4. A multifaceted quality improvement process improved the rate of receipt of appropriate HIV-PEP regimens for pediatric victims of sexual assault. Decision support tools are instrumental in sustaining ideal care delivery, but require ongoing evaluation and improvement in order to remain optimally effective.

Child-Adult Relationship Enhancement in Primary Care (PriCARE): A Randomized Trial of a Parent Training for Child Behavior Problems

OBJECTIVE

Child-Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group parent training designed to teach positive parenting skills. Our objective was to measure PriCARE's impact on child behavior and parenting attitudes.

METHODS

Parents of children 2 to 6 years old with behavior concerns were randomized to PriCARE (n = 80) or control (n = 40). Child behavior and parenting attitudes were measured at baseline (0 weeks), program completion (9 weeks), and 7 weeks after program completion (16 weeks) using the Eyberg Child Behavior Inventory (ECBI) and the Adult Adolescent Parenting Inventory 2 (AAPI2). Linear regression models compared mean ECBI and AAPI2 change scores from 0 to 16 weeks in the PriCARE and control groups, adjusted for baseline scores.

RESULTS

Of those randomized to PriCARE, 43% attended 3 or more sessions. Decreases in mean ECBI intensity and problem scores between 0 and 16 weeks were greater in the PriCARE group, reflecting a larger improvement in behavior problems [intensity: -22 (-29, -16) vs -7 (-17, 2), P = .012; problem: -5 (-7, -4) vs -2 (-4, 0), P = .014]. Scores on 3 of the 5 AAPI2 subscales reflected greater improvements in parenting attitudes in the PriCARE group compared to control in the following areas: empathy toward children's needs [0.82 (0.51, 1.14) vs 0.25 (-0.19, 0.70), P = .04], corporal punishment [0.22 (0.00, 0.45) vs -0.30 (-0.61, 0.02), P = .009], and power and independence [0.37 (-0.02, 0.76) vs -0.64 (-1.19, -0.09), P = .003].

CONCLUSIONS

PriCARE shows promise in improving parent-reported child-behavior problems in preschool-aged children and increasing positive parenting attitudes.

[A 10-year evaluation of geriatric rehabilitation in Rhineland-Palatinate]

BACKGROUND

An evaluation of geriatric rehabilitation has been carried out in Rhineland-Palatinate for over 10 years by collecting data of patients absolving an inpatient geriatric rehabilitation program. The aim of the project was to improve the transparency of outcome quality. The procedure is equally supported by geriatric rehabilitation clinics, health insurance companies and the Medical Service of Health Insurance (MDK).

MATERIAL AND METHODS

Consented information about the rehabilitation process has been collected from every geriatric rehabilitation clinic in Rhineland-Palatinate. The data were pseudonymized and sent to the MDK in Rhineland-Palatinate for statistical analysis. The dataset included age, diagnosis, life circumstances before rehabilitation, duration of the rehabilitation, therapy implemented and need for support (with or without personal assistance) in eight activities of daily living at the beginning and at the end of rehabilitation.

RESULTS

The results of 45,751 participants who underwent rehabilitation between 2005 and 2014 are presented. There was a slight tendency towards an increase in the number of very old geriatric patients undergoing rehabilitation. The average duration of rehabilitation decreased slightly during the observation period, while the frequency of therapy increased. The reduction in the need for assistance during rehabilitation remained constant over the observation period.

CONCLUSION

Systematic evaluation improves the transparency of the rehabilitation process.

Testing and Treatment After Adolescent Sexual Assault in Pediatric Emergency Departments

OBJECTIVE

To examine rates of recommended of testing and prophylaxis for chlamydia, gonorrhea, and pregnancy in adolescents diagnosed with sexual assault across pediatric emergency departments (EDs) and to determine whether specialized sexual assault pathways and teams are associated with performance of recommended testing and prophylaxis.

METHODS

In this retrospective study of 12- to 18-year-old adolescents diagnosed with sexual assault at 38 EDs in the Pediatric Hospital Information System database from 2004 to 2013, information regarding routine practice for sexual assault evaluations and presence and year of initiation of specialized ED sexual assault pathways and teams was collected via survey. We examined across-hospital variation and identified patient- and hospital-level factors associated with testing and prophylaxis using logistic regression models, accounting for clustering by hospital.

