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Shahraki K, Suh DW. An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse. CHILDREN (BASEL, SWITZERLAND) 2024; 11:586. [PMID: 38790581 PMCID: PMC11119297 DOI: 10.3390/children11050586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Abusive head trauma (AHT) is an extreme form of physical child abuse, a subset of which is shaken baby syndrome (SBS). While traumatic injury in children is most readily observed as marks of contusion on the body, AHT/SBS may result in internal injuries that can put the life of the child in danger. One pivotal sign associated with AHT/SBS that cannot be spotted with the naked eye is retinal injury (RI), an early sign of which is retinal hemorrhage (RH) in cases with rupture of the retinal vasculature. If not addressed, RI can lead to irreversible outcomes, such as visual loss. It is widely assumed that the major cause of RI is acceleration-deceleration forces that are repeatedly imposed on the patient during abusive shaking. Still, due to the controversial nature of this type of injury, few investigations have ever sought to delve into its biomechanical and/or biochemical features using realistic models. As such, our knowledge regarding AHT-/SBS-induced RI is significantly lacking. In this mini-review, we aim to provide an up-to-date account of the traumatology of AHT-/SBS-induced RI, as well as its biomechanical and biochemical features, while focusing on some of the experimental models that have been developed in recent years for studying retinal hemorrhage in the context of AHT/SBS.
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Affiliation(s)
| | - Donny W. Suh
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine School of Medicine, Irvine, CA 92697, USA;
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McNamara CR, Kalinowski A, Horvat CM, Gaines BA, Richardson WM, Simon DW, Kochanek PM, Berger RP, Fink EL. New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study. Pediatr Crit Care Med 2024; 25:250-258. [PMID: 38088760 DOI: 10.1097/pcc.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up. DESIGN Retrospective single center cohort study. SETTING AND PATIENTS Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05). CONCLUSIONS In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.
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Affiliation(s)
- Caitlin R McNamara
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Anne Kalinowski
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ward M Richardson
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Dennis W Simon
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Child Advocacy, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Sokoloff M, Feldman KW, Levin AV, Rockter A, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Hymel KP. Retinal hemorrhage variation in inertial versus contact head injuries. CHILD ABUSE & NEGLECT 2024; 149:106606. [PMID: 38134727 DOI: 10.1016/j.chiabu.2023.106606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.
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Affiliation(s)
- Michael Sokoloff
- Department of Pediatrics, Pediatric Intensive Care, Sacred Heart Children's Hospital, Spokane, WA, United States of America.
| | - Kenneth W Feldman
- Department of Pediatrics, Seattle Children's, University of Washington's Harborview Medical Center, Seattle, WA, United States of America; Department of Pediatrics, Safe Child and Adolescent Network, Seattle Children's, Seattle, WA, United States of America.
| | - Alex V Levin
- Department of Ophthalmology, Flaum Eye Institute, University of Rochester, Rochester, NY, United States of America.
| | - Adam Rockter
- University of Rochester School of Medicine, Rochester, NY, United States of America.
| | - Veronica Armijo-Garcia
- Department of Pediatrics, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, United States of America.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS, United States of America.
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA, United States of America.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States of America.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States of America.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States of America
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