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Fortin K, Wood JN, Udell SM, Christian CW. Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns. Pediatr Emerg Care 2024; 40:527-531. [PMID: 38713852 DOI: 10.1097/pec.0000000000003191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVES The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services. METHODS This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ 2 , Fisher exact, Kruskal-Wallis). RESULTS Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting. CONCLUSION Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Harris S, Chinnery HR, Semple BD, Mychasiuk R. Shaking Up Our Approach: The Need for Characterization and Optimization of Pre-clinical Models of Infant Abusive Head Trauma. J Neurotrauma 2024. [PMID: 38497766 DOI: 10.1089/neu.2023.0598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Traumatic brain injuries (TBIs) are a large societal and individual burden. In the first year of life, the vast majority of these injuries are the result of inflicted abusive events by a trusted caregiver. Abusive head trauma (AHT) in infants, formerly known as shaken baby syndrome, is the leading cause of inflicted mortality and morbidity in this population. In this review we address clinical diagnosis, symptoms, prognosis, and neuropathology of AHT, emphasizing the burden of repetitive AHT. Next, we consider existing animal models of AHT, and we evaluate key features of an ideal model, highlighting important developmental milestones in children most vulnerable to AHT. We draw on insights from other injury models, such as repetitive, mild TBIs (RmTBIs), post-traumatic epilepsy (PTE), hypoxic-ischemic injuries, and maternal neglect, to speculate on key knowledge gaps and underline important new opportunities in pre-clinical AHT research. Finally, potential treatment options to facilitate healthy development in children following an AHT are considered. Together, this review aims to drive the field toward optimized, well-characterized animal models of AHT, which will allow for greater insight into the underlying neuropathological and neurobehavioral consequences of AHT.
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Affiliation(s)
- Sydney Harris
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Holly R Chinnery
- Department of Optometry and Vision Science, University of Melbourne, Parkville, Victoria, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
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Alghanim FF, Almubayedh TA, Alseba Z. Assessing Awareness, Knowledge, and Attitude of Saudi Mothers Regarding Shaken Baby Syndrome in the Eastern Province of Saudi Arabia: A Cross-Sectional Prospective Study. Cureus 2024; 16:e51884. [PMID: 38192531 PMCID: PMC10773940 DOI: 10.7759/cureus.51884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/10/2024] Open
Abstract
Shaken baby syndrome (SBS) is a form of traumatic brain injury. Shaking babies can cause the brain matter to bounce within the cranium causing bruising and bleeding, which can result in permanent brain injury. Understanding the attitudes and knowledge of mothers on SBS would help establish effective interventions to raise awareness and establish preventive measures and education programs to avoid debilitating sequelae from SBS in newborns and infants. This study aimed to explore the awareness and attitude regarding SBS. An observational, cross-sectional study was conducted from April 1st through July 31st, 2023. The study population is comprised of mothers who are residents of the Eastern Province of Saudi Arabia and excluded females with no children and those who refused to participate, in addition to mothers not in the Eastern Province. The final sample size included 403 participants. An online-based validated questionnaire was used in the Arabic language. The questionnaire included demographic information and questions to assess the knowledge and attitude of participants regarding SBS. The chi-square test was used to test for significant associations. The majority of the participants were married (72%), while 15.6% were divorced and 10.2% were widowed. Only 7.4% of the participants were illiterates, 30.5% had primary education only, and 15.9% had postgraduate studies. Of note, 37% of the participants said that they would shake their children to calm them if they started to cry. Only 33% of the participants said that shaking babies is harmful. The most commonly reported complications of shaking babies were intracranial bleeding (48.1%), behavioral changes (23.8%), and learning disability (23.5%). Regarding attitude toward SBS, more than two-thirds (72.5%) of the participants said that they want to know more about SBS. Only the educational level had statistically significant relationship between the awareness and the sociodemographic level of the participants. This study concludes that Saudi mothers' knowledge about SBS is inadequate despite the favorable attitude toward gaining information about it. The awareness level is significantly associated with educational status, which reflects the importance of education programs, especially during the pregnancy period, in raising awareness about SBS and its complications.
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Affiliation(s)
| | | | - Zahra Alseba
- Pediatrics, Maternity and Children Hospital, Dammam, SAU
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Raghupathi R, Prasad R, Fox D, Huh JW. Repeated mild closed head injury in neonatal rats results in sustained cognitive deficits associated with chronic microglial activation and neurodegeneration. J Neuropathol Exp Neurol 2023; 82:707-721. [PMID: 37390808 PMCID: PMC10357947 DOI: 10.1093/jnen/nlad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023] Open
Abstract
Abusive head trauma in infants is a consequence of multiple episodes of abuse and results in axonal injury, brain atrophy, and chronic cognitive deficits. Anesthetized 11-day-old rats, neurologically equivalent to infants, were subjected to 1 impact/day to the intact skull for 3 successive days. Repeated, but not single impact(s) resulted in spatial learning deficits (p < 0.05 compared to sham-injured animals) up to 5 weeks postinjury. In the first week following single or repetitive brain injury, axonal and neuronal degeneration, and microglial activation were observed in the cortex, white matter, thalamus, and subiculum; the extent of the histopathologic damage was significantly greater in the repetitive-injured animals compared to single-injured animals. At 40 days postinjury, loss of cortical, white matter and hippocampal tissue was evident only in the repetitive-injured animals, along with evidence of microglial activation in the white matter tracts and thalamus. Axonal injury and neurodegeneration were evident in the thalamus up to 40 days postinjury in the repetitive-injured rats. These data demonstrate that while single closed head injury in the neonate rat is associated with pathologic alterations in the acute post-traumatic period, repetitive closed head injury results in sustained behavioral and pathologic deficits reminiscent of infants with abusive head trauma.
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Affiliation(s)
- Ramesh Raghupathi
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Rupal Prasad
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas Fox
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Sarmiento CA, Wyrwa JM, Chambliss AV, Stearns-Yoder KA, Hoffberg AS, Appel A, Brenner BO, Brenner LA. Developmental Outcomes Following Abusive Head Trauma in Infancy: A Systematic Review. J Head Trauma Rehabil 2023; 38:283-293. [PMID: 36730957 DOI: 10.1097/htr.0000000000000808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A systematic review of the literature was conducted to identify measures used to evaluate developmental outcomes after abusive head trauma (AHT), as well as describe outcomes among those with AHT, and explore factors and interventions influencing such outcomes. DESIGN This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol is in PROSPERO, registration number CRD42020179592. On April 17, 2020, OVID Medline, Embase, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were searched (since inception). Inclusion criteria included original, peer-reviewed study data; AHT exposure; infants younger than 24 months at time of AHT; and evaluation of developmental outcomes. Reviewers independently evaluated studies for inclusion and assessed risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. A descriptive synthesis approach was utilized as variability of study designs, follow-up periods, and outcome assessment tools precluded a meta-analytic approach. RESULTS Fifty-nine studies were included; 115 assessment tools were used to evaluate developmental outcomes; and 42 studies examined factors influencing outcomes. Two studies evaluated interventions. Five percent of studies ( n = 3) were rated low risk of bias. CONCLUSIONS Notable variation was observed in terms of case ascertainment criteria. Developmental outcomes after AHT have been assessed in a manner that limits understanding of how AHT impacts development, as well as the efficacy of interventions intended to improve outcomes. Researchers and clinicians are encouraged to adopt consistent diagnostic and assessment approaches.
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Affiliation(s)
- Cristina A Sarmiento
- Departments of Pediatric Rehabilitation Medicine (Drs Sarmiento, Wyrwa, Chambliss, and Appel) and Pediatrics (Drs Chambliss and Appel), Children's Hospital Colorado, Aurora; Departments of Physical Medicine and Rehabilitation (Drs Sarmiento, Wyrwa, Chambliss, Appel, and Brenner and Ms Stearns-Yoder) and Psychiatry and Neurology (Dr Brenner), University of Colorado Anschutz School of Medicine, Aurora; Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado (Ms Stearns-Yoder, Mr Hoffberg, and Dr Brenner); and Brandeis University, Waltham, Massachusetts (Mr Brenner)
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Wang PY, Tseng WC, Lee MC, Hsu LM, Shin SD, Jamaluddin SF, Tanaka H, Son DN, Hong KJ, Riyapan S, Haedar A, Chiang WC. Characteristics of non-accidental injuries in children and adolescents in Asia: a cross-national, multicenter cohort study. Sci Rep 2023; 13:6602. [PMID: 37088796 PMCID: PMC10123055 DOI: 10.1038/s41598-023-33471-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 04/13/2023] [Indexed: 04/25/2023] Open
Abstract
Children and adolescents are vulnerable to non-accidental injury. Early identification and prevention rely on detailed epidemiological studies, which are limited in Asia. This retrospective study used the registry data of Pan-Asian Trauma Outcome Study (PATOS) from October 1, 2015 to December, 31, 2020. Pediatric patients (aged < 20 years) with non-accidental injuries were enrolled, which were divided by age into preschool (0-6 years), child (7-12 years), and adolescent (13-19 years) groups. Baseline characteristics, injury epidemiology, and excess mortality ratio-adjusted injury severity score (EMR-ISS) were collected. Major trauma was defined as an EMR-ISS score > 24. The study enrolled 451 patients with non-accidental injuries, accounting for 2.81% of pediatric trauma events presented to an emergency department in the PATOS registry. The overall mortality rate was 0.9%, similar to those in Western countries. Mortality rate was high in preschool children (8.7%, p = 0.017) than in other age groups. The sex-specific incidence was higher in boys (3.10% vs. 2.13%, p = 0.001). In adolescents, more events occurred on the street (25.9%), whereas home remained the most common locale in girls of all ages. In the multivariable regression analysis, abdominal and multiple injuries were risk factors for major trauma.
