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Lorenzo M, Cory E, Cho R, Pusic M, Fish J, Adelgais KM, Boutis K. Deliberate Practice as an Effective Method for Reducing Diagnostic Error in Identifying Burn and Bruise Injuries Suspicious for an Abusive Injury. J Pediatr 2024; 274:114183. [PMID: 38964439 DOI: 10.1016/j.jpeds.2024.114183] [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: 04/15/2024] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE To examine the effectiveness of an education intervention for reducing physician diagnostic error in identifying pediatric burn and bruise injuries suspicious for abuse, and to determine case-specific variables associated with an increased risk of diagnostic error. STUDY DESIGN This was a multicenter, prospective, cross-sectional study. A convenience sample of pediatricians and other front-line physicians who treat acutely injured children in the United States and Canada were eligible for participation. Using a web-based education and assessment platform, physicians deliberately practiced with a spectrum of 300 pediatric burn and bruise injury image-based cases. Participants were asked if there was a suspicion for abuse present or absent, were given corrective feedback after every case, and received summative diagnostic performance overall (accuracy), suspicion for abuse present (sensitivity), and absent (specificity). RESULTS Of the 93/137 (67.9%) physicians who completed all 300 cases, there was a significant reduction in diagnostic error (initial 16.7%, final 1.6%; delta -15.1%; 95% CI -13.5, -16.7), sensitivity error (initial 11.9%, final 0.7%; delta -11.2%; 95% CI -9.8, -12.5), and specificity error (initial 23.3%, final 6.6%; delta -16.7%; 95% CI -14.8, -18.6). Based on 35 627 case interpretations, variables associated with diagnostic error included patient age, sex, skin color, mechanism of injury, and size and pattern of injury. CONCLUSIONS The education intervention substantially reduced diagnostic error in differentiating the presence vs absence of a suspicion for abuse in children with burn and bruise injuries. Several case-based variables were associated with diagnostic error, and these data can be used to close specific skill gaps in this clinical domain.
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Affiliation(s)
- Melissa Lorenzo
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Emma Cory
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Romy Cho
- Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Martin Pusic
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard University, Boston, MA
| | - Joel Fish
- Division of Plastic Surgery, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Kathy Boutis
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Canada.
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Sagah GA, Sharif AF, Moustafa IMES, Hasan SF, Elhawary AE. Medico-legal evaluation of burn trauma injuries. Epidemiological features and predictors of mortality and other adverse outcomes. Injury 2024; 55:111276. [PMID: 38141390 DOI: 10.1016/j.injury.2023.111276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Burn trauma is a devastating, life-threatening public health issue responsible for significant morbidity and mortality. Developing countries suffer more from the medical, psychological, and economic consequences of burns. The current study aimed to investigate the medicolegal aspects of burn trauma by identifying the epidemiological factors and injury characteristics associated with increased risk of mortality, intentional infliction, and different types of complications. METHODS A prospective cross-sectional study was conducted enrolling the burn trauma patients admitted to Burn Unit, Tanta University Hospital, Egypt over one year. RESULTS The current study was conducted among 138 burn trauma patients with a case fatality rate of 13.8 %. Of them, 5.8 % were victims of intentional burns, 44.9 % were complicated, and the length of hospital stay ranged between one day and 52 days. Patients aged less than 10 years constituted about 33.3 %. The burn trauma was the highest in June, May and March. Intentionally exposed patients, patients with third-degree burns affecting the head, neck and trunk and those with burns involving a total body surface area (TBSA) of more than 33 % were at high mortality risk. Intentional burns were induced mainly by flame (100 %) and characterized by high severity (TBSA = 85 % and 87.5 % third-degree burns). Intentional burns involved mainly the trunk (p = 0.002) and external genitalia (p = 0.022). The involved TBSA and the highest burn degree were significant predictors of mortality with an excellent area under curves of 0.956 and 0.870, respectively and (p < 0.001). The TBSA of more than 17 % and the burn degrees above the second were significant predictors of in hospital complications (p < 0.001). Daytime intentional burns, burns involving the upper extremities and face, deep and widely distributed burns, and infected wounds were associated with a significant need for surgical treatments. The median length of hospital stay was ten days, primarily attributed to the in hospital complications (p = 0.02). CONCLUSION A high degree of vigilance and accurate assessment of burn size, depth and distribution with meticulous interpretation of the mechanism of infliction are central not only for treatment interventions but from the medicolegal point of view.