RESULTS

Among 12,687 included cases, 93% were female, 79% were <16 years old, 34% were non-Hispanic white, 38% were non-Hispanic black, 21% were Hispanic, and 52% had public insurance. Overall, 44% of adolescents received recommended testing (chlamydia, gonorrhea, pregnancy) and 35% received recommended prophylaxis (chlamydia, gonorrhea, emergency contraception). Across EDs, unadjusted rates of testing ranged from 6% to 89%, and prophylaxis ranged from 0% to 57%. Presence of a specialized sexual assault pathway was associated with increased rates of prophylaxis even after adjusting for case-mix and temporal trends (odds ratio 1.46, 95% confidence interval 1.15 to 1.86).

CONCLUSIONS

Evaluation and treatment of adolescent sexual assault victims varied widely across pediatric EDs. Adolescents cared for in EDs with specialized sexual assault pathways were more likely to receive recommended prophylaxis.

Medical Management and Trauma-Informed Care for Children in Foster Care

Children enter foster care with a myriad of exposures and experiences, which can threaten their physical and mental health and development. Expanding evidence and evolving guidelines have helped to shape the care of these children over the past two decades. These guidelines address initial health screening, comprehensive medical evaluations, and follow-up care. Information exchange, attention to exposures, and consideration of how the adversities, which lead to foster placement, can impact health is crucial. These children should be examined with a trauma lens, so that the child, caregiver, and community supports can be assisted to view their physical and behavioral health from the perspective of what we now understand about the impact of toxic stress. Health care providers can impact the health of foster children by screening for the negative health consequences of trauma, advocating for trauma-informed services, and providing trauma-informed anticipatory guidance to foster parents. By taking an organized and comprehensive approach, the health care provider can best attend to the needs of this vulnerable population.

Expression, purification and initial characterization of human meprin β from Pichia pastoris

Human meprin β (h-meprin β), a single-zinc metalloendoprotease of the astacin family, is potentially involved in disorders such as fibrosis and Alzheimer's disease. Here, we describe the expression of the enzyme in the yeast Pichia pastoris. The N-terminal signal sequence was replaced by the α-leader of Saccharomyces, enabling efficient secretion of the mature enzyme, harboring either an N-terminal or C-terminal His-tag. The purification by affinity and hydrophobic interaction chromatography resulted in isolation of 58.4 mg/l of homogenous human pro-meprin β from fermentation broth. The activated enzyme isolated from yeast (yh-meprin β) displayed virtually identical enzymatic activity as h-meprin from a mammalian cell line. Furthermore, the yh-meprin β was N-glycosylated and secreted as a dimer with a molecular mass of 148 kDa. Endoglycosidase H treatment generated a protein with a molecular mass of 133 kDa, but essentially unchanged kinetic parameters. Thus, our data suggest that human meprin β expressed in P. pastoris displays virtually identical parameters as meprin from other sources. The high yield of protein expression, the ease of purification and the deglycosylation in its native state appear to favor further studies aiming at inhibitor screening and structure-based inhibitor refinement.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the ‘European Network for HIDs’ conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

Child physical abuse and neglect

This article provides an overview of child physical abuse and neglect, and describes the magnitude of the problem and the triggers and factors that place children at risk for abuse and neglect. After examining the legal and clinical definitions of child abuse and neglect, common clinical outcomes and therapeutic strategies are reviewed, including the lifelong poor physical and mental health of victims and evidence-supported treatment interventions. Mandated reporting laws, and facilitating collaboration among child welfare, judicial, and health care systems are considered. Important tools and resources for addressing child maltreatment in clinical practice are discussed, and future approaches posited.

Disrupted cross-laminar cortical processing in β amyloid pathology precedes cell death

Disruption of neuronal networks in the Alzheimer-afflicted brain is increasingly recognized as a key correlate of cognitive and memory decline in Alzheimer patients. We hypothesized that functional synaptic disconnections within cortical columnar microcircuits by pathological β-amyloid accumulation, rather than cell death, initially causes the cognitive impairments. During development of cortical β-amyloidosis with still few plaques in the transgenic 5xFAD mouse model single cell resolution mapping of neuronal thallium uptake revealed that electrical activity of pyramidal cells breaks down throughout infragranular cortical layer V long before cell death occurs. Treatment of 5xFAD mice with the glutaminyl cyclase inhibitor, PQ 529, partially prevented the decline of pyramidal cell activity, indicating pyroglutamate-modified forms, potentially mixed oligomers of Aβ are contributing to neuronal impairment. Laminar investigation of cortical circuit dysfunction with current source density analysis identified an early loss of excitatory synaptic input in infragranular layers, linked to pathological recurrent activations in supragranular layers. This specific disruption of normal cross-laminar cortical processing coincided with a decline of contextual fear learning.

