Case of Accidental Trauma Resulting in Condylar Fractures in 3-Month-Old

While mandibular fractures represent the most common craniofacial injury in the pediatric population, craniofacial fractures in infants are rare. Diagnosis is challenging with nonspecific presenting symptoms and often limited radiographic imaging. We report a case of nondisplaced mandibular condylar head fractures in a 3-month-old patient as a result of a fall with impact onto the chin, with associated sublingual hematoma (Coleman's sign). Although the initially observed sole finding of sublingual hematoma raised concern for child physical abuse, detailed history, oral exam, and multidisciplinary review of radiologic records by pediatrics, otolaryngology, and child protection teams established the accidental trauma diagnosis. The patient was managed conservatively with normal resumption of feeding. Detailed history and multidisciplinary approach to the management of pediatric facial trauma are important in establishing diagnoses and management.

Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review

BACKGROUND

Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.

OBJECTIVE

This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample.

PARTICIPANTS AND SETTING

Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions.

METHODS

Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses.

RESULTS

For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001).

CONCLUSIONS

A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.

Nationwide efforts for trauma-informed care implementation and workforce development in healthcare and related fields: a systematic review

There is building evidence that Adverse Childhood Experiences without early and proper intervention leads to subsequent short- and long-term behavioral, social, physical and mental health problems. Practitioners, researchers, and healthcare systems have been implementing trauma-informed care (TIC) in a variety of health and human services settings, resulting in improvements in clinical care and prevention of illness by identifying high risk populations. This has led to positive health outcomes including improved compliance, better access to mental health services and reduced health care costs. A systematic review was conducted of studies that focused on TIC implementation in healthcare settings, statewide TIC implementation, impact of adverse childhood experiences on health outcomes, impact of TIC on health outcomes, and evaluation of TIC implementation. A search was conducted in March 2019 to identify studies in PubMed, Medline, and other online literature. We limited our search to articles published in English after 2000. This article aims to review the components of TIC phases of implementation in healthcare settings, success stories across the nation to help the readers understand the importance of a paradigm shift to improve healthcare delivery and health outcomes and to prevent illness starting from childhood with a family centered care perspective.

Trends, Diagnoses, and Hospitalization Costs of Child Abuse and Neglect in the United States of America

We conducted a secondary analysis of the National Inpatient Sample (NIS) to examine child abuse and neglect hospitalization from 1998-2016. The NIS is the largest all-payer, inpatient care database in the United States and is maintained by the Health Care Utilization Project. Participants were youth 18 years and younger with discharged diagnoses of child abuse and neglect from hospitals. The rate of child abuse or neglect hospitalizations did not vary significantly over the study period (1998-2016), which on average was 6.9 per 100,000 children annually. Males (53.0%), infants (age < 1; 47.3%), and young children (age 1-3; 24.2%) comprised most of the child maltreatment cases. Physical abuse was the most frequent type of maltreatment leading to hospitalization. Government insurance was the most common payer source, accounting for 77.3% of all child maltreatment hospitalizations and costing 1.4 billion dollars from 2001-2016. Hospitalizations due to child abuse and neglect remain steady and are costly, averaging over $116 million per year. The burden on government sources suggests a high potential for return on investment in effective child abuse prevention strategies.

The burden of adverse childhood experiences in children and those of their parents in a burn population

OBJECTIVE

To determine the prevalence, type, and associations of parental and child adverse childhood experiences (ACEs) in children presenting with burn injuries.

METHODS

Parents of burned children completed an ACE-18 survey, including questions on parent and child ACEs, needs, and resiliency. Demographics, burn injury, hospital course, and follow up data were collected. Family needs and burn outcomes of children with and without ACEs' exposure (NO ACE vs. 1-2 ACE vs ≥ 3 ACE) was analyzed. P < 0.05 was considered significant.

RESULTS

Seventy-five children were enrolled; 58.7% were male, 69.3% white. The average age was 6.0 ± 5.2 years. The average total burn surface area was 4.4 ± 5.7% (0.1 to 27%). Parent ACE exposure correlated with child ACE exposure (r = 0.57; p = 0.001) and this intensified by increasing child age (p = 0.004). Child ACE exposure showed a graded response to family needs, including food and housing insecurity and childcare needs. Stress and psychosocial distress of the parents was significantly associated with their children's ACE burden.