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Affiliation(s)
- Ghada Attia Sagah
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asmaa F Sharif
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt; Clinical Medical Sciences Department, College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia.
| | | | - Sohier F Hasan
- Department of Emergency Medicine and Traumatology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amira Elsayed Elhawary
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
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Bennett CV, Hollén L, Wilkins D, Emond A, Kemp A. The impact of a clinical prediction tool (BuRN-Tool) for child maltreatment on social care outcomes for children attending hospital with a burn or scald injury. Burns 2023; 49:941-950. [PMID: 35987740 DOI: 10.1016/j.burns.2022.07.014] [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] [Received: 05/09/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022]
Abstract
Burns are common childhood injuries and 10-20% are associated with maltreatment. This prospective before/after study investigated the impact of introducing the BuRN-Tool (a child maltreatment clinical prediction tool), on actions taken by children's social care department (CSC). Before introduction (pre-intervention): we collected standardised data on cause and characteristics of burns, in four regional hospitals. A BuRN-Tool-score was calculated retrospectively pre-intervention and by the attending clinician post-intervention. CSC involvement and actions taken relative to BuRN-Tool-score were compared pre- and post-BuRN-Tool. Data were collected for 1688 children from 17 local authorities. The percentage that received a CSC action decreased post-BuRN-Tool (pre: 58.0%, 51/88; post: 37.5%, 33/88, p = 0.007). A greater percentage of cases with a BuRN-Tool-score of ≥ 3 had a CSC action, than those with a BuRN-Tool-score 3, pre-intervention (≥3 70.0%, 35/50; = 0.04) and post-intervention (≥3 50.0%, 21/42; = 0.01). Children with a BuRN-Tool-score ≥ 3 but no contact/referral recorded by CSC for the burn, and those who had a contact/referral but no action taken, were significantly more likely than those scoring 3 to have new CSC involvement within six months following the burn. The BuRN-Tool-score ≥ 3 has the potential to alert clinicians to maltreatment concerns.
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Affiliation(s)
- C Verity Bennett
- Division of Population Medicine, School of Medicine, Cardiff University, CF14 4YS, UK; CASCADE, School of Social Sciences, Cardiff University, CF10 3BD, UK.
| | - Linda Hollén
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, BS8 2PS, UK
| | - David Wilkins
- CASCADE, School of Social Sciences, Cardiff University, CF10 3BD, UK
| | - Alan Emond
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, BS8 2PS, UK
| | - Alison Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, CF14 4YS, UK
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4
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Ford K, Hughes K, Cresswell K, Griffith N, Bellis MA. Associations between Adverse Childhood Experiences (ACEs) and Lifetime Experience of Car Crashes and Burns: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16036. [PMID: 36498109 PMCID: PMC9735663 DOI: 10.3390/ijerph192316036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
Unintentional injury is a significant cause of disease burden and death. There are known inequalities in the experience of unintentional injuries; however, to date only a limited body of re-search has explored the relationship between exposure to adverse childhood experiences (ACEs) and unintentional injury. Using a cross-sectional sample of the adult general public (n = 4783) in Wales (national) and England (Bolton Local Authority), we identify relationships between ACE exposure and experience of car crashes and burns requiring medical attention across the life course. Individuals who had experienced 4+ ACEs were at significantly increased odds of having ever had each outcome measured. Furthermore, compared to those with no ACEs, those with 4+ were around two times more likely to report having had multiple (i.e., 2+) car crashes and over four times more likely to report having had burns multiple times. Findings expand the evidence base for the association between ACEs and negative health consequences and emphasise the need for effective interventions to prevent ACEs and their impact on life course health and well-being. Such knowledge can also be used to develop a multifaceted approach to injury prevention.