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Affiliation(s)
- Po-Yuan Wang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wei-Chieh Tseng
- Graduate Institute of Clinical Medicine, Medical College, National Taiwan University, Taipei, Taiwan.
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Meng-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Li-Min Hsu
- Department of Traumatology and Critical Care, National Taiwan University Hospital, Taipei, Taiwan
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | | | - Hideharu Tanaka
- Graduate School of Emergency Medical Service System, Kokushikan University, Tokyo, Japan
| | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Ali Haedar
- Department of Emergency Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan.
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Obry S, Roman E, Tavernier E, Boutry N, Delval A, Blouet M, Tanase A, De Milly MN, Alison M, Vial J, Saint Martin P, Adamsbaum C, Morel B. The monthly incidence of abusive head trauma, inflicted skeletal trauma, and unexplained skin lesion in children in six French university hospitals during the COVID-19 pandemic. CHILD ABUSE & NEGLECT 2023; 138:106063. [PMID: 36758374 PMCID: PMC9884623 DOI: 10.1016/j.chiabu.2023.106063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The COVID-19 pandemic was a stressful period. Lockdowns may have added to parental difficulty leading to an increase in violence. This study aimed to compare the monthly incidence of high suspicion of child physical abuse before and during the COVID-19 pandemic. MATERIAL We have retrospectively reviewed imaging examinations of children having a skeletal X-ray examination in six university hospitals with high suspicion of abusive head traumatism (AHT), inflicted skeletal trauma (IST) and unexplained skin lesions (USL) between March 2020 and June 2021 and compared with the similar period from 2018 to 2019. The monthly incidence of the different physical maltreatment was analyzed using a QuasiPoisson regression model. RESULTS We included 178 children (n = 127 boys, 71.3 %), 110 during the pandemic period, median age 5 months. AHT was diagnosed in 91 children, 55 had inflicted skeletal trauma (IST) and 46 had unexplained skin lesions (USL). Among the 91 patients with AHT, 86 had a subdural hematoma (95.6 %) and 40 had bridging veins thrombosis (44 %). The ophthalmological examination performed on 89 children (97.9 %) revealed retinal hemorrhages in 57 children (89.8 %). The incidence of AHT doubled during the months of COVID-19 lockdowns (rate ratio = 2; 95 % CI [1.1; 3.6], p = 0.03). No difference in monthly incidence was observed for IST and USL groups. CONCLUSION A significant increase in AHT was observed during the months with lockdowns and curfews during the COVID-19 pandemic. This highlights the need for developing a national strategy to prevent physical abuse in children in this context.
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Affiliation(s)
- Sandra Obry
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | - Elodie Roman
- Department of Pediatric Radiology, Jeanne de Flandre Hospital, CHU, Lille, France
| | - Elsa Tavernier
- INSERM, SPHERE, UMR1246, Université de Tours et Nantes, Tours, France
| | - Nathalie Boutry
- Department of Pediatric Radiology, Jeanne de Flandre Hospital, CHU, Lille, France
| | | | - Marie Blouet
- Department of Pediatric Imaging, Fondation Lenval Children's Hospital, Nice, France
| | - Anca Tanase
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Marie Noelle De Milly
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Marianne Alison
- Department of Pediatric Imaging, Robert Debré Hospital, APHP (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Julie Vial
- Department of Pediatric Radiology, Children's Hospital, CHU, Toulouse, France
| | | | - Catherine Adamsbaum
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | - Baptiste Morel
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.
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Nikam RM, Kecskemethy HH, Kandula VVR, Averill LW, Langhans SA, Yue X. Abusive Head Trauma Animal Models: Focus on Biomarkers. Int J Mol Sci 2023; 24:4463. [PMID: 36901893 PMCID: PMC10003453 DOI: 10.3390/ijms24054463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
Abusive head trauma (AHT) is a serious traumatic brain injury and the leading cause of death in children younger than 2 years. The development of experimental animal models to simulate clinical AHT cases is challenging. Several animal models have been designed to mimic the pathophysiological and behavioral changes in pediatric AHT, ranging from lissencephalic rodents to gyrencephalic piglets, lambs, and non-human primates. These models can provide helpful information for AHT, but many studies utilizing them lack consistent and rigorous characterization of brain changes and have low reproducibility of the inflicted trauma. Clinical translatability of animal models is also limited due to significant structural differences between developing infant human brains and the brains of animals, and an insufficient ability to mimic the effects of long-term degenerative diseases and to model how secondary injuries impact the development of the brain in children. Nevertheless, animal models can provide clues on biochemical effectors that mediate secondary brain injury after AHT including neuroinflammation, excitotoxicity, reactive oxygen toxicity, axonal damage, and neuronal death. They also allow for investigation of the interdependency of injured neurons and analysis of the cell types involved in neuronal degeneration and malfunction. This review first focuses on the clinical challenges in diagnosing AHT and describes various biomarkers in clinical AHT cases. Then typical preclinical biomarkers such as microglia and astrocytes, reactive oxygen species, and activated N-methyl-D-aspartate receptors in AHT are described, and the value and limitations of animal models in preclinical drug discovery for AHT are discussed.
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Affiliation(s)
- Rahul M. Nikam
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Heidi H. Kecskemethy
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Vinay V. R. Kandula
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Lauren W. Averill
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Sigrid A. Langhans
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Nemours Biomedical Research, Nemours Children’s Health, Wilmington, DE 19803, USA
| | - Xuyi Yue
- Diagnostic & Research PET/MR Center, Nemours Children’s Health, Wilmington, DE 19803, USA
- Department of Radiology, Nemours Children’s Health, Wilmington, DE 19803, USA
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11
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Hahnemann ML, Kronsbein K, Karger B, Feld K, Banaschak S, Helmus J, Mentzel HJ, Pfeiffer H, Wittschieber D. Characterization of subdural collections in initial neuroimaging of abusive head trauma: Implications for forensic age diagnostics and clinical decision-making. Eur J Radiol 2023; 159:110652. [PMID: 36577185 DOI: 10.1016/j.ejrad.2022.110652] [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: 08/22/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/16/2022]
Abstract
PURPOSE Subdural collections (SDCs) represent a key finding in abusive head trauma (AHT), a serious form of child physical abuse. Common SDC entities in this context are subdural hematoma (SDH), subdural hygroma (SDHy), subdural hematohygroma (SDHHy), and chronic subdural hematoma (cSDH). The present study examines the prevalence of the different SDC entities and investigates the influence of the SDC diagnosis on the forensic age estimation of the injury. METHODS In this retrospective multi-center study from three German university hospitals of a 10-year period, the initial neuroimaging material (CT or MRI) of 56 children (36 males, 20 females; age median 3.9 months) with medico-legally well-documented AHT was analyzed. SDCs were characterized by determining presence, location, extension, and visual appearance, by assigning to one of the five entities, and by categorizing with three different classification systems, one of which represents a novel system based on focality and Mixed Appearance Pattern and especially developed for children with AHT. The data were correlated with demographic and clinical data. By means of court files, AHT cases were also sub-divided into confession (n = 14) and non-confession cases (n = 42) and then compared. RESULTS Most cases showed a multifocal presence of SDCs (96.4%) and the presence of a Mixed Appearance Pattern (82.1%). The most common SDC entity was the heterogeneous variant of the SDHHy (66.1%). The cSDH occurred infrequently only (3.6%). Our novel classification system illustrates that unifocal SDCs rarely occur in AHT, and that more complex SDC patterns are common. In nearly all cases (94.6%), additional signs of recently caused brain injury were present beside the SDCs. Comparison between confession and non-confession groups did not reveal any significant differences, indicating that the diagnostic criteria of AHT are robust. CONCLUSIONS Although precise dating of SDCs based on initial neuroimaging alone remains unrealistic, the exact diagnosis of the SDC entity provide an important basis for differentiation between acute trauma and chronic post-traumatic state. Therefore, especially the confirmation or exclusion of subdural neomembranes, that define the cSDH, should be considered indispensable.