CONCLUSIONS

The ACE burden of parents of burned children can affect the ACE load of their children. Burned children with more ACEs tend to have significantly more needs and more family distress. Awareness of past trauma can help identify a vulnerable population to ensure successful burn recovery.

A national educational campaign to raise awareness of child physical abuse among health care professionals

Education is necessary to improve child physical abuse detection and management. A few studies have described national child abuse training programs, but none has measured changes in knowledge among participants. A collaboration of child abuse experts from the USA, an academic pediatric department, and a non-governmental organization in child protection aimed at (a) training hospital physicians in a train-the-trainer course for the detection and management of child physical abuse and (b) conducting workshops and measuring attendance and gain of knowledge of participants. A train-the-trainer and a national curriculum were created. A 78-item and a 20-item knowledge questionnaire were used pre and post the train-the-trainer course and all workshops, respectively. Nineteen physicians from all pediatric departments of the seven medical schools in Greece attended the course. Eight workshops in seven cities took place with a total attendance of 1220 health care professionals. Gain of knowledge was demonstrated for participants in the train-the-trainer course (p = 0.0015) and local workshops (p < 0.001).Conclusion: We successfully engaged physicians from all medical schools in Greece and conducted a train-the-trainer module and eight workshops in major cities that improved the participants' knowledge in child physical abuse. This approach may help address physician deficiencies in emerging areas of child abuse clinical practice. What is Known: • Education is necessary to improve child physical abuse detection and management. • Although national training programs have been described, none has measured participants' changes in knowledge. What is New: • A collaboration of child abuse experts, all medical schools in Greece, and a non-governmental organization resulted in a national educational campaign in child physical abuse and gains in knowledge for participants. • This approach may help address deficiencies in emerging areas of clinical practice.

The Impact of Adverse Childhood Experiences on Burn Outcomes in Adult Burn Patients

Adverse childhood experiences (ACEs), including child maltreatment and household dysfunction, define adverse events that occur before 18 years of age. National and state data show that between 12.5 and 14.5% of the adult population report ≥4 ACEs (HIGH-ACE), respectively. HIGH-ACEs are associated with more chronic health problems. To date, the interaction between ACEs and burn injuries has not been studied. Herein, we sought to define the ACE exposure in our burn patients and its impact on early outcomes. Inpatient and outpatient adult burn survivors (≥18 years of age) were enrolled. Subjects completed surveys assessing adverse experiences (ACEs-18), needs, strengths, and resiliency at consent, and pain, depression, post-traumatic stress disorder (PTSD), and social participation surveys at 2 weeks to 3 months postinjury. Demographics, burn, and hospital course data were also collected. Chi-square and student's t-tests were used for descriptive analysis and to compare the groups (HIGH-ACE vs LOW-ACE). The HIGH-ACE group (n = 24; 45.3%) reported more depressive symptoms (P < .04) than the LOW-ACE group (n = 29, 54.7%). HIGH-ACE patients were less resilient when facing stressful events (P ≤ .02) and more likely to screen positive for probable PTSD (P = .01) and to score lower on the Life Impact Burn Recovery Evaluation Profile (LIBRE Profile), which assesses for social participation, in the domain of Family and Friends (P = .015). Our exploratory study suggests that ACE screening may help detect burn patients at risk for a more complicated recovery, thereby promoting personalized assistance in recovery.

Two-generational trauma-informed assessment improves documentation and service referral frequency in a child protection program

BACKGROUND

Two-generational trauma-informed assessment (TIA) helps providers conduct holistic family well-being assessment (FWbA). This tool makes it possible to use families' trauma history in the case-finding process.

OBJECTIVE

This study compares the documentation and frequency of adverse childhood experiences (ACEs) and service referral rates for index children and their caretakers in two groups of families evaluated in a child abuse clinic (CAC).

PARTICIPANTS AND SETTING

The sample consisted of 364 children stratified into two groups: Group 1 - children seen in the CAC after implementation of FWbA in years 2014, 2015, 2016 and Group 2 - children seen in the CAC prior to implementation of FWbA in years 2011, 2012, 2013.

METHODS

Researchers utilized retrospective chart review method and analyzed data regarding ACEs and service referrals for patients and their caregivers.