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Affiliation(s)
- Kat Ford
- Public Health Collaborating Unit, School of Medical and Health Sciences, College of Human Sciences, Bangor University, Wrexham LL13 7YP, UK
| | - Karen Hughes
- Public Health Collaborating Unit, School of Medical and Health Sciences, College of Human Sciences, Bangor University, Wrexham LL13 7YP, UK
- World Health Organization Collaborating Centre on Investment for Health and Well-Being, Policy and International Health, Public Health Wales, Wrexham LL13 7YP, UK
| | - Katie Cresswell
- Public Health Collaborating Unit, School of Medical and Health Sciences, College of Human Sciences, Bangor University, Wrexham LL13 7YP, UK
| | - Nel Griffith
- Public Health Collaborating Unit, School of Medical and Health Sciences, College of Human Sciences, Bangor University, Wrexham LL13 7YP, UK
| | - Mark A. Bellis
- Public Health Collaborating Unit, School of Medical and Health Sciences, College of Human Sciences, Bangor University, Wrexham LL13 7YP, UK
- World Health Organization Collaborating Centre on Investment for Health and Well-Being, Policy and International Health, Public Health Wales, Wrexham LL13 7YP, UK
- Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, UK
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5
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Loos MLHJ, Meij-de Vries A, Nagtegaal M, Bakx R. Child abuse and neglect in paediatric burns: The majority is caused by neglect and thus preventable. Burns 2022; 48:688-697. [PMID: 34103201 DOI: 10.1016/j.burns.2021.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/05/2021] [Accepted: 05/14/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION It is complex to distinguish negligent burns from inflicted and non-intentional burns, especially since no deliberate action caused the burn. Its recognition is important to create a safe life without (future) burns for our loved-ones who cannot take care of themselves (yet). Our aim was to investigate the incidence and associated characteristics of negligent burns are among children treated at a burn center. METHODS We retrospectively reviewed medical files of all children attending a Dutch burn center with an acute burn between January 2013-December 2015. The conclusion of the Child Abuse and Neglect team (CAN) was used to define inflicted, negligent or non-intentional burns. The remaining cases were reviewed by an expert panel using a standardized protocol. Demographic and social data as well as clinical information about the burn were collected. RESULTS In total 330 children were included. Negligent burns accounted for 56%, non-intentional for 42% and inflicted for 2% of the burns. Negligent burns were associated with: hot beverages (OR 4.40, 95%CI 2.75-7.05), a younger age (p < 0.001), occurrence at home (OR 4.87 95%CI 2.80-8.45) and were located at the anterior trunk (OR 2.75, 95%CI 1.73-4.35) and neck (OR 1.98, 95%CI 1.12-3.50). CONCLUSION This study shows that neglect is a major factor in the occurrence of burns in young children, therefore we conclude that the majority of paediatric burns are preventable. Educational programs creating awareness and focussing on prevention of these burns should be aimed at households, since the majority of negligent as cause of preventable burns occur at home.
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Affiliation(s)
- Marie-Louise H J Loos
- Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Paediatric Surgery, Amsterdam, The Netherlands.
| | - Annebeth Meij-de Vries
- Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Paediatric Surgery, Amsterdam, The Netherlands; Red Cross Hospital, Burn Center Beverwijk, Vondellaan 13, 1942 LE, Beverwijk, The Netherlands.
| | - Michelle Nagtegaal
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Social Paediatrics, Amsterdam, The Netherlands; Department of Forensic Medicine, Section on Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands.
| | - Roel Bakx
- Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Paediatric Surgery, Amsterdam, The Netherlands.