Infection control practices in facilities for highly infectious diseases across Europe

BACKGROUND

The management of patients with highly infectious diseases (HIDs) is a challenge for healthcare provision requiring a high level of care without compromising the safety of other patients and healthcare workers.

AIM

To study the infection control practice in isolation facilities participating in the European Network for Highly Infectious Diseases (EuroNHID) project.

METHODS

A survey was conducted during 2009 of 48 isolation facilities caring for patients with HIDs in 16 European countries. Checklists and standard evaluation forms were used to collect and interpret data on hand hygiene, routine hygiene and disinfection, and waste management.

FINDINGS

Forty percent of HIDs had no non-hand-operated sinks or alcohol-based antiseptic distributors, while 27% did not have procedures for routine hygiene, final disinfection, or safe discarding of non-disposable objects or equipment. There was considerable variation in the management of waste and in the training of housekeeping personnel. EuroNHID has developed recommendations for hand hygiene, disinfection, routine hygiene, and waste management.

CONCLUSIONS

Most aspects of hand hygiene, routine hygiene and disinfection, and waste management were considered at least partially adequate in the majority of European isolation facilities dedicated for the care of patients with HIDs. But considerable variability was observed, with management of waste and training of housekeeping personnel being generally less satisfactory.

Mice over-expressing salmon calcitonin have strongly attenuated osteoarthritic histopathological changes after destabilization of the medial meniscus

OBJECTIVE

Calcitonin is well-known for its inhibitory actions on bone-resorbing osteoclasts and recently potential beneficial effects on cartilage were shown. We investigated effects of salmon calcitonin (sCT) on the articular cartilage and bone, after destabilization of the medial meniscus (DMM) in normal and sCT over-expressing mice.

DESIGN

Bone phenotype of transgenic (TG) C57Bl/6 mice over-expressing sCT at 6 months and 12 months was investigated by (1) serum osteocalcin and urinary deoxypyridinoline and (2) dynamic and normal histomorphometry of vertebrae bodies. In subsequent evaluation of cartilage and subchondral bone changes, 44 10-week old TG or wild-type (WT) mice were randomized into four groups and subjected to DMM or sham-operations. After 7 weeks animals were sacrificed, and knee joints were isolated for histological analysis.

RESULTS

Trabecular bone volume (BV/TV) increased 150% after 6 months and 300% after 12 months in sCT-expressing mice when compared to WT controls (P<0.05). Osteoblast number, bone formation rate and osteocalcin measurements were not affected in TG mice over-expressing sCT. In WT animals, a 5-fold increase in the quantitative erosion index was observed after DMM, and the semi-quantitative OARSI score showed over 400% (P<0.001) increase, compared to sham-operated WT mice. DMM-operated TG mice were protected against cartilage erosion and showed a 65% and 64% (P<0.001) reduction, respectively, for the two histopathological evaluation methods.

CONCLUSIONS

sCT over-expressing mice had higher bone volume, and were protected against cartilage erosion. These data suggest that increased levels of sCT may hamper the pathogenesis of osteoarthritis (OA). However more studies are necessary to confirm these preliminary results.

Thyroid function during controlled ovarian hyperstimulation as part of in vitro fertilization

OBJECTIVE

To determine the exact nature and timing of alterations in thyroid function throughout controlled ovarian hyperstimulation (COH).

DESIGN

Prospective cohort study.

SETTING

University fertility clinic.

PATIENT(S)

Fifty-seven women undergoing COH as part of planned in vitro fertilization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Timing and magnitude of change in serum thyroid hormones, including TSH, total and free T(4), E(2), and thyroxine-binding globulin (TBG), measured at six time points from before stimulation to 2 weeks after serum pregnancy test.

RESULT(S)

Geometric mean serum TSH increased during stimulation, peaking 1 week after hCG administration compared with baseline (2.44 vs. 1.42 mIU/L), as did free T(4) (1.52 vs. 1.38 ng/dL) and TBG (32.86 vs. 21.52 μg/mL). Estradiol levels increased, peaking at hCG administration (1743.21 vs. 71.37 pg/mL). Of 50 women with baseline TSH ≤ 2.5 mIU/L, 22 (44.0%) had a subsequent rise in TSH to >2.5 during or after COH. The pattern of change over time in TSH concentrations was significantly influenced by baseline hypothyroidism and whether pregnancy was achieved.