RESULTS

Documentation of ACEs was higher in Group 1 for children (77.7 % vs 26.6 %,p <  0.0001) and caretakers (60.7 % vs 7.3 % p <  0.0001). Caretakers in Group 1 had a higher rate of four or more ACEs (47.0 % vs 5.1 % p <  0.001) while the increase for children was not statistically significant (61.4 % vs 51.1 %, p =  0.110). Both children and caretakers were referred to more services in Group 1 (2.7 + 1.5 vs 1.5 + 1.3, and 3.0 + 1.9 vs 1.2 + 1.2, respectively, p <  0.0001).

CONCLUSIONS

In families evaluated for child abuse and neglect, conducting TIA in addition to conventional psychosocial evaluation increased documentation regarding trauma history, which led to increased referral rates.

Statement of the Independent Forensic Expert Group on Conversion Therapy

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Child abuse and neglect experts' determination of when a child being left home alone constitutes child neglect

Background

Only 14 states have laws or guidelines regarding the minimum age a child may be left home alone. These ages range from 6 to 14 years. Our objective was to identify factors that influence child neglect determination by experts with regards to parents leaving children home alone.

Methods

American Academy of Pediatrics Section on Child Abuse and Neglect members (N = 523) were surveyed from July–August, 2015. Respondents were asked whether scenarios involving a child of varying age knowingly left home alone for 4 h were neglect in the presence or absence of injury to the child and the legality of the situation. Comparisons were performed using the chi-square test.

Results

One hundred ninety-three members responded (36.9%). In the scenario where there were no relevant laws and the child was uninjured, nearly 100% of the child experts determined this as being child neglect when the child was 6 years old. For 8, 10, 12, and 14 year olds, this was 88, 48, 4, and 1%, respectively. However, a significantly higher percentage of experts considered it child neglect for most ages when there was a law making the scenario illegal as compared when there was no law, and when the child was injured versus when they were not. The only demographic variable that showed a difference in child neglect determination was that females were more likely to consider higher aged children as having been neglected when there were no laws but the child was injured. The vast majority of experts (85%) stated that leaving a child home alone for 4 h should be illegal if the child is < 9 years old, and nearly one-half (44%) said it should be illegal for children < 11 years old.

Conclusions

A number of factors affect how experts view children being left home alone as potential child neglect. Our data suggests that such cases may be evaluated differently due to variations in state laws, even though the risk to the child is the same. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and better protect the safety of children.

Measuring awareness about child abuse and neglect: Validity and reliability of a newly developed tool-child abuse and neglect awareness scale

Altan H, Budakoğlu Iİ, Şahin-Dağlı F, Oral R. Measuring awareness about child abuse and neglect: Validity and reliability of a newly developed tool-child abuse and neglect awareness scale. Turk J Pediatr 2018; 60: 392-399. In this study, we aimed at determining child abuse and neglect awareness of medical students attending one of the top medical schools in Turkey. The study group comprised 350 third-year medical students at Gazi University, School of Medicine, Ankara. The items in the scale were prepared by two experienced pediatricians and revised according to feedback received from two pilot studies and experts in this field of study. A 20-item `Child Abuse and Neglect Awareness` scale (CANA-S) was developed by an expert panel. Exploratory and confirmatory factor analyses were performed. We also measured test-retest reliability and internal consistency. Conformity for factor analysis of the scale`s construct validity revealed a Kaiser-Meyer-Olkin sample concordance coefficient of 0.799. For the Bartlett Sphericity test, χ2 value was 1157.750 (p < 0.01). Based on these analyses, the scale explains 44.9% of the total variance and consists of 20 items and 4 subscales. Cronbach`s alpha value and correlation coefficient were 0.768 and r=0.204 (p=0.045), respectively. This scale is a valid and reliable measurement tool for evaluating awareness about child abuse and neglect among the medical students.

Adverse childhood experiences and trauma informed care: the future of health care

Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.

Quantitative measurement of retinal hemorrhages in suspected victims of child abuse

PURPOSE

Child abuse is one of the leading causes of death in early childhood. The presence of retinal hemorrhages often supports the diagnosis. The purpose of this study was to determine whether the specific measurement of retinal hemorrhages when present on fundus photography correlates with other clinical findings typically seen in children suspected of having been abused.