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Eismann EA, Shapiro RA, Makoroff KL, Theuerling J, Stephenson N, Duma EM, Fain ET, Frey TM, Riney LC, Thackeray JD. Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition. Pediatr Emerg Care 2021; 37:e1503-e1509. [PMID: 32433455 DOI: 10.1097/pec.0000000000002100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.
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Affiliation(s)
- Emily A Eismann
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Jack Theuerling
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | - Nicole Stephenson
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Theresa M Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lauren C Riney
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Hadjiandreou M, Martin N. Towards artificial intelligence for identifying cases of suspected maltreatment in paediatric burns. Burns 2021; 47:1459-1460. [PMID: 34116871 DOI: 10.1016/j.burns.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Michalis Hadjiandreou
- St. Andrews Centre for Plastic Surgery & Burns, Broomfield University Hospital, Court Road, Chelmsford, Essex CM1 7ET, UK.
| | - Niall Martin
- St. Andrews Centre for Plastic Surgery & Burns, Broomfield University Hospital, Court Road, Chelmsford, Essex CM1 7ET, UK; Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London E1 2AT, UK
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8
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Kontaktverbrennungen durch einen Nachtspeicherofen – Unfall oder Misshandlung? Rechtsmedizin (Berl) 2021. [DOI: 10.1007/s00194-021-00467-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ZusammenfassungEin 7 Monate alter weiblicher Säugling wurde mit Kontaktverbrennungen 2. Grades an beiden Beinen von seinen Eltern in der Notaufnahme eines Krankenhauses vorgestellt. Die Eltern berichteten, das Kind sei unbeaufsichtigt und nur mit einem Body bekleidet gegen den Nachtspeicherofen im Kinderzimmer gekrabbelt. Bei der 10 Tage später durchgeführten klinisch-rechtsmedizinischen Untersuchung zeigten sich streifige, teils parallel zueinander gestellte und gelenkübergreifende Verbrennungen an der rechten Oberschenkelaußen- und Unterschenkelrückaußenseite, an beiden Fußrücken und den Zehen sowie ein flächenhaftes Verbrennungsareal an der linken Unterschenkelaußenseite mit abgrenzbaren streifigen Anteilen.Im Rahmen einer Ortsbegehung der elterlichen Wohnung mit Vermessung und Begutachtung der in der Wohnung befindlichen 3 Nachtspeicheröfen konnte zunächst festgestellt werden, dass sich die Verbrennungsmuster an den Beinen des Kindes mit dem Luftauslassgitter der beiden Nachtspeicheröfen im Wohn- und im Elternschlafzimmer (jeweils identisches Modell), hingegen nicht mit dem des Nachtspeicherofens im Kinderzimmer in Deckung bringen ließen. Für die Begutachtung konnte durch ergänzende Informationen eines technischen Sachverständigen zu den entsprechenden Nachtspeicheröfen und durch eine Literaturrecherche ein möglicher Geschehensablauf rekonstruiert werden.Dieser Fall verdeutlicht zum einen, welche Gefahr für Säuglinge und Kleinkinder von Nachtspeicheröfen ausgehen kann, wenn diese nicht regelrecht gesichert und die Kinder unbeaufsichtigt sind. Zum anderen wird die Bedeutung einer detaillierten und – wenn nötig – interdisziplinären Rekonstruktion, inklusive einer Ortsbegehung, zur Abgrenzung eines möglichen Unfallhergangs von einer Kindesmisshandlung unterstrichen.