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Affiliation(s)
- Maria L Hahnemann
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany; Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Kronsbein
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Westfalian Wilhelms University Münster, Münster, Germany; Institute of Legal Medicine, University Hospital Münster, Westfalian Wilhelms University Münster, Münster, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Westfalian Wilhelms University Münster, Münster, Germany
| | - Katharina Feld
- Institute of Legal Medicine, Medical Faculty, University of Cologne, Cologne, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, Medical Faculty, University of Cologne, Cologne, Germany
| | - Janine Helmus
- Formerly, Institute of Legal Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Westfalian Wilhelms University Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany.
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12
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Echegaray JJ, Iyer P, Acon D, Negron C, El Hamichi S, Berrocal AM. Superficial and Deep Capillary Plexus Nonperfusion in Nonaccidental Injury on OCTA. JOURNAL OF VITREORETINAL DISEASES 2023; 7:79-82. [PMID: 36704609 PMCID: PMC9873236 DOI: 10.1177/24741264221120643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A 5-year-old Caucasian male with a history nonaccidental injury (NAI) at age 1 presented with new onset no light perception in the left eye due to a closed funnel retinal detachment. The right eye showed optic nerve pallor, peripheral vascular attenuation, and leakage. Optical coherence tomography angiography (OCTA) revealed significant parafoveal attenuation of the superficial vascular plexus, intermediate capillary plexus, and the deep capillary plexus. This correlated with inner and middle retinal layer thinning temporal to the fovea and preservation of the ellipsoid zone. The peripapillary vascular plexus was preserved. Laser photocoagulation was performed to the nonperfused peripheral retina and intravitreal bevacizumab was injected. OCTA may be used in patients with NAI to characterize macular ischemia changes. Attenuation of the superficial, intermediate, and deep capillary plexuses in our patient may represent chronic ischemic retinal changes that arise from traumatic injury to the vitreoretinal interface and inner retina in NAI.
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Affiliation(s)
- Jose J. Echegaray
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
- University Hospitals Eye Institute, Case
Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Prashanth Iyer
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
| | - Dhariana Acon
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
| | - Catherin Negron
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
| | - Sophia El Hamichi
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
| | - Audina M. Berrocal
- Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, USA
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13
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Primalani NK, Chan YH, Ng ZM, Chong SL, Seow WT, Loh LE, Mok YH, Low SYY. Abusive head injury in the very young: outcomes from a Singapore children's hospital. Childs Nerv Syst 2022; 38:2397-2407. [PMID: 35851614 DOI: 10.1007/s00381-022-05572-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.
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Affiliation(s)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, #02-03 (c/o CBmE Office), 10 Medical Drive, Singapore, 117597, Singapore
| | - Zhi Min Ng
- Neurology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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14
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Hemophilia and non-accidental head trauma in two siblings: lessons and legal implications. Childs Nerv Syst 2022; 38:2415-2423. [PMID: 36303077 DOI: 10.1007/s00381-022-05713-2] [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: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 11/03/2022]
Abstract
Non-accidental head trauma (NAHT) is a common cause of traumatic brain injury in childhood, origin of profound and disabling neurological sequalae, and in the most disgraceful cases, ultimately death.Subdural hematoma (SDH) is the most common intracranial finding in NAHT. On the other hand, congenital bleeding disorders are a minor but a significant cause of ICH in the neonate and toddler. Not uncommonly, intracranial bleeding is the first sign of a severe inherited coagulation disorder. In the presence of an unexpected intracranial bleeding after a minor trauma or without a clear history of the related events, physicians and caregivers may be confronted to the dilemma of a possible child abuse. It must be bear in mind that physical abuse and bleeding disorders can co-exist in the same child.We report here the case of two siblings in whom a diagnosis of hemophilia coexisted with the presumption of a non-accidental head trauma. Child abuses were inflicted in both children with a spare time of 2 years. A diagnosis of mild hemophilia was prompted in the first sibling after initial NAHT, while inflicted trauma was evident in the second sibling after neuroimaging findings and concomitant lesions. Lessons from this case in co-existing bleeding disorders and inflicted trauma and legal implications derived will be discussed thereafter.The possibility of a bleeding disorder should be considered in all children presenting with unexplained bleeding at a critical site in the setting of suspected physical maltreatment, particularly intracranial hemorrhage (ICH).
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15
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Miller DC, Stacy CC, Duff DJ, Guo S, Morse P. Neuropathology and Ophthalmological Pathology of Fatal Central Nervous System Injuries in Young Children: Forensic Neuropathology of Deaths of Children Under Age 2, 2008-2016, in Central Missouri. J Neuropathol Exp Neurol 2022; 81:854-864. [PMID: 36094646 DOI: 10.1093/jnen/nlac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nonaccidental head injuries are significant causes of morbidity and mortality among young children. Despite broad agreement among medical experts, controversies remain over diagnostic criteria, including from autopsies, because of opinions expressed by a small group of expert witnesses who testify for defendants in suspected child homicide cases. We reviewed 249 autopsies in children 2 years old and younger from the files of our Medical Examiner office in the University of Missouri School of Medicine done between January 1, 2008 and December, 31, 2016. Because of gradually instituted mandatory examination of spinal cords and retinas, we had 127 autopsies with brain examinations by a neuropathologist plus retinal examinations of which 67 also had spinal cord examinations. Results were correlated with clinical records, police and EMS reports, and imaging. We found that subdural hematomas, cerebral edema, and retinal hemorrhages were mostly limited to autopsy findings in children who suffered from fatal head trauma, whether accidental (3 cases) or inflicted (14); they were not encountered in cases of homicide by other mechanisms or from natural diseases including infections, brain tumors, SIDS/SUID, or SUDC. Two cases with no other evidence of head trauma had focal retinal hemorrhages. We advocate for examination of retinas and spinal cords in all autopsies of children in this age group.
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Affiliation(s)
- Douglas C Miller
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - C Christopher Stacy
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA.,Office of the Chief Medical Examiner of Boone and Callaway Counties, Columbia, Missouri, USA
| | - Deiter J Duff
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA.,Office of the Chief Medical Examiner of Boone and Callaway Counties, Columbia, Missouri, USA
| | - Shunhua Guo
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Patrick Morse
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
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16
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Lãzãrescu AM, Benichi S, Blauwblomme T, Beccaria K, Bourgeois M, Roux CJ, Vergnaud E, Montmayeur J, Meyer P, Cohen JF, Chalumeau M, Blangis F, Orliaguet G. Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area. JAMA Netw Open 2022; 5:e2226182. [PMID: 36040743 PMCID: PMC9428740 DOI: 10.1001/jamanetworkopen.2022.26182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. OBJECTIVE To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS In a time-series analysis of a longitudinal, population-based, cohort study, all consecutive cases of AHT in infants younger than 12 months old referred between January 2017 and December 2021 to Necker Hospital for Sick Children, the single regional pediatric neurosurgery center for the Paris metropolitan area, were included. AHT was defined as 1 or more subdural hemorrhage and a positive multidisciplinary evaluation after a social, clinical, biological, and radiological workup. Data were analyzed from January to March 2022. MAIN OUTCOMES AND MEASURES The primary outcome was the monthly incidence of AHT, which was analyzed using Poisson regression modeling. Secondary outcomes included mortality and severe morbidity and were studied with logistic and linear regressions. The monthly incidence of neurosurgical interventions for hydrocephalus was used as a control series. RESULTS Among the 99 included infants with AHT (median [IQR] age, 4 [3-6] months; 64 boys [65%]), 86 of 99 (87%) had bridging vein thrombosis, 74 of 99 (75%) had retinal hemorrhages, 23 of 72 (32%) had fractures, 26 of 99 (26%) had status epilepticus, 20 of 99 (20%) had skin injuries, 53 of 99 (54%) underwent neurosurgical interventions, and 13 of 99 (13%) died. Compared with the prepandemic period (2017-2019), AHT incidence was stable in 2020 (adjusted incidence rate ratio, 1.02; 95% CI, 0.59-1.77) and then significantly increased in 2021 (adjusted incidence rate ratio, 1.92; 95% CI, 1.23-2.99). The severity of AHT worsened in 2021 in terms of mortality (odds ratio 9.39; 95% CI, 1.88-47.00). Other secondary outcomes and the control series were not significantly modified. CONCLUSIONS AND RELEVANCE In this cohort study, a marked increase in AHT incidence and severity occurred during the COVID-19 pandemic in the Paris metropolitan area. These results suggest the need for clinical awareness and preventive actions.