METHODS

The medical records of children with retinal hemorrhages who were suspected of being victims of abusive head trauma from June 2003 to June 2013 and who had widefield retinal photography performed were retrospectively reviewed. Data collected included hemorrhage-covered percentage (HCP) of the central retina (posterior pole or 40° circle centered on fovea) measured by ImageJ in relation to death, length of hospital stay, presence of abnormal findings on neuroimaging or skeletal survey, and definite versus possible abuse.

RESULTS

Significant difference in retinal hemorrhage measured on fundus photography was found in patients with axial skeletal fracture (P = 0.016), signs of severe brain trauma on neuroimaging (P = 0.014) and definite versus possible abuse (P = 0.023). No correlation of quantitative measurement of the retinal hemorrhage to length of hospital stay, death, or the presence of skull fracture was found in this cohort.

CONCLUSIONS

The quantitative measurement of total retinal hemorrhage when present on fundus photography centered on posterior pole in children suspected of having been abused correlated with some but not all findings typically seen in abused children.

Missed cases of multiple forms of child abuse and neglect

Child abuse and neglect is a public health problem and usually associated with family dysfunction due to multiple psychosocial, individual, and environmental factors. The diagnosis of child abuse may be difficult and require a high index of suspicion on the part of the practitioners encountering the child and the family. System-related factors may also enable abuse or prevent the early recognition of abuse. Child abuse and neglect that goes undiagnosed may give rise to chronic abuse and increased morbidity-mortality. In this report, we present two siblings who missed early diagnosis and we emphasize the importance of systems issues to allow early recognition of child abuse and neglect.

Retinal hemorrhages in intubated pediatric intensive care patients

PURPOSE

To define the diagnoses associated with the presence of retinal hemorrhages, to clarify the association between retinal hemorrhages, cardiopulmonary resuscitation (CPR), and coagulopathy, and to describe the type of retinal hemorrhages found in intubated critically ill patients <4 years of age.

METHODS

This was a prospective observational study of intubated patients <4 years of age admitted to the pediatric intensive care unit of a tertiary care center from March 2010 to May 2012. The presence and description of retinal hemorrhages was recorded along with diagnoses, international normalized ratio (INR), CPR (in minutes), and mortality.

RESULTS

A total of 85 intubated, critically ill patients (37 females) were included; average patient age was 8.2 months (range, 0.1-46.8 months). Of the 85 patients, 6 (7%) had retinal hemorrhages (95% CI, 0.029-0.153). Of the 6 patients with RH, abusive head trauma (AHT) was diagnosed in 4 patients, 1 patient had direct head trauma, and 1 had CPR. There were 8 patients with CPR out of the 85. AHT was highly associated with severe multilayered retinal hemorrhages (P = 0.0001) but coagulopathy (P = 0.2671) and CPR (P = 0.5342) were not.

CONCLUSIONS

Severe multilayered retinal hemorrhages were associated with AHT in this cohort of patients. Without a history of trauma, retinal hemorrhages occurred in only 1 of 85 patients; in this case the hemorrhages were mild, confined to the posterior pole, and found only in the retinal layer.

Epidemiological study of negative childhood experiences in three provinces of Turkey

AIM

This study aimed to determine the frequencies of negative childhood experiences in the past years and negative childhood experiences throughout life in 11, 13 and 16 year-age group children who attended school in three separate provinces.

MATERIAL AND METHODS

Approval was obtained from the provincial National Education Directorates and educated investigators applied the ISPCAN child abuse screening tool questionnaire form which measures negative childhood events experienced at home in children. Statistical analysis was performed with chi-square test using SPSS 16.0 program. Approval from the ethics committee was obtained from İzmir Tepecik Education and Research Hospital Chief Physician Office Local Ethics Committee (29/11/2011-29).

RESULTS

The study was conducted with 7 540 children in İzmir, Denizli and Zonguldak. The frequency of psychological and physical negative childhood experiences and neglect throughout life was found to be 70.5%, 58.3% and 42.6% in the 11, 13 and 16-year age groups, respectively; the frequencies in the last one year was found to be 62.7%, 46.0% and 37.5%, respectively. Psychological negative childhood experiences were found with a higher rate in children who lived in urban areas compared to children who lived in rural areas. Neglect was found with a higher rate in girls and physical negative childhood experiences were found with a higher rate in boys. The frequency of negative childhood experiences increased proportionally with the age of the child independent of the type of experience.