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Hollen L, Bennett V, Nuttall D, Emond AM, Kemp A. Evaluation of the efficacy and impact of a clinical prediction tool to identify maltreatment associated with children's burns. BMJ Paediatr Open 2021; 5:e000796. [PMID: 33644416 PMCID: PMC7883870 DOI: 10.1136/bmjpo-2020-000796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/23/2020] [Accepted: 12/03/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND An estimated 10%-24% of children attending emergency departments with a burn are maltreated. OBJECTIVE To test whether a clinical prediction tool (Burns Risk assessment for Neglect or abuse Tool; BuRN-Tool) improved the recognition of maltreatment and increased the referral of high-risk children to safeguarding services for assessment. METHODS A prospective study of children presenting with burns to four UK hospitals (2015-2018), each centre providing a minimum of 200 cases before and after the introduction of the BuRN-Tool. The proportions of children referred to safeguarding services were compared preintervention and postintervention, and the relationship between referral and the recommended cut-off for concern (BuRN-Tool score (BT-score) ≥3) was explored. RESULTS The sample was 2443 children (median age 2 years). Nurses and junior doctors mainly completed the BuRN-Tool, and a BT-score was available for 90.8% of cases. After intervention, 28.4% (334/1174) had a BT-score ≥3 and were nearly five times more likely to be discussed with a senior clinician than those with a BT-score <3 (65.3% vs 13.4%, p<0.001). There was no overall difference in the proportion of safeguarding referrals preintervention and postintervention. After intervention, the proportion of referrals for safeguarding concerns was greater when the BT-score was ≥3 (p=0.05) but not for scores <3 (p=0.60). A BT-score of 3 as a cut-off for referral had a sensitivity of 72.1, a specificity of 82.7 and a positive likelihood ratio of 4.2. CONCLUSIONS A BT-score ≥3 encouraged discussion of cases of concern with senior colleagues and increased the referral of <5 year-olds with safeguarding concerns to children's social care.
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Affiliation(s)
- Linda Hollen
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Verity Bennett
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Dianne Nuttall
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Alan M Emond
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Alison Kemp
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Rosado N, Charleston E, Gregg M, Lorenz D. Characteristics of accidental versus abusive pediatric burn injuries in an urban burn center over a 14-year period. J Burn Care Res 2020; 40:437-443. [PMID: 30869138 DOI: 10.1093/jbcr/irz032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The aim of this study was to determine the demographic and associated characteristics of abusive burn injuries in children. Understanding the characteristics of burn injuries may help clinicians differentiate and recognize abusive injuries. We conducted a retrospective study of patients less than 5 years old admitted to an urban burn center from March 1999 to July 2013. Per protocol, all patients with burn injuries were evaluated by a multidisciplinary team (child abuse pediatrician, social worker, and nurse clinician). Demographic information, social risk factors, clinical presentation, caregiver at time of injury, radiographic studies and results, multidisciplinary team determination, and the Department of Children and Family Services investigation outcome were abstracted from the American Burn Association Burn Registry and patient's chart. Patient characteristics were evaluated with abuse status through Wilcoxon rank sum tests for continuous variables and chi-square tests or Fisher's exact test for categorical variables. A multiple logistic regression was fit to identify factors associated with abusive burns. One hundred and ten patients under 5 years were categorized as abuse (38) or accident (72). Demographic characteristics were similar between the abuse and accident groups. A determination of abuse was significantly associated with caregiver type (paramour), site of incident (outside of kitchen), time to seeking help (>4 hours), and the presence of nonburn skin injuries. A detailed history of the burn mechanism as well as psychosocial family risk factors are critical when evaluating pediatric patients with burn injuries, as it may assist the physician in distinguishing abusive from accidental burn injuries.