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Affiliation(s)
- Alina-Marilena Lãzãrescu
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Kévin Beccaria
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Marie Bourgeois
- Department of Pediatric Neurosurgery, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Charles-Joris Roux
- Department of Pediatric Radiology, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Estelle Vergnaud
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Juliette Montmayeur
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Philippe Meyer
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Université Paris Cité, Institut National de la Santé et de la Recherche Medicale, Paris, France
- Child Protection Unit, Department of General Pediatrics and Pediatric Infectious Diseases, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Gilles Orliaguet
- Department of Pediatric Anesthesia and Intensive Care, Assistance Publique–Hôpitaux de Paris, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Unit EA7323 Evaluation of Therapeutics and Pharmacology in Perinatality and Pediatrics, Université Paris Cité, Paris, France
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17
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Manan MR, Rahman S, Komer L, Manan H, Iftikhar S. A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children. Cureus 2022; 14:e27276. [PMID: 36039273 PMCID: PMC9404682 DOI: 10.7759/cureus.27276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
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18
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Hymel KP, Fingarson AK, Pierce MC, Kaczor K, Makoroff KL, Wang M. External Validation of the PediBIRN Screening Tool for Abusive Head Trauma in Pediatric Emergency Department Settings. Pediatr Emerg Care 2022; 38:269-272. [PMID: 35267249 PMCID: PMC9156553 DOI: 10.1097/pec.0000000000002670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
METHODS We conducted a retrospective, secondary analysis of an existing, deidentified, prospective data set captured to derive a bruising CDR. Subjects were patients under 3 years with bruising and confirmed acute head trauma. An expert medical panel had previously identified patients with AHT. Measures of the CDR's AHT screening performance (sensitivity, specificity, likelihood ratios) were calculated with 95% confidence intervals (CIs). RESULTS Expert medical panel members had classified 78 of 117 eligible patients (67%) as AHT, 38 (33%) as non-AHT, and 1 as indeterminate. Excluding the indeterminate case, the PediBIRN-4 demonstrated a sensitivity of 0.96 (95% CI, 0.88-0.99), specificity of 0.29 (95% CI, 0.16-0.46), positive likelihood ratio of 1.35 (95% CI, 1.10-1.67), and negative likelihood ratio of 0.13 (95% CI, 0.04-0.46). Close inspection of the data revealed that 1 of the CDR's predictor variables had lowered specificity without impacting sensitivity. Eliminating this variable would have increased specificity to 0.84 (95% CI, 0.68-0.93). CONCLUSIONS The PediBIRN 4-variable CDR demonstrated AHT screening sensitivity in the pediatric ED equivalent to pediatric intensive care unit and other inpatient settings, but lower specificity. Further study of a simplified 3-variable PediBIRN AHT screening tool for the ED setting is warranted.
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Affiliation(s)
- Kent P. Hymel
- Penn State College of Medicine, Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA
| | - Amanda K. Fingarson
- Northwestern University Feinberg School of Medicine, Department of Pediatrics
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Mary Clyde Pierce
- Northwestern University Feinberg School of Medicine, Department of Pediatrics
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Kim Kaczor
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Kathi L. Makoroff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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19
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Dai X, Kuwera E. Saccadic intrusions in pediatric non-accidental trauma. Am J Ophthalmol Case Rep 2022; 26:101564. [PMID: 35572610 PMCID: PMC9092189 DOI: 10.1016/j.ajoc.2022.101564] [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] [Received: 09/15/2021] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose To report a case of saccadic intrusions in a 9-month-old under the context of non-accidental trauma. Observations A 9-month-old female presented with the eye finding of intermittent ocular flutter. Upon imaging for neuroblastoma, she was discovered to have bilateral supratentorial subdural hematomas with internal septations, moderate mass effect on adjacent cerebral parenchyma, pachymeningeal and tentorial enhancement, and cortical vein thrombosis. This constellation of findings was concerning for non-accidental trauma. Conclusions and importance Although an extremely rare occurrence, ocular flutter may be a presenting sign in non-accidental trauma, and imaging should absolutely be considered under such circumstances.
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Affiliation(s)
- Xi Dai
- The Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Edward Kuwera
- The Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
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20
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Sayrs LW, Ortiz JB, Notrica DM, Kirsch L, Kelly C, Stottlemyre R, Cohen A, Misra S, Green TR, Adelson PD, Lifshitz J, Rowe RK. Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP6785-NP6812. [PMID: 33092447 DOI: 10.1177/0886260520967151] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(β) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.
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Affiliation(s)
- Lois W Sayrs
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - J Bryce Ortiz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - David M Notrica
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Lisa Kirsch
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Cara Kelly
- Phoenix Children's Hospital, Phoenix, AZ, USA
- Arizona State University School of Social Work, Phoenix, AZ, USA
| | | | - Aaron Cohen
- Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Shivani Misra
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Tabitha R Green
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - P David Adelson
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
| | - Jonathan Lifshitz
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
| | - Rachel K Rowe
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, AZ, USA
- Phoenix Veteran Affairs Health Care System, Phoenix, AZ, USA
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21
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Kwak YH. Diagnosis of Abusive Head Trauma : Neurosurgical Perspective. J Korean Neurosurg Soc 2022; 65:370-379. [PMID: 35468707 PMCID: PMC9082129 DOI: 10.3340/jkns.2021.0284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.
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Affiliation(s)
- Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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22
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Park YS. Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants. J Korean Neurosurg Soc 2022; 65:385-396. [PMID: 35468708 PMCID: PMC9082116 DOI: 10.3340/jkns.2021.0289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.
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Affiliation(s)
- Young Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University, Kashihara, Japan
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23
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Abstract
BACKGROUND Abusive head trauma (AHT), previously known as the shaken baby syndrome, is a severe and potentially fatal form of traumatic brain injury in infant children who have been shaken, and sometimes also sustained an additional head impact. The clinical and autopsy findings in AHT are not pathognomonic and, due to frequent obfuscation by perpetrators, the circumstances surrounding the alleged abuse are often unclear. The concept has evolved that the finding of the combination of subdural hemorrhage, brain injury, and retinal hemorrhages ("the triad") is the result of shaking of an infant ("shaken baby syndrome") and has led to the ongoing controversy whether shaking alone is able to generate sufficient force to produce these lesions. OBJECTIVE In an attempt to investigate whether shaking can engender this lesion triad, animal models have been developed in laboratory rodents and domestic animal species. This review assesses the utility of these animal models to reliably reproduce human AHT pathology and evaluate the effects of shaking on the immature brain. RESULTS Due largely to irreconcilable anatomic species differences between these animal brains and human infants, and a lack of resemblance of the experimental head shaking induced by mechanical devices to real-world human neurotrauma, no animal model has been able to reliably reproduce the full range of neuropathologic AHT changes. CONCLUSION Some animal models can simulate specific brain and ophthalmic lesions found in human AHT cases and provide useful information on their pathogenesis. Moreover, one animal model demonstrated that shaking of a freely mobile head, without an additional head impact, could be lethal, and produce significant brain pathology.
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Watanabe Y, Shiga K, Kikuchi N, Kurihara Y, Sato A. A regional multidisciplinary network enhances child abuse case management. Pediatr Int 2022; 64:e15240. [PMID: 35859263 DOI: 10.1111/ped.15240] [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: 01/28/2022] [Revised: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We previously reported an inadequate response to intracranial hemorrhage (ICH) cases under 24 months of age in Yokohama from 2011 to 2013. Hence, it is very important to evaluate how the establishment of a regional multidisciplinary network for child abuse affects the response to ICH cases in medical institutions. METHODS We conducted a questionnaire survey of ICH cases under 24 months of age from 2014 to 2016 using a regional multidisciplinary network for child abuse established in Yokohama in September 2013. We investigated the patients' characteristics, examinations to identify inflicted injury, and reports made to the hospital-based child protection team (CPT) or regional child protective service (CPS), and compared the results of a previous study and the current study, which corresponds to before and after the establishment of the regional network, respectively. RESULTS The total number of ICH cases was 50 in 3 years. The number of cases surveyed for covert fracture and fundus hemorrhage increased significantly after the establishment of the regional network (P = 0.0001 and P = 0.0182, respectively). The number of cases reported as suspected child abuse was 41 (82%) to the hospital-based CPTs and 27 (54%) to the regional CPSs. There were significant differences between before and after the establishment of the regional network regarding CPT (P = 0.0062) and CPS (P = 0.0215) reports. CONCLUSIONS A regional multidisciplinary network can enhance response and cooperation to address child abuse. It deepens our understanding of such care and improves awareness by hospital personnel of child abuse.