CONCLUSION

The frequencies of negative childhood experiences for the last one year and for the life-long period were determined using ISPCAN child abuse screening tool in Turkey for the first time in three provinces and in such a large population. The frequency of negative childhood experiences related with child abuse and neglect screened were found to be 42%-70% and it was elucidated that we are confronted with a very significant public health problem and adult health risk in these regions of Turkey.

Child abuse and neglect in Turkey: professional, governmental and non-governmental achievements in improving the national child protection system

Since ratification of the United Nations Convention on the Rights of the Child in 1995, significant efforts were made in Turkey to improve protection of children from abuse and neglect. The government took steps to amend relevant laws. Several state departments recognized the need for professional in-service training of relevant governmental agency staff. University hospitals established numerous hospital-based multidisciplinary child protection centres. The government established an Interministerial Higher Council, which has been overseeing the foundation of 13 child advocacy centres for a multidisciplinary and interagency response to child sexual abuse. In addition to undertaking research, non-governmental organizations contributed to this process by instituting professional and public education. These ground-breaking developments in the last decade give promise of even further improvement in the national child protection system from investigative, child protective and rehabilitative perspectives.

Abusive head trauma: report of 3 cases

Abusive head trauma (AHT) is perpetrated when an infant or young child is shaken violently by an abuser, resulting in injuries to various intracranial structures, historically called "shaken baby syndrome" (SBS). Three cases of AHT with different constellations of clinical symptoms are presented here. Case 1- Three-month-old female infant was admitted with recurrent seizures, drowsiness, and low grade fever. Ophthalmologic examination revealed retinal hemorrhages (RH) in the left eye. Computed tomography of cranium showed left frontal intra-parenchymal subdural hematoma (SDH). Case 2- Twelve-month-old male infant was admitted with a history of favoring left leg. Ophthalmologic examination revealed RH in the right eye. Cranial magnetic resonance imaging (MRI) revealed subacute SDH in the right frontoparietal region. Case 3- Three-month-old male infant was admitted with irritability and seizures. Ophthalmologic examination revealed bilateral disseminated RH. Cranial MRI scan showed bilateral frontoparietal subacute SDH. All cases were reported to Child Protective Services, who decided not to remove children from homes, but evaluated psychosocial risks and developed a safety plan, including home visits and family education. Physicians must be aware of possibility of AHT in infants presenting both subtle and overt neurologic symptoms. It is important to provide training on AHT to staff involved in the management of these cases.

Pediatric condition falsification (Munchausen syndrome by Proxy) as a continuum of maternal factitious disorder (Munchausen syndrome)

Pediatric condition falsification (PCF), also known as Munchausen syndrome by Proxy or Medical Child Abuse, is a somewhat rare form of child abuse and neglect. Its association with a history of adult factitious disorder (AFD) or Munchausen syndrome in the perpetrator is also well known. Exogenous insulin injection to cause hypoglycemia both in the context of PCF and AFD has been reported in the literature. However, the coexistence of both conditions via insulin injection in the same family has not been reported in the literature. This paper presents a family, in which the mother was diagnosed with AFD and her three children with PCF perpetrated by their mother via exogenous insulin injection.

Six-year experience of a hospital-based child protection team in Turkey

The objective of this article was to review the case series' profile followed up by the Gazi University Multidisciplinary Team for Child Protection and to describe the challenges in our child protection system. The cases referred to this team between February 2001 and January 2007 were analyzed. In addition to the clinical management, challenges encountered during follow-up due to gaps in the child protection system were reviewed. A total of 139 patients were referred to the team during the study period. Mean age for physical abuse, sexual abuse, and neglect were 8.9 +/- 6.2, 10.8 +/- 4.2, and 5.1 +/- 5.5 years, respectively. Sexual abuse was significantly less common while neglect was significantly more common in the 0-5 years of age group. In addition to the gaps within each link of the child protection system (medical, legal and social services) in Turkey, interagency collaboration seems to be inadequate. Hospital-based multidisciplinary teams can start such a collaboration.

Establishment of interdisciplinary child protection teams in Turkey 2002-2006: identifying the strongest link can make a difference!

OBJECTIVES

The University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome.

METHODS

A team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software.

RESULTS

Eighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period.

CONCLUSIONS

A culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear.