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Affiliation(s)
- Norell Rosado
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Elizabeth Charleston
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Mary Gregg
- Department of Bioinformatics and Biostatistics, University of Louisville, Kentucky
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Kentucky
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11
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Incidence and characteristics of non-accidental burns in children: A systematic review. Burns 2020; 46:1243-1253. [DOI: 10.1016/j.burns.2020.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/24/2019] [Accepted: 01/24/2020] [Indexed: 11/18/2022]
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12
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Hermetet C, Laurent É, El Allali Y, Gaborit C, Urvois-Grange A, Biotteau M, Le Touze A, Grammatico-Guillon L. Child maltreatment by non-accidental burns: interest of an algorithm of detection based on hospital discharge database. Int J Legal Med 2020; 135:509-519. [PMID: 32856118 DOI: 10.1007/s00414-020-02404-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To build a detection algorithm of non-accidental pediatric burns (NAB) using hospital resumes from the French Hospital Discharge Database (HDD) and to describe cases with no judicial or administrative report. MATERIALS AND METHODS Children aged 0-16 years old hospitalized at the University Hospital of Tours from 2012 to 2017 with a coded burn were included. "Probable" or "possible" HDD cases of NAB were defined based on the International Classification of Diseases 10th version codes during the inclusion stay or the previous year. A chart review was performed on all the HDD cases and HDD non cases matched on sex and age with a 1:2 ratio. Performance parameters were estimated for three clinical definitions of child maltreatment: excluding neglect, including neglect in a restrictive definition, and in a broad definition. For clinical cases, report to the judicial or administrative authorities was searched. RESULTS Among the 253 included children, 83 "probable" cases and 153 non-cases were analyzed. Sensitivity varied from 48 (95%CI [36-60], excluding neglect) to 90% [55-100] and specificity from 70 [63;77] to 68% [61;74]. The proportion of clinical cases with no report without justification varied from 0 (excluding neglect) to > 85% (with the broadest definition); all corresponded to possible isolated neglect. CONCLUSION The performances of the algorithm varied tremendously according to the clinical definition of child maltreatment. Neglect is obviously complex and tough to clinically detect. Training for healthcare professionals and qualitative studies on obstacles to report should be added to this work.
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Affiliation(s)
- Coralie Hermetet
- Public Health and Epidemiology Unit, Teaching Hospital of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France.
- Research Team "Education, Ethics and Health" (EA 7505), University of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France.
- Medicolegal Unit, Teaching Hospital of Rennes, 2 rue Henri Le Guilloux, 35033, Rennes cedex 9, France.
| | - Émeline Laurent
- Public Health and Epidemiology Unit, Teaching Hospital of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France
- Research Team "Education, Ethics and Health" (EA 7505), University of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France
| | - Yasmine El Allali
- Department of Paediatrics, Hospital of Blois, Les Sept Arpents, 41260, Blois, France
| | - Christophe Gaborit
- Public Health and Epidemiology Unit, Teaching Hospital of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France
| | - Annie Urvois-Grange
- Paediatric Emergency Department, Teaching Hospital of Tours, 49 boulevard Béranger, 37044, Tours cedex 9, France
| | - Mélanie Biotteau
- Public Health and Epidemiology Unit, Teaching Hospital of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France
- University Psychiatric Clinic, Teaching Hospital of Tours, 12 rue du Coq, 37540, Saint-Cyr-sur-Loire, France
| | - Anne Le Touze
- Pediatric Burn Unit, Teaching Hospital of Tours, 49 boulevard Béranger, 37044, Tours cedex 9, France
| | - Leslie Grammatico-Guillon
- Public Health and Epidemiology Unit, Teaching Hospital of Tours, 2 boulevard Tonnellé, 37044, Tours cedex 9, France
- University of Tours, 60 rue du Plat d'Étain, 37020, Tours cedex 1, France
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Anderson KT, Bartz-Kurycki MA, Garwood GM, Martin R, Gutierrez R, Supak DN, Wythe SN, Kawaguchi AL, Austin MT, Huzar TF, Tsao K. Let the right one in: High admission rate for low-acuity pediatric burns. Surgery 2019; 165:360-364. [DOI: 10.1016/j.surg.2018.06.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/11/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