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Affiliation(s)
- Yoshihiro Watanabe
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kentaro Shiga
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Nobuyuki Kikuchi
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yachiyo Kurihara
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Atsuo Sato
- Yokohama Medical Network for Maltreated Children, Child and Youth Bureau, Yokohama Municipal Government, Yokohama, Japan.,Department of Pediatrics, Yokohama Rosai Hospital, Yokohama, Japan
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Varol F, Sahin E, Ozgunay B, Cengiz M, Altas ZM, Guven S. The changing face of abuse cases in a pediatric intensive care unit: A single-center experience. Pediatr Int 2022; 64:e15293. [PMID: 36181689 DOI: 10.1111/ped.15293] [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: 03/25/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to the increase in abuse and neglect cases in recent years, the purpose of this study was to assess child abuse and neglect of patients who were hospitalized and followed up in our pediatric intensive care unit (PICU). METHODS A total of 34 abuse and neglect patients who were admitted to the PICU from August 2020 to March 2021 were included retrospectively in the study. Patients' clinical and demographic characteristics were obtained from our hospital's patient record system (HIS). Comorbidities and the mental status of the patients, affected systems, treatments, and outcomes were extracted. RESULTS In this study, 44.1% (n: 15) of the patients were male and 55.9% (n: 19) were female. Physical neglect such as foreign body aspiration, malnutrition, electrocution, drowning, traffic accident, and body collision was detected in 14 (41.2%) patients. Emotional neglect (taking drugs, alcohol, or suicide) was found in 19 (55.9%) of our patients. Only 1 (2.9%) patient presented with physical abuse. CONCLUSIONS Perception of neglect varies among different cultures. Any infant or child who is admitted to the PICU with a history that is not consistent, a history of delay in seeking medical attention, a previous history of abuse or suspected abuse, or the absence of the primary caretaker at the appearance of illness should signal possible abuse. Health-care professionals should give more attention to these patients to prevent the overlooking and recurrence of neglect and abuse cases due to the intense work tempo in the PICU.
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Affiliation(s)
- Fatih Varol
- Department of Pediatric Intensive Care, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Ebru Sahin
- Department of Pediatric Intensive Care, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Busra Ozgunay
- Department of Pediatrics, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Mehmet Cengiz
- Department of Pediatrics, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Zeynep Meva Altas
- Department of Public Health, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Sirin Guven
- Department of Pediatrics, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Health Science University, Istanbul, Turkey
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Binder H, Majdan M, Leitgeb J, Payr S, Breuer R, Hajdu S, Tiefenboeck TM. Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center. CHILDREN (BASEL, SWITZERLAND) 2021; 8:854. [PMID: 34682119 PMCID: PMC8534601 DOI: 10.3390/children8100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence. METHODS Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score. RESULTS In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died. CONCLUSION The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery. TRIAL REGISTRATION (researchregistry 2686).
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Affiliation(s)
- Harald Binder
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Johannes Leitgeb
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Stephan Payr
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Robert Breuer
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Thomas M. Tiefenboeck
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
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Hymel KP, Armijo-Garcia V, Musick M, Marinello M, Herman BE, Weeks K, Haney SB, Frazier TN, Carroll CL, Kissoon NN, Isaac R, Foster R, Campbell KA, Tieves KS, Livingston N, Bucher A, Woosley MC, Escamilla-Padilla D, Jaimon N, Kustka L, Wang M, Chinchilli VM, Dias MS, Noll J. A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings. J Pediatr 2021; 236:260-268.e3. [PMID: 33798512 PMCID: PMC8403132 DOI: 10.1016/j.jpeds.2021.03.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT03162354.
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Affiliation(s)
- Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | | | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Mark Marinello
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Suzanne B. Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Terra N. Frazier
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Natalie N. Kissoon
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Robin Foster
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Kristine A. Campbell
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kelly S. Tieves
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Nina Livingston
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Ashley Bucher
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Maria C. Woosley
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | | | - Nancy Jaimon
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Lucinda Kustka
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Mark S. Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennie Noll
- Department of Human Development and Family Studies, Penn State University, State College, Pennsylvania
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Manfield J, Oakley K, Macey JA, Waugh MC. Understanding the Five-Year Outcomes of Abusive Head Trauma in Children: A Retrospective Cohort Study. Dev Neurorehabil 2021; 24:361-367. [PMID: 33478304 DOI: 10.1080/17518423.2020.1869340] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Understanding the long-term medical and developmental outcomes for children who survive abusive head trauma (AHT) is important to ensure necessary supports and services are available. This study examined the retrospective global and specific medical and developmental outcomes of 55 children with AHT who were treated at The Children's Hospital at Westmead. Global outcomes were assessed using the Kings Outcome Scale of Childhood Head Injury (KOSCHI). Five years post-injury, one child had died and two had made a complete recovery. Forty-five children (81.8%) had a moderate or severe disability, an increase from 64.5% at acute discharge. At follow-up, the main impairments were behavioral problems (53%), vision impairment (44%), fine motor difficulties (26%), gross motor problems (26%), communication problems (24%) and 16% had seizures. A Spearman's Rank correlation revealed that only 41% of variance in KOSCHI scores five years post-injury could be accounted for KOSCHI scores at the time of acute discharge (rs(55) = 0.638, p < .001), and many children's presentation was worse at follow-up. Therefore, all children presenting with AHT need long term follow up regardless of early indications of good recovery.
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Affiliation(s)
- Jaimi Manfield
- The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - Karen Oakley
- Kids Rehab, The Children's Hospital at Westmead, NSW, Australia.,The Children's Hospital at Westmead Clinical School, Discipline of Child and Adolescent Health, University of Sydney, Sydney, NSW, Australia
| | | | - Mary-Clare Waugh
- Kids Rehab, The Children's Hospital at Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Lim CC, Saniasiaya J, Kulasegarah J. Postauricular swelling secondary to salmonella extradural abscess in a toddler: a near miss condition. BMJ Case Rep 2021; 14:e243412. [PMID: 34210704 PMCID: PMC8252683 DOI: 10.1136/bcr-2021-243412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2021] [Indexed: 11/03/2022] Open
Abstract
Postauricular swelling is usually encountered in an emergency setting in otorhinolaryngology, resulting from complication of acute or chronic suppurative otitis media. Besides that, postauricular swelling may occur secondary to various other conditions including infectious disease, tumour, vascular malformation, granulomatous condition and even trauma. Children less than 2 years old are prone to fall and up to 10% sustain traumatic brain injury without any obvious signs of neurological deficit. We describe a rare case of a postauricular swelling in a toddler which turned out to be salmonella extradural abscess from an infected traumatic haematoma. The importance of high clinical suspicion especially in a child with a history of fall cannot be emphasised more because a missed brain abscess could lead to potentially life-threatening problems. We would like to highlight that meticulous history taking along with prompt assessment and intervention is prudent for a better prognosis and recovery.
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Affiliation(s)
- Chee Chean Lim
- Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jeyasakthy Saniasiaya
- Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jeyanthi Kulasegarah
- Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Cowley LE, Adesman A. The Challenge of Identifying Pediatric Abusive Head Trauma During the COVID-19 Pandemic. Pediatrics 2021; 148:peds.2021-050612. [PMID: 33879522 DOI: 10.1542/peds.2021-050612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Laura Elizabeth Cowley
- Research and Evaluation Division, Knowledge Directorate, Public Health Wales, Cardiff, Wales, United Kingdom.,National Centre for Population Health and Wellbeing Research, Medical School, Swansea University, Swansea, Wales, United Kingdom
| | - Andrew Adesman
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York .,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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31
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Evaluation of Pediatric Patients Admitted to the Emergency Department with Head Trauma. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.914518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Costine-Bartell B, Price G, Shen J, McGuone D, Staley K, Duhaime AC. A perfect storm: The distribution of tissue damage depends on seizure duration, hemorrhage, and developmental stage in a gyrencephalic, multi-factorial, severe traumatic brain injury model. Neurobiol Dis 2021; 154:105334. [PMID: 33753291 PMCID: PMC8135256 DOI: 10.1016/j.nbd.2021.105334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/14/2021] [Indexed: 11/08/2022] Open
Abstract
The pathophysiology of extensive cortical tissue destruction observed in hemispheric hypodensity, a severe type of brain injury observed in young children, is unknown. Here, we utilize our unique, large animal model of hemispheric hypodensity with multifactorial injuries and insults to understand the pathophysiology of this severe type of traumatic brain injury, testing the effect of different stages of development. Piglets developmentally similar to human infants (1 week old, “infants”) and toddlers (1 month old, “toddlers”) underwent injuries and insults scaled to brain volume: cortical impact, creation of mass effect, placement of a subdural hematoma, seizure induction, apnea, and hypoventilation or a sham injury while anesthetized with a seizure-permissive regimen. Piglets receiving model injuries required overnight intensive care. Hemispheres were evaluated for damage via histopathology. The pattern of damage was related to seizure duration and hemorrhage pattern in “toddlers” resulting in a unilateral hemispheric pattern of damage ipsilateral to the injuries with sparing of the deep brain regions and the contralateral hemisphere. While “infants” had the equivalent duration of seizures as “toddlers”, damage was less than “toddlers”, not correlated to seizure duration, and was bilateral and patchy as is often observed in human infants. Subdural hemorrhage was associate with adjacent focal subarachnoid hemorrhage. The percentage of the hemisphere covered with subarachnoid hemorrhage was positively correlated with damage in both developmental stages. In “infants”, hemorrhage over the cortex was associated with damage to the cortex with sparing of the deep gray matter regions; without hemorrhage, damage was directed to the hippocampus and the cortex was spared. “Infants” had lower neurologic scores than “toddlers”. This multifactorial model of severe brain injury caused unilateral, wide-spread destruction of the cortex in piglets developmentally similar to toddlers where both seizure duration and hemorrhage covering the brain were positively correlated to tissue destruction. Inherent developmental differences may affect how the brain responds to seizure, and thus, affects the extent and pattern of damage. Study into specifically how the “infant” brain is resistant to the effects of seizure is currently underway and may identify potential therapeutic targets that may reduce evolution of tissue damage after severe traumatic brain injury.