PRACTICE IMPLICATIONS

Pioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

Characteristics of household falls in children under 2 years of age

We hypothesized that young children uncommonly acquire significant injuries due to household falls that necessitate medical attention. Data on recalled fall experiences were collected from parents of children younger than two years visiting the University Pediatrics Clinic. Statistical analysis was performed using Student's t test and chi square test. Of 573 children, 36% experienced no falls, while 64% experienced 782 falls. Eleven percent of falls occurred from a distance of three to five feet (approximately 90-150 cm). In 6% of all falls, medical care was sought. In 40% of this subcategory, examination was normal; in 33%, medical work-up revealed normal results; in 23%, injuries necessitated subsequent intervention. No fall led to neurological findings. This study supports that it is uncommon for household falls to cause injuries significant enough to require professional medical care. Even falls from a distance of greater than three feet result in only mild injury with no neurological findings.

The effects of nonylphenol and octylphenol on embryonic development of sea urchin (Paracentrotus lividus)

In this study, embryotoxic and genotoxic effects of nonylphenol (NP) and octylphenol (OP), which are the derivates of alkylphenol (APs), were evaluated using the gametes and embryos of the sea urchin Paracentrotus lividus. The sperm and eggs of sea urchins were exposed to increasing concentrations of NP (0.937-18.74 microg/L) and OP (5-160 microg/L) under static conditions. The endpoints were sperm fertilization success, quantitative and morphologic changes in mitotic activity, larval malformations, developmental arrest, and embryonic/larval mortality. A dose-response-related reduction (approximately 20%) was observed in fertilization success and significant increases in the number of larvae with skeleton malformations at the pluteus stage of the contaminated sperms. The spermiotoxic and embryotoxic concentrations were determined as 0.937 microg/L for NP and 4.685 microg/L for OP for this species. The embryotoxicity of NP and OP is concentration dependent, and significant growth reduction at the early life stages and an increase in larval malformations as skeleton deformities at the pluteus stage were observed. Cytogenetic analysis of embryos showed a decreasing curve in mitotic indexes (number of mitosis per embryo) with increasing concentrations of NP and OP. It can be concluded that NP and OP adversely affect the reproduction and embryonic developmental stages of the P. lividus and this is of great ecological importance because of the hazard at the population level.

Neonatal illicit drug screening practices in Iowa: the impact of utilization of a structured screening protocol

OBJECTIVE

The purpose of the study was to determine the neonatal illicit drug screening practices of Iowa birthing hospitals.

STUDY DESIGN

Cross-sectional survey design was implemented. The impact of structured screening protocols on the numbers of neonates screened and positive testing in 2004 was reviewed.

RESULTS

Of 81 birthing hospitals, 53 (65%) participated in the study. Screening and positive test rates were higher in hospitals utilizing a structured screening protocol compared to those not utilizing one (10.9 versus 2.1% and 0.9 versus 0.2%, respectively, P < 0.0001). Hospitals with higher population, numbers of outpatients, inpatients, deliveries, and availability of drug abuse treatment services utilized a structured screening protocol more often.

CONCLUSION

Utilization of a structured screening protocol increases the number of neonates screened for illicit drugs and positive testing rate regardless of urbanization. Regional standardization of structured screening protocols may improve the recognition of perinatal illicit drug exposure and provision of treatment services.

Intentional avulsion fracture of the second cervical vertebra in a hypotonic child

Children uncommonly present with cervical fractures due to high-impact injuries. A 4-year-old child with developmental delay and chronic hypotonia presented to the hospital with acute onset of irritability and transient difficulty in walking. Lateral neck x-rays showed avulsion fracture of the second cervical vertebra. Neck magnetic resonance imaging study showed injury to the interspinal ligaments between the first and second cervical vertebrae in addition to confirming the acute avulsion fracture of C-2. The child was injured after he was thrown onto a bed from a distance of 1 to 2 ft according to his babysitter's admission. This is the first reported pediatric case presenting this type of inflicted fracture in a hypotonic child, although hypotonia may not have played a causal role.

Level of knowledge and attitude of primary care physicians in Eastern Anatolian cities in relation to child abuse and neglect

BACKGROUND

Child abuse and neglect is not a new phenomenon. It has always existed in every nation and culture in one form or another. The aim of this study was to determine the level of knowledge and attitude toward child abuse and neglect of primary care physicians serving in eastern Turkish cities.

