Personal practice: An approach to investigation of easy bruising

Safeguarding essentials in modern-day paediatrics: inflicted injuries, body maps and section 47 investigations

The second case in the Safeguarding Essentials in Modern-day Paediatrics series, this article focuses on inflicted injuries, body maps and child protection investigations (CPIs). Using the scenario of a 6-year-old presenting to the emergency department having 'fallen off a swing', this article focuses on key considerations for history taking and examination in cases where you suspect injuries may have been inflicted, and how to discuss raising these suspicions with the family, as well as the importance of accurate body map completion. Also covered are CPIs, giving consideration to the legal framework surrounding these, and relevant useful resources and guidance are provided for dealing with the challenging circumstances that arise when physical abuse is first suspected.

Prevalence of Coagulopathy in Patients with Celiac Disease: A Single-Center Retrospective Case-Control Study

Introduction: Despite being one of the most frequent chronic digestive diseases worldwide, with a prevalence of 1%, celiac disease (CD) remains severely underdiagnosed. Among the instruments used to improve its diagnostic rate, hematologic parameters have been proposed as screening tests to select patients with an increased probability of having CD. Assessment of coagulation is included in routine check-ups, and CD has been reported to be associated with coagulopathy. We aimed to assess if subtle changes in coagulation tests could be used in clinical practice to prompt testing for CD. Methods: We retrospectively recruited all patients with clinical suspicion for CD during a study period of 7 years (between 2015 and 2022), who were tested using IgA tissue transglutaminase (tTG) serology and serum total IgA (IgG tTG in case of IgA deficiency) and who underwent upper gastrointestinal endoscopy with multiple biopsy sampling of the duodenal bulb and distal duodenum. We stratified patients into three groups: newly diagnosed CD, gluten-free diet-treated CD, and non-CD controls. Results: Altogether, there were 133 CD patients (71 newly diagnosed, 62 GFD-treated) and 57 non-CD controls. Mean age and gender distribution were similar among the three groups: 43.3 years for newly diagnosed CD, 41.6 years for non-CD controls, and 44 years for GFD-treated CD patients, with a male gender distribution of 21.1%, 28%, and 24.1%, respectively. Among the included newly diagnosed CD patients, 14% had a prolonged INR. The mean INR was slightly higher in newly diagnosed CD patients, compared to GFD-treated CD patients and non-CD controls: 1.12 ± 0.30, 1.02 ± 0.83, and 1.00 ± 0.08, respectively (p = 0.009). Consequently, prothrombin activity was slightly lower in newly diagnosed CD patients, compared to GFD-treated CD and non-CD controls: 94.9 ± 19.3%, 102.3 ± 12.8%, and 101.9 ± 15.15, respectively. Interestingly, after GFD, the mean INR and prothrombin activity of CD individuals reached a value similar to that of non-CD controls. Conclusions: Subtle changes in INR, defined as a value within the normal range, but closer to the upper limit, could be an indicator of probability for CD.

Experimental modelling of imposed upper airway obstruction in infants and children

The interpretation of injuries to children and infants poses a number of difficulties to any medical practitioner involved in their care or tasked with the investigation their death. This includes differentiating accidental from non-accidental trauma and the consideration of medical factors making a child more prone to injury. Non-fatal but life-threatening upper airway obstruction is unfortunately a well-recognized pattern of abuse which may precede a fatal episode. In this experimental study, we aimed to model theoretical digit marks to the head using infant and young child resuscitation dummies, exposed to various methods of deliberate upper airway obstruction. This work has demonstrated that digit marks can be left anywhere on the head and face. However, the distribution of these marks varies dramatically based on how the airway was obstructed. Moreover, digit marks also appeared to be linked together in fairly reproducible patterns. Given the findings in this study, the identification of one or more fingertip type bruises anywhere on an infant or child's face or scalp, should raise the index of suspicion that the individual may have been subject to deliberate upper airway obstruction. This should prompt healthcare professionals to examine the child for markers of mechanical asphyxia, in order to accurately interpret any inadequately explained bruising to the head and face.

Telangiectatic Matting is Associated with Hypersensitivity and a Bleeding Tendency

OBJECTIVE

The aim was to investigate the pathogenesis of telangiectatic matting (TM) and identify possible risk factors.

METHODS

This study had two parts. The clinical records of consecutive patients were retrospectively analysed to identify risk factors for TM. In the second part, the haemostatic and coagulation profile of the subset of patients with TM were analysed and compared with controls using standard coagulation tests, platelet function and a global assay of coagulation (rotational thromboelastometry, ROTEM).

RESULTS

In 352 consecutive patients presenting to a phlebology practice, 25 patients had TM (7.1%). All 25 patients were female with the median age of 45 (27-57) years. A comprehensive medical history was taken. Among 27 possible risk factors assessed, statistically significant associations included recurrent epistaxis, easy bruising, hypersensitivity (eczema, hives, hay fever, and rhinitis), previous treatment with sclerotherapy or endovenous laser for lower limb veins, and a family history of telangiectasias. Variables not associated with TM included oral contraceptive intake, hormone replacement therapy, and age. The haemostatic and coagulation profile of 12 patients (6 male and 6 female) with TM did not differ significantly from those without TM.

CONCLUSION

TM is associated with both hypersensitivity and a bleeding tendency. This study revealed no significant increase in the incidence of haemostatic abnormalities in patients with TM compared with the control group. Given the significant association with hypersensitivity disorders, the underlying mast cell hyper-reactivity may contribute to both hypersensitivity and a bleeding tendency and predispose patients to TM.