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Affiliation(s)
- Beth Costine-Bartell
- Department of Neurosurgery, Massachusetts General Hospital, Charlestown, MA, United States; Department of Neurosurgery, Harvard Medical School, Boston, MA, United States.
| | - George Price
- Department of Neurosurgery, Massachusetts General Hospital, Charlestown, MA, United States
| | - John Shen
- Department of Neurosurgery, Massachusetts General Hospital, Charlestown, MA, United States
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Kevin Staley
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital, Charlestown, MA, United States; Department of Neurosurgery, Harvard Medical School, Boston, MA, United States
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Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history. J Pediatr Surg 2021; 56:390-396. [PMID: 33220974 DOI: 10.1016/j.jpedsurg.2020.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity. CONCLUSIONS To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE Prognostic, Level III.
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Rilling JK, Richey L, Andari E, Hamann S. The neural correlates of paternal consoling behavior and frustration in response to infant crying. Dev Psychobiol 2021; 63:1370-1383. [PMID: 33452675 DOI: 10.1002/dev.22092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/15/2020] [Accepted: 12/23/2020] [Indexed: 12/23/2022]
Abstract
Human fathers often form strong attachments to their infants that contribute to positive developmental outcomes. However, fathers are also the most common perpetrators of infant abuse, and infant crying is a known trigger. Research on parental brain responses to infant crying have typically employed passive listening paradigms. However, parents usually engage with crying infants. Therefore, we examined the neural responses of 20 new fathers to infant cries both while passively listening, and while actively attempting to console the infant by selecting soothing strategies in a video game format. Compared with passive listening, active responding robustly activated brain regions involved in movement, empathy and approach motivation, and deactivated regions involved in stress and anxiety. Fathers reporting more frustration had less activation in basal forebrain areas and in brain areas involved with emotion regulation (e.g., prefrontal cortex and the supplementary motor area). Successful consolation of infant crying activated regions involved in both action-outcome learning and parental caregiving (anterior and posterior cingulate cortex). Overall, results suggest that active responding to infant cries amplifies activation in many brain areas typically activated during passive listening. Additionally, paternal frustration during active responding may involve a combination of low approach motivation and low engagement of emotion regulation.
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Affiliation(s)
- James K Rilling
- Department of Anthropology, Emory University, Atlanta, GA, USA.,Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Center for Behavioral Neuroscience, Emory University, Atlanta, GA, USA.,Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA.,Center for Translational Social Neuroscience, Emory University, Atlanta, GA, USA
| | - Lynnet Richey
- Department of Anthropology, Emory University, Atlanta, GA, USA
| | - Elissar Andari
- Department of Psychiatry, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
| | - Stephan Hamann
- Department of Psychology, Emory University, Atlanta, GA, USA
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Bass DI, Lee A, Browd SR, Ellenbogen RG, Hauptman JS. Medicolegal issues in abusive head trauma for the pediatric neurosurgeon. Neurosurg Focus 2020; 49:E23. [PMID: 33130608 DOI: 10.3171/2020.8.focus20599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/18/2020] [Indexed: 11/06/2022]
Abstract
The purpose of this article is to serve as a rational guide for the pediatric neurosurgeon in navigating common medicolegal issues that arise in the management of abusive head trauma (AHT). Many of these issues may be unfamiliar or unpleasant to surgeons focused on addressing disease. The authors begin with a brief history on the origins of the diagnosis of AHT and the controversy surrounding it, highlighting some of the facets of the diagnosis that make it particularly unique in pediatric neurosurgery. They then review some special medical considerations in these patients through the perspective of the neurosurgeon and provide several examples as illustration. The authors discuss how to appropriately document these cases in the medical record for expected legal review, and last, they provide an overview of the legal process through which the neurosurgeon may be called to provide testimony.
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Affiliation(s)
- David I Bass
- 1Department of Neurological Surgery, University of Washington; and
| | - Amy Lee
- 1Department of Neurological Surgery, University of Washington; and.,2Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Samuel R Browd
- 1Department of Neurological Surgery, University of Washington; and.,2Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Richard G Ellenbogen
- 1Department of Neurological Surgery, University of Washington; and.,2Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Jason S Hauptman
- 1Department of Neurological Surgery, University of Washington; and.,2Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington
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Is there a common denominator for Brief Resolved Unexplained Events, Sudden Infant Death Syndrome, and alleged Shaken Baby Syndrome? Med Hypotheses 2020; 144:109939. [DOI: 10.1016/j.mehy.2020.109939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/17/2022]
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Ajmera S, Motiwala M, Weeks M, Oravec CS, Hersh DS, Fraser BD, Vaughn B, Klimo P. What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury? Neurosurgery 2020; 87:803-810. [PMID: 32243538 DOI: 10.1093/neuros/nyaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The spectrum of injury severity for abusive head trauma (AHT) severity is broad, but outcomes are unequivocally worse than accidental trauma. There are few publications that analyze different outcomes of AHT. OBJECTIVE To determine variables associated with different outcomes of AHT. METHODS Patients were identified using our AHT database. Three different, but not mutually exclusive, outcomes of AHT were modeled: (1) death or hemispheric stroke (diffuse loss of grey-white differentiation); (2) stroke(s) of any size; and (3) need for a neurosurgical operation. Demographic and clinical variables were collected and correlations to the 3 outcomes of interest were identified using bivariate and multivariable analysis. RESULTS From January 2009 to December 2017, 305 children were identified through a prospectively maintained AHT database. These children were typically male (60%), African American (54%), and had public or no insurance (90%). A total of 29 children (9.5%) died or suffered a massive hemispheric stroke, 57 (18.7%) required a neurosurgical operation, and 91 (29.8%) sustained 1 or more stroke. Death or hemispheric stroke was statistically associated with the pupillary exam (odds ratio [OR] = 45.7) and admission international normalized ratio (INR) (OR = 17.3); stroke was associated with the pupillary exam (OR = 13.2), seizures (OR = 14.8), admission hematocrit (OR = 0.92), and INR (9.4), and need for surgery was associated with seizures (OR = 8.6). CONCLUSION We have identified several demographic and clinical variables that correlate with 3 clinically applicable outcomes of abusive head injury.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David S Hersh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey Clinic, Memphis, Tennessee
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chendrasekhar A, Kuczabski B, Cohen D, Grageda M, Genovese-Scullin D, Patwari J, Harris L. Delayed Sequelae Related to Mild Traumatic Brain Injury in Children. Glob Pediatr Health 2020; 7:2333794X20947988. [PMID: 32923524 PMCID: PMC7448128 DOI: 10.1177/2333794x20947988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 11/17/2022] Open
Abstract
Delayed sequelae from mild traumatic brain injury (Glasgow Coma Score at admission >13, TBI) has been documented in case reports however larger studies of these effects are sparse. We undertook a telephone based survey to assess the long term sequelae of TBI. We tracked 100 pediatric TBI patients via our trauma registry for demographic data including age, injury severity, and mechanism of injury. Then we proceeded to contact these patient’s parents via telephone. We asked regarding residual symptoms and signs of concussive injury. Duration out from initial concussive injury ranged from 4 to 68 months. The parents of 66 boys and 34 girls were surveyed. The age of the patients at the time of mild TBI ranged from 1 to 14 years. The injury severity score ranged from 1 to 21. One being the most common Injury severity score. Thirty-three percent of patients had residual effects of concussion at the time of telephone survey. Fourteen percent had memory loss issues, 21% had anxiety/depression issues, 20% had learning disability issues, and 15% had sleep disturbance issues. Duration of time post concussive injury, mechanism, and age did not influence incidence of sequelae. Mild traumatic brain injury has significant long term sequelae. Better identifying characteristics are needed to characterize patients susceptible to long term residual effects of concussion.
