Skeletal survey yields in low vs. high risk pediatric patients with skull fractures

BACKGROUND

To assess for occult fractures, physicians often opt to obtain skeletal surveys (SS) in young, acutely head-injured patients who present with skull fractures. Data informing optimal decision management are lacking.

OBJECTIVE

To determine the positive yields of radiologic SS in young patients with skull fractures presumed to be at low vs. high risk for abuse.

PARTICIPANTS AND SETTING

476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021.

METHODS

We conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set.

RESULTS

204 (43 %) of 476 patients had simple, linear, parietal skull fractures. 272 (57 %) had more complex skull fracture(s). Only 315 (66 %) of 476 patients underwent SS, including 102 (32 %) patients presumed to be at low risk for abuse (patients who presented with a consistent history of accidental trauma; intracranial injuries no deeper than the cortical brain; and no respiratory compromise, alteration or loss of consciousness, seizures, or skin injuries suspicious for abuse). Only one of 102 low risk patients revealed findings indicative of abuse. In two other low risk patients, SS helped to confirm metabolic bone disease.

CONCLUSIONS

Less than 1 % of low risk patients under three years of age who presented with simple or complex skull fracture(s) revealed other abusive fractures. Our results could inform efforts to reduce unnecessary skeletal surveys.

Financing pediatric hospital child abuse teams in 2015: National survey results

BACKGROUND

Data available on the economics of medical child protection teams stems from prior surveys delivered in 2008 and 2012.

OBJECTIVE

The objective was to describe the current financing strategies of medical child maltreatment groups for benchmarking purposes. Additionally, we aimed to quantify often difficult to measure child abuse services that provide value to pediatric hospitals.

PARTICIPANTS AND SETTING

In 2017, a 115-item survey was distributed to 230 pediatric hospitals inquiring about child abuse services for the 2015 calendar year.

METHODS

The financial topics including budget, revenue, reimbursement, expenses, research, education, and community partnership were analyzed using descriptive statistics. Previous data from similar surveys deployed in 2008 and 2012 were used when applicable to formulate trends.

RESULTS

One hundred and thirteen children's hospitals responded comprising a response rate of 49 %. One hundred and four hospitals provided child abuse services at some level. Sixty-two programs (26 %) responded to items about budget. Overall, average team operating budgets increased from $1.15 million in 2008 to $1.4 million in 2015. Few clinical services rendered received full reimbursement. Valuable non-clinical services were poorly reimbursed. An average of 5.45 funding sources were used to supplement remunerations.

CONCLUSION

Child maltreatment teams within pediatric hospitals provide services that are largely unfunded as they are not currently recognized by healthcare payment models. These specialists perform a variety of clinical and non-clinical responsibilities that are critical to the care of this population while relying on a variety of funding sources to support their efforts.

Inpatient Food Insecurity in Caregivers of Hospitalized Pediatric Patients: A Mixed Methods Study

BACKGROUND AND OBJECTIVE

Among US households with children, 14% are food insecure. Household food insecurity (FI) is associated with poorer health outcomes and increased hospital admissions. There is less known about caregivers' ability to obtain adequate food during hospitalization (inpatient FI).

METHODS

We conducted a mixed methods study of primary caregivers of hospitalized children 0 to 18 years. A modified US Household Food Security Survey was used to identify inpatient FI. Associated factors were identified using logistic regression adjusted for covariables. Caregiver semistructured interviews were conducted to elicit perceptions on food accessibility and effects of and solutions for inpatient FI.

RESULTS

The prevalence of inpatient FI was 43%. Household FI was present in 38% of families. Inpatient FI was associated with household FI (P < .01). In multivariable analysis, odds of inpatient FI were increased among caregivers with annual household income <$30,000 (adjusted odds ratio [aOR] 2.14), public transportation use (aOR 6.33), living >30 miles from the hospital (aOR 2.80), self-rated fair/poor health (aOR 3.31), maternity leave (aOR 4.75), and past/current Supplemental Nutrition Assistance Program benefit utilization (aOR 2.52). Qualitative analysis identified barriers to food access, such as lack of affordable options, and found that caregivers made sacrifices for their hospitalized child, including skipping meals. Caregivers viewed their presence at their child's bedside and personal nourishment as important factors affecting their child's care.

CONCLUSIONS

Inpatient FI may affect a significant proportion of hospitalized children's caregivers. Pediatric hospitals should ensure that caregivers have access to food in order to fully engage in their child's care.

The first step in an investigation of quantitative ultrasound as a technique for evaluating infant bone strength

This study's purpose is to evaluate whether bone speed of sound (SOS) data, a parameter of quantitative ultrasound, collected from an infant autopsy sample are comparable to data collected from healthy, living infants. We hypothesize that SOS values obtained from deceased term-born infants will fall within the normal range for healthy, living infants. The study sample consists of 351 deceased infants between the ages of 30 weeks gestation at birth to 1 year postnatal at the time of death receiving autopsies at the Harris County Institute of Forensic Sciences or Texas Children's Hospital in Houston, TX. Various multivariate and univariate statistics were used to examine the relationship between SOS and age, prematurity, and chronic illness. The results of an ANOVA comparing the study sample data to published data from healthy, living infants indicate the SOS data are comparable. Additionally, a MANOVA indicated significant differences in SOS related to prematurity (p = 0.001) and age (p < 0.001). Mean SOS was significantly greater among term-born infants (M = 3065.66, SD =165.05) than premature infants (M = 2969.71, SD =192.72). Age had a significant polynomial (cubic) relationship with SOS for both the premature and term groups (p < 0.001). Results suggest that bone from an infant autopsy sample is an appropriate surrogate to examine the relationship between SOS and determinants of bone strength. Therefore, future research will use this study sample to investigate the relationship between SOS and determinants of bone strength in infants.

Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines

New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.

Demystifying the Medical Literature

The published literature is not just the ongoing record of current medical and scientific knowledge; it is a record of the past and can give an eye toward future knowledge. Reading the published literature can give a view of the evolution of knowledge on a particular question, the growth of a discipline, the identification of new diseases, and the refinement of diagnostic tests. The reality is that most busy physicians read only the abstract of an article. The purpose of this article is to place published medical literature into a context and to provide some considerations for critically evaluating articles. This paper will provide historic background of evidence-based medicine and medical publications. Specific strategies for critical literature appraisal are highlights and pitfalls to avoid are outlined.

The Scope and Trends of Pediatric Hospitalizations in Texas, 2004-2010

OBJECTIVE

To examine demographics and trends of financial cost and prominent diseases/conditions resulting in inpatient hospitalizations for infants, children, and adolescents in Texas between 2004 and 2010.

METHODS

Longitudinal retrospective cross-sectional study using the Texas Hospital Inpatient Discharge Database, including all pediatric hospitalizations in the state of Texas, 2004 to 2010.

RESULTS

Texas has an average of 591 571 pediatric hospitalizations per year. Birth was the most common reason for hospitalization, representing 64% of all pediatric hospitalization annually in Texas. Respiratory illnesses were the most common discharge diagnosis for hospitalized children ages 1 month to 9 years and demonstrated a 2% decrease over the study period. The rate of hospitalizations for digestive conditions and childbirth also demonstrated a decrease over this time frame: 4.7% and 3.0%, respectively. The rate of mental illness diagnoses increased 2.5% over the time frame and represented the most common discharge diagnosis for children aged 10 to 14. Childbirth was the most common reason for hospitalization for adolescents aged 15 to 17 years. There was no increase in total cost of pediatric hospitalizations over the time period under study.

CONCLUSIONS

After birth, respiratory illnesses represent the most common reason for hospitalization for children (between 1 month and 10 years of age) in Texas. Mental health conditions and childbirth represent the most common reason for hospitalization for young adolescents (10-14 years) and older adolescents (15-17 years), respectively.

Novel classification system of rib fractures observed in infants

Rib fractures are considered highly suspicious for nonaccidental injury in the pediatric clinical literature; however, a rib fracture classification system has not been developed. As an aid and impetus for rib fracture research, we developed a concise schema for classifying rib fracture types and fracture location that is applicable to infants. The system defined four fracture types (sternal end, buckle, transverse, and oblique) and four regions of the rib (posterior, posterolateral, anterolateral, and anterior). It was applied to all rib fractures observed during 85 consecutive infant autopsies. Rib fractures were found in 24 (28%) of the cases. A total of 158 rib fractures were identified. The proposed schema was adequate to classify 153 (97%) of the observed fractures. The results indicate that the classification system is sufficiently robust to classify rib fractures typically observed in infants and should be used by researchers investigating infant rib fractures.

Practical surveillance of water quality in a low-resource setting: a pilot program

Diarrheal diseases represent a tremendous health burden in low-resource countries affecting child mortality. The main sources of diarrheal diseases are water source contamination and fecal-oral transmission. A major obstacle in disease control is the ability to identify and monitor water source quality for potential infectious contamination. We explore a technique for real-time surveillance of coliform bacteria contamination in water sources which is of modest cost and does not require electricity. Specifically, we used body heat as a source for thermal regulation in contrast to traditional incubation for the enumeration of coliforms on 3M petrifilm™ Escheriachia coli/coliform count plates. Our data support that the body heat incubation technique is a promising strategy for water source surveillance in low resource settings.

Presentations of thyroglossal duct cysts in adults

The thyroglossal duct cyst is the most common congenital neck mass, resulting from persistence and dilatation of remnants of an epithelial tract formed during migration of the thyroid during embryogenesis. Approximately 7% of the population has thyroglossal duct remnants. Although thyroglossal duct cysts generally present clinically in children, it is important to understand that the lesion can present in adults as well, sometimes much later in life. Incidental carcinoma of the thyroglossal duct cyst is rare, but is more likely to occur in adults than children. Between 1991 and 1998, 11 cases of thyroglossal duct cysts were seen in adult patients at Georgetown University Medical Center, including 2 cases containing papillary carcinoma. This report discusses their clinical presentations and management.

Microglandular hyperplasia of the cervix: a true "pill" lesion?

For many years, it has been assumed that microglandular hyperplasia (MGH) of the cervix occurs almost exclusively in women with endogenous (pregnancy) or exogenous (oral contraceptives) progestational stimulation, but this relationship has never been subjected to rigorous epidemiologic study. All available cases of MGH in our 1990 surgical pathology files were reviewed and clinical histories obtained. For each case of MGH, a control was chosen, consisting of a case in the same time frame of a woman of similar age who had undergone the same procedure (biopsy, conization, hysterectomy) for the same indication. A documented history of current oral contraception or pregnancy within the past 6 months was obtained in 57.9% (22 of 38) of the MGH cases and 47.4% (18 of 38) of the controls. This difference was not statistically significant by McNemar's test for paired data. The histologic features of the MGH lesions (lesion size, cytologic atypia, prominence of inflammation, and presence of solid component and of squamous metaplasia) were evaluated blindly without knowledge of the hormonal history. There were no statistically significant differences by the chi 2 test of association between cases with and without hormonal histories. This study provides no support for considering MGH or any of its constituent features. This study provides no support for considering MGH or any of its constituent features as causally related to oral contraception or other known hormonal perturbations.