CONCLUSION(S)

COH led to significant elevations in TSH, often above pregnancy appropriate targets. These findings were particularly evident in women with preexisting hypothyroidism and may have important clinical implications for screening and thyroid hormone supplementation.

Vitamin D status in abused and nonabused children younger than 2 years old with fractures

OBJECTIVE

To examine vitamin D levels in children with (1) suspected abusive and accidental fractures, (2) single and multiple fractures, and (3) fracture types highly associated with inflicted trauma.

DESIGN AND METHODS

A study of children younger than 2 years of age with fractures admitted to a large children's hospital was performed. Bivariate analysis and test for trend were performed to test for the association of vitamin D status and biochemical markers of bone health with the primary outcomes of fracture etiology, number, and type.

RESULTS

Of 118 subjects in the study, 8% had deficient vitamin D levels (<20 ng/mL; <50 nmol/L), 31% were insufficient (≥20 < 30 ng/mL; ≥50 < 78 nmol/L), and 61% were sufficient (≥30 ng/mL; ≥78 nmol/L). Lower vitamin D levels were associated with higher incidences of hypocalcemia (P = .002) and elevated alkaline phosphatase (P = .05) but not hypophosphatemia (P = .30). The majority of children sustained accidental fractures (60%); 31% were nonaccidental and 9% were indeterminate. There was no association between vitamin D levels and any of the following outcomes: child abuse diagnosis (P = .32), multiple fractures (P = .24), rib fractures (P = .16), or metaphyseal fractures (P = .49).

CONCLUSIONS

Vitamin D insufficiency was common in young children with fractures but was not more common than in previously studied healthy children. Vitamin D insufficiency was not associated with multiple fractures or diagnosis of child abuse. Nonaccidental trauma remains the most common cause of multiple fractures in young children.

Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury

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).

Fumaric acid esters are effective in chronic experimental autoimmune encephalomyelitis and suppress macrophage infiltration

Fumaric acid esters (FAE) have proven their therapeutic efficacy in psoriasis, a Th1 mediated skin disease. More recently, preliminary data have suggested an activity in multiple sclerosis (MS) as well. To investigate further possible mechanisms of action of these compounds in inflammatory diseases, we studied the FAE methyl hydrogen fumarate (MHF) and dimethyl fumarate (DMF) in chronic experimental autoimmune encephalomyelitis (EAE) induced by immunization of C57BL/6 mice with MOG peptide aa 35-55. Preventive treatment with these FAE was delivered twice a day by oral gavage. Both esters had a significant therapeutic effect on the disease course and histology showed a strongly reduced macrophage inflammation in the spinal cord. Multiparameter cytokine analysis from blood detected an increase of IL-10 in the treated animals. We conclude that the underlying biological activity of FAE in EAE is complex and, to elucidate the molecular mechanisms, further investigation is needed.

[A young infant with afebrile pneumonia caused by Chlamydia trachomatis]

Pregnant women who have an urogenital Chlamydia trachomatis infection may transmit the infection to their infants. Conjunctivitis and nasopharyngeal infection are the most frequent manifestations. Less frequently the infants may develop pneumonia. We report a case of a 5-week-old girl with poor feeding, staccato cough and clinical signs of pneumonia. Chest radiography revealed severe bronchopneumonia. Despite of intravenous therapy with ampicillin and gentamicin respiration deteriorated and oxygen supplementation became necessary. After additional treatment with oral erythromycin (50 mg/kg per day) had been started the clinical condition improved. Polymerase chain reaction with a nasopharyngeal specimen was found to be positive for Chlamydia trachomatis.

Plasmaaustausch bei steroidresistenten Multiple-Sklerose-Schüben

Patients with severe multiple sclerosis (MS) relapses which do not respond sufficiently to corticosteroids can undergo escalating immunotherapy with plasma exchange. We review the course of 14 apheresis cycles in 13 adult patients and three pediatric cases from our center between 2004 and 2005. Nine cases were due to optic neuritis, five had experienced clinically isolated syndromes, and two suffered from Devic's disease. Of the adult patients, 71% had good or very good outcome. The mean time point of improvement was after the third plasmapheresis session, and early initiation of plasma exchange therapy (within 1 month after begin of relapse) was associated with better outcome. In pediatric MS, two of three patients showed clear improvement. These data argue for a very good therapeutic effect of plasma exchange if performed early and with adequate indication.