METHODS

The study was done in four Eastern Turkish cities involving Elazig, Tunceli, Malatya, and Bingol. All the primary care physicians serving in these cities were contacted. Of 266 primary care physicians, 175 replied (65.8% reply rate) and participated in the study.

RESULTS

Most of the participated primary care physicians did not have adequate knowledge about physical assessment of suspected child abuse and neglect. Those physicians serving in primary care centers had better knowledge than those serving in Mother-Child Health and Family Planning Centers.

CONCLUSIONS

Results from this study indicate that primary care physicians working in the eastern cities of Turkey do not have adequate knowledge and proper attitudes toward the identification and reporting of suspected child abuse. There is a need for educational programs to primary care physicians and other health personals working with child abuse and neglect to increase their knowledge and skills in detection, assessment, reporting, treatment, and prevention of child abuse and neglect.

Trans-metatarsal amputation as a complication of child sexual abuse

A case of chronic physical abuse and acute sexual abuse via anal penetration complicated with disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and subsequent bilateral trans-metatarsal amputation is reported. A 13-year-old male presented with old cigarette burns on his chest and acute anal laceration. Four days after laceration repair, he developed DIC and ARDS. The child had to undergo bilateral trans-metatarsal amputation. Due to the systemic defects of the child protection system in Turkey, sexual and physical abuse were recognized by medical personnel 45 days after admission, child protective services never got involved, and prosecution failed to punish the perpetrator(s) of this extreme victimization. This is the only reported case of bilateral trans-metatarsal amputation due to sexual abuse complicated with DIC and ARDS. Social and medico-legal management of sexual abuse is suboptimal in Turkey. Within that context, professionals should be trained on how to recognize, assess, diagnose and manage victims of child abuse and neglect.

Hormetic versus toxic effects of vegetable tannin in a multitest study

Tannin from mimosa trees (Acacia sp.) utilized in traditional leather tanning was tested for toxicity in sea urchin (Sphaerechinus granularis and Paracentrotus lividus) embryos and sperm, marine, and freshwater algae (Selenastrum capricornutum and Dunaliella tertiolecta), and Daphnia magna. Based on a two-step tanning procedure used in traditional tanneries, two mimosa tannin preparations, i.e., fresh tannin (FT) and used tannin (UT), were tested as suspensions. The early results in S. granularis embryos showed that UT exerted lower acute toxicity than FT, namely, 1 vs 100 mg/L, to obtain 100% mortality, respectively. Subsequent bioassays were conducted on fresh tannin water extracts (TWE) corresponding to nominal tannin concentrations ranging from 0.1 to 30 mg/L. Developmental toxicity, up to embryonic mortality was exerted by TWE at levels > 1 mg/L, S. granularis being more sensitive than P. lividus embryos/larvae. At the concentration of 0.1 mg/L, the frequencies of larval malformations were significantly lower than in controls. This positive stimulatory effect (currently termed as hormesis) was observed in extended numbers of culture replicates (up to 14) and was significant in the embryo cultures characterized by a relatively poor control quality (with < 70% viable larvae in controls), whereas this effect was not observed in good-quality cultures (with > or = 70% viable larvae in controls). Cytogenetic analysis of S. granularis embryos reared in FT or UT suspensions (1 mg/L to 1 g/L) showed mitotoxic effects (decrease in active mitoses per embryo) in FT-exposed, but not in UT-exposed embryos. Mitotic aberrations were significantly increased by 10 mg/L UT. Sperm fertilization success in both sea urchin species showed an increasing fertilization rate (FR) up to 0.3 mg/L TWE and a dose-related decrease in FR up to 30 mg/L. Again, the offspring of P. lividus sperm exposed to TWE (0.1 and 0.3 mg/L) showed a decrease in larval malformations compared to controls, whereas a dose-related increase in developmental defects was observed in the offspring of P. lividus sperm exposed to higher TWE levels (1 to 30 mg/L). Algal cell growth bioassays in two species (S. capricornutum and D. tertiolecta) also showed a maximum growth at TWE levels ranging from 0.3 to 3 mg/L and a subsequent decline up to 30 mg/L TWE. D. magna bioassays resulted in daphnid immobilization by TWE concentrations ranging from 100 to 300 mg/L. The results demonstrate that tannins utilized in traditional leather tanning industry may raise concern of environmental damage at relatively high concentrations, whereas low-level tannins may result in hormetic effects. The present study also points to the need for bioassay design that should rely on adequate criteria in control quality, allowing to detect both inhibitory and hormetic effects.