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Affiliation(s)
- Akella Chendrasekhar
- Richmond University Medical Center, Staten Island, NY, USA.,SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - Douglas Cohen
- Richmond University Medical Center, Staten Island, NY, USA
| | | | | | - Jakey Patwari
- Richmond University Medical Center, Staten Island, NY, USA
| | - Loren Harris
- Richmond University Medical Center, Staten Island, NY, USA.,SUNY Downstate Medical Center, Brooklyn, NY, USA
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Gencturk M, Cam I, Koksel Y, McKinney AM. Role of Susceptibility-Weighted Imaging in Detecting Retinal Hemorrhages in Children with Head Trauma. Clin Neuroradiol 2020; 31:611-617. [DOI: 10.1007/s00062-020-00939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
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Deutsch SA. Understanding Abusive Head Trauma: A Primer for the General Pediatrician. Pediatr Ann 2020; 49:e347-e353. [PMID: 32785719 DOI: 10.3928/19382359-20200720-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abusive head trauma (AHT) refers to a well-recognized constellation of injuries caused by the direct application of force to an infant or young child, resulting in trauma to the head, intracranial contents, and/or neck, with potentially devastating health outcomes. Mechanisms of AHT include impulsive injurious acts, such as violent shaking and impact, often due to caregiver frustration or exhaustion. Subdural and retinal hemorrhage, and associated extracranial injury (fractures, abdominal trauma), are common. Suspected victims require laboratory/diagnostic testing and occult injury screening, as well as protective measures by investigative authorities to ensure safety. Medicolegal controversies persist around AHT diagnosis, including alternative hypotheses proffered in court by skeptics despite advances in scientific understanding, biomechanical research, neuroimaging techniques, and perpetrator confessions. Pediatricians play a key role in prevention and reduction of AHT morbidity and mortality through anticipatory guidance and caregiver education about the risks of shaking, normal infant development and behavior, and encouragement of stress reduction strategies. [Pediatr Ann. 2020;49(8):e347-e353.].
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Effectiveness of an Educational Video in Maternity Wards to Prevent Self-Reported Shaking and Smothering during the First Week of Age: A Cluster Randomized Controlled Trial. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2020; 21:1028-1036. [PMID: 32696120 PMCID: PMC7569084 DOI: 10.1007/s11121-020-01145-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study aimed to investigate whether watching an educational video on infant crying and the dangers of shaking and smothering within 1 week after delivery at maternity wards reduces self-reported shaking and smothering, at a 1-month health checkup. A cluster randomized controlled trial, stratified by area and hospital function, was employed in 45 obstetrics hospitals/clinics in Osaka Prefecture, Japan. In the intervention group, mothers watched an educational video on infant crying and the dangers of shaking and smothering an infant, within 1 week of age, during hospitalization at maternity wards, without blinding on group allocation. Control group received usual care. A total of 4722 (N = 2350 and 2372 for intervention and control group, respectively) mothers who delivered their babies (still birth and gestational age < 22 weeks were excluded) between October 1, 2014, and January 31 were recruited. Outcomes were self-reported shaking and smothering behaviors, knowledge on infant crying and shaking, and behaviors to cope with infant crying, assessed via a questionnaire at a 1-month health checkup. In all, 2718 (N = 1078 and 1640) responded to the questionnaire (response rate: 58.3%), and analytic sample size was 2655 (N = 1058 and 1597 for intervention and control group, respectively). Multilevel analysis was used to adjust for correlation within the cluster. Prevalence of shaking was significantly lower in the intervention group (0.19%) than in the control group (1.69%). Intention-to-treat analysis showed an 89% reduction in the reported prevalence of self-reported shaking (OR: 0.11, 95% CI: 0.02–0.53) due to watching the educational video. However, self-reported smothering behavior showed no significant reduction (OR: 0.66, 95% CI: 0.27–1.60). No side effects were reported. Watching an educational video on infant crying and the dangers of shaking and smothering within 1 week after delivery at maternity wards reduced self-reported shaking at 1 month of age. UMIN Clinical Trial Registry UMIN000015558.
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Byrne MP, McMillan KR, Coats B. Morphological Analysis of Retinal Microvasculature to Improve Understanding of Retinal Hemorrhage Mechanics in Infants. Invest Ophthalmol Vis Sci 2020; 61:16. [PMID: 32176264 PMCID: PMC7401705 DOI: 10.1167/iovs.61.3.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose In this experimental study, we quantify retinal microvasculature morphological features with depth, region, and age in immature and mature ovine eyes. These data identify morphological vulnerabilities in young eyes to inform the mechanics of retinal hemorrhage in children. Methods Retinal specimens from the equator and posterior pole of preterm (n = 4) and adult (n = 9) sheep were imaged using confocal microscopy. Vessel segment length, diameter, angular asymmetry, tortuosity, and branch points were quantified using a custom image segmentation code. Significant differences were identified through two-way ANOVAs and correlation analyses. Results Vessel segment lengths were significantly shorter in immature eyes compared to adults (P < 0.003) and were significantly shorter at increasing depths in the immature retina (P < 0.04). Tortuosity significantly increased with depth, regardless of age (P < 0.05). These data suggest a potential vulnerability of vasculature in the deeper retinal layers, particularly in immature eyes. Preterm retina had significantly more branch points than adult retina in both the posterior pole and equator, and the number increased significantly with depth (P < 0.001). Conclusions The increased branch points and decreased segment lengths in immature microvasculature suggest that infants will experience greater stress and strain during traumatic loading compared to adults. The increased morphological vulnerability of the immature microvasculature in the deeper layers of the retina suggest that intraretinal hemorrhages have a greater likelihood of occurring from trauma compared to preretinal hemorrhages. The morphological features captured in this study lay the foundation to explore the mechanics of retinal hemorrhage in infants and identify vulnerabilities that explain patterns of retinal hemorrhage in infants.
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Bryce I. Responding to the accumulation of adverse childhood experiences in the wake of the COVID-19 pandemic: implications for practice. CHILDREN AUSTRALIA 2020; 45:80-87. [PMCID: PMC7298091 DOI: 10.1017/cha.2020.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 05/20/2023]
Abstract
In early 2020, the world as we knew it began to change dramatically and rapidly with the COVID-19 outbreak. Social distancing restrictions and lockdown measures have been the most effective course of action and an inarguably imperative approach at this time. However, in trying to keep the global population safe, social distancing measures unwittingly placed children already experiencing maltreatment and disadvantage in harm’s way. This paper will consider the evidence base which attests to the importance of considering the accumulation of adversity when seeking to understand risk and impact of child maltreatment and disadvantage. Given the unique and unprecedented circumstances which have accompanied the COVID-19 outbreak, and the dearth of research pertaining to the impact of pandemics on child welfare, the paper draws on an emerging body of literature about the effect of natural disasters, conflict and significant global events on child maltreatment. The paper synthesises the research to date in order to call attention to the cumulative impact of the COVID-19 pandemic on children already experiencing abuse and neglect. The paper concludes with an outline of the implications for practice in the helping professions.