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Kemp AM, Hollén L, Emond AM, Nuttall D, Rea D, Maguire S. Raising suspicion of maltreatment from burns: Derivation and validation of the BuRN-Tool. Burns 2018; 44:335-343. [DOI: 10.1016/j.burns.2017.08.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/22/2017] [Accepted: 08/25/2017] [Indexed: 11/26/2022]
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A 6-Year Case-Control Study of the Presentation and Clinical Sequelae for Noninflicted, Negligent, and Inflicted Pediatric Burns. J Burn Care Res 2018; 38:e101-e124. [PMID: 28009699 DOI: 10.1097/bcr.0000000000000408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflicted burns are one of the leading causes of abuse-related fatalities in children. Between 30 and 60% of children accidentally returned to abusive homes suffer reabuse. Given the high chance for abuse recurrence and the associated morbidity/mortality, it is critical that inflicted burns are promptly identified to guide appropriate medical and child welfare management. Although previous studies proposed historical and mechanistic features using noncomparative or poorly powered data, this study utilized comparative data from a 6-year period (2009-2014) at a certified burn center along with expert analysis from Child Advocacy and Protective Services (CAPS) to provide higher level evidence supporting classical findings while elucidating new features with respect to burn severity and required interventions. A retrospective chart review of 408 pediatric burns was cross-referenced with the respective CAPS consultations to construct a multidisciplinary, deidentified database. The average age was 2.9 years (0.04-17 years) with 232 (57%) males and 330 (81%) African-Americans. CAPS investigations confirmed burn etiologies: noninflicted (346 [85%]), negligent (30 [7%]), and inflicted (32 [8%]). In comparing the three etiologies, statistical significance (P < .05) was observed for numerous variables including historical inconsistency, burn age, child welfare history, burn size and depth, distribution, concomitant injury rates, number of surgical interventions, infectious complications, and hospital length of stay. In addition to reaffirming classical features of abusive burns to fortify etiologic diagnoses, this study elucidated appreciable differences in burn severity, interventional sequelae, and burn-related complications, which will help guide medical and surgical interventions for future pediatric burn patients.
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Abstract
One in 4 American children have been abused and up to 5 children die per day from abuse. Children are vulnerable and error or lag in diagnosis may lead to further injury or death. In contrast, misdiagnosis of abuse is also unacceptable. Burns are a leading cause of abuse-related fatality and determination of cause can be difficult. It is critical that clinicians distinguish between burns of abuse (inflicted) and neglect and those received accidentally (noninflicted). Discordant narratives, use of alcohol and illicit substances, characteristics of the burn wound, and concomitant injury are all red flags for inflicted and negligent burns.
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Affiliation(s)
- Zachary J Collier
- Biological Sciences Division, Pritzker School of Medicine, University of Chicago, 924 East 57th Street, Chicago, IL 60637, USA.
| | - Michelle C Roughton
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 7040 Burnett-Womack, Chapel Hill, NC 27599, USA
| | - Lawrence J Gottlieb
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, 5841 South Maryland Avenue, Room J-641, Chicago, IL 60637, USA
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Bousema S, Stas HG, van de Merwe MH, Oen IM, Baartmans MG, van Baar ME, Dokter J, van Es A, van der Vlies C, van Baar M. Epidemiology and screening of intentional burns in children in a Dutch burn centre. Burns 2016; 42:1287-94. [DOI: 10.1016/j.burns.2016.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/24/2015] [Accepted: 01/03/2016] [Indexed: 11/28/2022]
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Hodgman EI, Pastorek RA, Saeman MR, Cripps MW, Bernstein IH, Wolf SE, Kowalske KJ, Arnoldo BD, Phelan HA. The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010. Burns 2016; 42:1121-1127. [PMID: 27268012 DOI: 10.1016/j.burns.2016.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/27/2016] [Accepted: 02/11/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pediatric burns due to abuse are unfortunately relatively common, accounting for 5.8-8.8% of all cases of abuse annually. Our goal was to evaluate our 36-year experience in the evaluation and management of the victims of abuse in the North Texas area. METHODS A prospectively maintained database containing records on all admissions from 1974 through 2010 was queried for all patients aged less than 18 years. Patients admitted for management of a non-burn injury were excluded from the analysis. RESULTS Of 5,553 pediatric burn admissions, 297 (5.3%) were due to abuse. Children with non-accidental injuries tended to be younger (2.1 vs. 5.0 years, p<0.0001) and male (66.0 vs. 56.5%, p=0.0008). Scald was the most common mechanism of injury overall (44.8%), and was also the predominant cause of inflicted burns (89.6 vs. 42.3%, p<0.0001). Multivariate logistic regression identified age, gender, presence of a scald, contact, or chemical burn, and injury to the hands, bilateral feet, buttocks, back, and perineum to be significant predictors of abuse. Victims of abuse were also found to have worse outcomes, including mortality (5.4 vs. 2.3%, p=0.0005). After adjusting for age, mechanism of injury, and burn size, abuse remained a significant predictor of mortality (OR 3.3, 95% CI 1.5-7.2) CONCLUSIONS: Clinicians should approach all burn injuries in young children with a high index of suspicion, but in particular those with scalds, or injuries to the buttocks, perineum, or bilateral feet should provoke suspicion. Burns due to abuse are associated with worse outcomes, including length of stay and mortality.
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Affiliation(s)
- Erica I Hodgman
- Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX.
| | | | - Melody R Saeman
- Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
| | - Michael W Cripps
- Division of Burns/Trauma/Critical Care, Dept. of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
| | - Ira H Bernstein
- Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center
| | - Steven E Wolf
- Division of Burns/Trauma/Critical Care, Dept. of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
| | - Karen J Kowalske
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
| | - Brett D Arnoldo
- Division of Burns/Trauma/Critical Care, Dept. of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX
| | - Herb A Phelan
- Division of Burns/Trauma/Critical Care, Dept. of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital, Dallas, TX.
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Pawlik MC, Kemp A, Maguire S, Nuttall D, Feldman KW, Lindberg DM. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. CHILD ABUSE & NEGLECT 2016; 55:52-61. [PMID: 27088728 DOI: 10.1016/j.chiabu.2016.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/08/2015] [Accepted: 03/17/2016] [Indexed: 06/05/2023]
Abstract
Intentional burns represent a serious form of physical abuse that must be identified to protect children from further harm. This study is a retrospectively planned secondary analysis of the Examining Siblings To Recognize Abuse (ExSTRA) network data. Our objective was to describe the characteristics of burns injuries in children referred to Child Abuse Pediatricians (CAPs) in relation to the perceived likelihood of abuse. We furthermore compare the extent of diagnostic investigations undertaken in children referred to CAPs for burn injuries with those referred for other reasons. Within this dataset, 7% (215/2890) of children had burns. Children with burns were older than children with other injuries (median age 20 months vs. 10 months). Physical abuse was perceived as likely in 40.9% (88) and unlikely in 59.1% (127). Scalds accounted for 52.6% (113) and contact burns for 27.6% (60). Several characteristics of the history and burn injury were associated with a significantly higher perceived likelihood of abuse, including children with reported inflicted injury, absent or inadequate explanation, hot water as agent, immersion scald, a bilateral/symmetric burn pattern, total body surface area ≥10%, full thickness burns, and co-existent injuries. The rates of diagnostic testing were significantly lower in children with burns than other injuries, yet the yield of skeletal survey and hepatic transaminases testing were comparable between the two groups. This would imply that children referred to CAPs for burns warrant the same level of comprehensive investigations as those referred for other reasons.
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Affiliation(s)
- Marie-Christin Pawlik
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Alison Kemp
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, UK.
| | - Sabine Maguire
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Diane Nuttall
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Kenneth W Feldman
- Children's Protection Program, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Kempe Center for the Prevention and Treatment of Child Abuse, Department of Pediatrics, Children's Hospital of Colorado, Aurora, CO, USA
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