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Affiliation(s)
- India Bryce
- School of Education, University of Southern Queensland, Toowoomba, Australia
- Author for correspondence: India Bryce,
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45
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Binder H, Tiefenboeck TM, Majdan M, Komjati M, Schuster R, Hajdu S, Leitgeb J. Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center. Wien Klin Wochenschr 2020; 132:499-505. [PMID: 32333270 PMCID: PMC7518988 DOI: 10.1007/s00508-020-01648-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
Background Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children. It is hypothesized, that with the adequate treatment of SDH in children and adolescence, excellent clinical and functional outcomes can be achieved. The aim of this study was to present the severity and outcome of traumatic SDH in children and adolescence as well as to analyze differences between patients treated surgically and conservatively. Methods In this study 47 infants and children with a subdural hematoma (SDH) were treated between 1992 and 2010 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow outcome scale (GOS) scores at hospital discharge and at follow-up visits were used. Severity of SDH was classified according to the Rotterdam score. Results In total, 47 cases were treated (21 surgically, 26 conservatively), with 10 patients needing delayed surgery. Overall, 89% of the patients were able to leave hospital, 5 patients died, 2 patients (5%) within 24 h, another 2 (5%) after 48 h and 1 (2%) within 7 days. In 25 patients (53%) a good recovery was recorded at the last follow-up visit. Outcome was mainly influenced by the following factors: age, severity of TBI, and neurological status. Overall, in 70% good clinical and neurological outcomes could be achieved. Conclusion The results of this study confirmed that pediatric SDH is a rare, but serious condition. Despite a poor prognosis, most patients could be treated with good outcomes, given that the choice of treatment is correct. Trial registration Research registry 2686 Electronic supplementary material The online version of this article (10.1007/s00508-020-01648-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harald Binder
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas M Tiefenboeck
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Marek Majdan
- International Neurotrauma Research Organization, Vienna, Austria
| | - Micha Komjati
- Department of Orthopaedics, Sacred Heart Hospital of Jesus, Vienna, Austria
| | - Rupert Schuster
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Johannes Leitgeb
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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46
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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47
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Babl FE, Pfeiffer H, Kelly P, Dalziel SR, Oakley E, Borland ML, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Lyttle MD, Bressan S, Donath S, Hearps SJC, Smith A, Crowe L. Paediatric abusive head trauma in the emergency department: A multicentre prospective cohort study. J Paediatr Child Health 2020; 56:615-621. [PMID: 31821681 DOI: 10.1111/jpc.14700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/10/2019] [Accepted: 10/27/2019] [Indexed: 11/30/2022]
Abstract
AIM Abusive head trauma (AHT) is associated with high morbidity and mortality. We aimed to describe characteristics of cases where clinicians suspected AHT and confirmed AHT cases and describe how they differed. METHODS This was a planned secondary analysis of a prospective multicentre cohort study of head injured children aged <18 years across five centres in Australia and New Zealand. We identified cases of suspected AHT when emergency department clinicians raised suspicion on a clinical report form or based on research assistant-assigned epidemiology codes. Cases were categorised as AHT positive, negative and indeterminate after multidisciplinary review. Suspected and confirmed AHT and non-AHT cases were compared using odds ratios with 95% confidence intervals. RESULTS AHT was suspected in 70 of 13 371 (0.5%) head-injured children. Of these, 23 (32.9%) were categorised AHT positive, 18 (25.7%) AHT indeterminate and 29 (27.1%) AHT negative. Median age was 0.8 years in suspected, 1.4 years in confirmed AHT and 4.1 years in non-AHT cases. Odds ratios (95% confidence interval) for presenting features and outcomes in confirmed AHT versus non-AHT were: loss of consciousness 2.8 (1.2-6.9), scalp haematoma 3.9 (1.7-9.0), seizures 12.0 (4.0-35.5), Glasgow coma scale ≤12 30.3 (11.8-78.0), abnormal neuroimaging 38.3 (16.8-87.5), intensive care admission 53.4 (21.6-132.5) and mortality 105.5 (22.2-500.4). CONCLUSIONS Emergency department presentations of children with suspected and confirmed AHT had higher rates of loss of consciousness, scalp haematomas, seizures and low Glasgow coma scale. These cases were at increased risk of abnormal computed tomography scans, need for intensive care and death.
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Affiliation(s)
- Franz E Babl
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Helena Pfeiffer
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Patrick Kelly
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Stuart R Dalziel
- Emergency department, Starship Children's Health, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Amit Kochar
- Emergency department, Women's & Children's Hospital, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Yuri Gilhotra
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Mark D Lyttle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom
| | - Silvia Bressan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen J C Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Anne Smith
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Victorian Forensic Paediatric Medical Service, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Louise Crowe
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Pasquesi SA, Seidi M, Hajiaghamemar M, Margulies SS. Predictions of neonatal porcine bridging vein rupture and extra-axial hemorrhage during rapid head rotations. J Mech Behav Biomed Mater 2020; 106:103740. [PMID: 32250951 DOI: 10.1016/j.jmbbm.2020.103740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/07/2020] [Accepted: 02/26/2020] [Indexed: 11/17/2022]
Abstract
When the head is rotated rapidly, the movement of the brain lags that of the skull. Intracranial contents between the brain and skull include meninges, cerebrospinal fluid (CSF), and cerebral vasculature. Among the cerebral vasculature in this space are the parasagittal bridging veins (BVs), which drain blood from the brain into the superior sagittal sinus (SSS), which is housed within the falx cerebri, adhered to the inner surface of the skull. Differential motion between the brain and skull that may occur during a traumatic event is thought to stretch BVs, causing damage and producing extra-axial hemorrhage (EAH). Finite element (FE) modeling is a technique often used to aid in the understanding and prediction of traumatic brain injury (TBI), and estimation of tissue deformation during traumatic events provides insight into kinematic injury thresholds. Using a FE model of the newborn porcine head with neonatal porcine brain and BV properties, single and cyclic rapid head rotations without impact were simulated. Measured BV failure properties were used to predict BV rupture. By comparing simulation outputs to observations of EAH in a development group of in vivo studies of rapid non-impact head rotations in the piglet, it was determined that failure of 16.7% of BV elements was associated with a 50% risk of EAH, and showed in a separate validation group that this threshold predicted the occurrence of EAH with 100% sensitivity and 100% specificity for single rapid non-impact rotations. This threshold for failed BV elements performed with 90% overall correct prediction in simulations of cyclic rotational head injuries. A 50% risk of EAH was associated with head angular velocities of 94.74 rad/s and angular accelerations of 29.60 krad/s2 in the newborn piglet. Future studies may build on these findings for BV failure in the piglet to develop predictive models for BV failure in human infants.
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Affiliation(s)
| | - Morteza Seidi
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, USA
| | - Marzieh Hajiaghamemar
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, USA
| | - Susan S Margulies
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, USA.
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Biomechanism of resistance to retinal injury in woodpecker’s eyes. SCIENCE CHINA-LIFE SCIENCES 2020; 63:592-598. [DOI: 10.1007/s11427-019-1664-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/01/2019] [Indexed: 10/24/2022]
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Pfeiffer H, Cowley LE, Kemp AM, Dalziel SR, Smith A, Cheek JA, Borland ML, O'Brien S, Bonisch M, Neutze J, Oakley E, Crowe LM, Hearps S, Lyttle MD, Bressan S, Babl FE. Validation of the PredAHT-2 prediction tool for abusive head trauma. Emerg Med J 2020; 37:119-126. [PMID: 31932397 DOI: 10.1136/emermed-2019-208893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/22/2019] [Accepted: 12/12/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool calculates the probability of abusive head trauma (AHT) in children <3 years of age who have sustained intracranial injuries (ICIs) identified on neuroimaging, based on combinations of six clinical features: head/neck bruising, seizures, apnoea, rib fracture, long bone fracture and retinal haemorrhages. PredAHT version 2 enables a probability calculation when information regarding any of the six features is absent. We aimed to externally validate PredAHT-2 in an Australian/New Zealand population. METHODS This is a secondary analysis of a prospective multicentre study of paediatric head injuries conducted between April 2011 and November 2014. We extracted data on patients with possible AHT at five tertiary paediatric centres and included all children <3 years of age admitted to hospital who had sustained ICI identified on neuroimaging. We assigned cases as positive for AHT, negative for AHT or having indeterminate outcome following multidisciplinary review. The estimated probability of AHT for each case was calculated using PredAHT-2, blinded to outcome. Tool performance measures were calculated, with 95% CIs. RESULTS Of 87 ICI cases, 27 (31%) were positive for AHT; 45 (52%) were negative for AHT and 15 (17%) had indeterminate outcome. Using a probability cut-off of 50%, excluding indeterminate cases, PredAHT-2 had a sensitivity of 74% (95% CI 54% t o89%) and a specificity of 87% (95% CI 73% to 95%) for AHT. Positive predictive value was 77% (95% CI 56% to 91%), negative predictive value was 85% (95% CI 71% to 94%) and the area under the curve was 0.80 (95% CI 0.68 to 0.92). CONCLUSION PredAHT-2 demonstrated reasonably high point sensitivity and specificity when externally validated in an Australian/New Zealand population. Performance was similar to that in the original validation study. TRIAL REGISTRATION NUMBER ACTRN12614000463673.
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Affiliation(s)
- Helena Pfeiffer
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Laura Elizabeth Cowley
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Alison Mary Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Anne Smith
- Victorian Forensic Paediatric Medical Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John Alexander Cheek
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Meredith L Borland
- Department of Emergency Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Sharon O'Brien
- Department of Emergency Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Megan Bonisch
- Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Jocelyn Neutze
- Department of Emergency Medicine, Kidzfirst Middlemore Hospital, Otahuhu, New Zealand
| | - Ed Oakley
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia.,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise M Crowe
- Department of Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Stephen Hearps
- Department of Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Academic Department of Emergency Care, University of the West of England, Bristol, Avon, UK
| | - Silvia Bressan
- Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics and Child Health, University of Padova, Padova, Italy
| | - Franz E Babl
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia .,Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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