Fractures in young children: are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse?

OBJECTIVES

1) To determine whether physicians are sufficiently investigating the cause of fractures in children younger than 3 years and 2) to find out what influences physicians' quality of history taking and documentation necessary to rule out inflicted trauma.

DESIGN

Descriptive, retrospective chart review.

SETTING

Pediatric emergency department and orthopedic clinic of an urban teaching hospital.

SUBJECTS

Children younger than 3 years treated between January 1, 1995, and December 31, 1998, presenting with a fracture.

RESULTS

A total of 653 charts met entry criteria. Information that was significantly lacking in the recorded history included witness presence, history of previous injury, review of past medical record, other injury description, and whether the injury was consistent with the development of the child. It was not possible to rule out inflicted injury in 42% of the patients. Four groups emerged from the entire cohort: group 1, accidental trauma, which made up 63% of the entire group (n = 413); group 2, inflicted trauma, which made up 13% (n = 85); group 3, missed inflicted trauma, which made up 23% (n = 151); and group 4, missed accidental trauma, which made up 0.6% (n = 4). Younger age of the child, multiple fractures, need for hospital admission, and the examining physician being a pediatrician positively influenced physicians' propensity to accurately report inflicted trauma.

CONCLUSIONS

A large percentage of the charts reviewed contained inadequate documentation to explain the cause of fractures and thereby rule out inflicted trauma. Information in 23% of the charts reviewed aroused suspicion of inflicted trauma. There is a need to ensure that adequate information is obtained and documented in hospital records to rule out inflicted injury. This will require changes in the knowledge, skills, and attitudes of physicians. The use of forms, protocols, and periodic chart review will help to ensure compliance.

Factors affecting R6 fungicide toxicity on sea urchin fertilization and early development: roles of exposure routes and mixture components

A technical fungicide mixture, R6 and its components, cymoxanil (CYM) and cupric oxychloride (Cu-OCl), were tested by sea urchin bioassays (Paracentrotus lividus and Sphaerechinus granularis). A set of toxicity endpoints was evaluated including both lethal and sublethal effects with the following endpoints: (a) acute embryotoxicity, (b) developmental defects, (c) changes in sperm fertilization success, (d) transmissible damage from sperm to the offspring, and (e) cytogenetic abnormalities. Acute effects on developing embryos were observed as early (prehatch) mortality at R6 levels > or =25 microg/ml. The pesticide mixture R6 was tested at realistic concentrations, ranging from 25 ng/ ml to 2.5 microg/ml, and the two components, CYM and Cu-OCl, were tested, either alone or in mixture, at concentrations equal to their levels in the corresponding R6 solutions. R6 was either dissolved in filtered seawater (water only, W-O), or spiked in "pristine" silt-clay sediment or soil samples before bioassays. Developmental toxicity of R6, following W-O dissolution, displayed a significant dose-related increase of larval malformations and differentiation arrest at concentrations of 750 ng/ml to 2.5 microg/ml both in P. lividus and in S. granularis larvae. Developmental toxicity was removed in spiked sediment up to R6 nominal levels (25 microg/ml), 10-fold above the embryotoxic R6 levels in W-O exposure. No significant developmental toxicity was exerted by CYM or Cu-OCl (W-O exposure) up to their concentrations equivalent to 2.5 microg/ml R6. The laboratory-prepared mixture of CYM and Cu-OCl, in the same concentration range, only resulted in minor effects, as larval retardation, suggesting the presence of toxic impurities (or additional components) in the R6 formulation. When sperm from either P. lividus or S. granularis were exposed to R6 before fertilization, a W-O exposure resulted in a dose-related decrease in fertilization of P. lividus sperm (up to 250 microg/ml R6), whereas S. granularis sperm underwent a significant increase of fertilization rate at the highest R6 nominal levels (up to 25 microg/ml). Equivalent CYM or Cu-OCl levels were ineffective on sperm fertilization success in both species. The offspring of S. granularis sperm exposed to 25 microg/ml R6 showed a significant increase in larval malformations, which were not detected in the offspring of R6-exposed P. lividus sperm. Again, CYM or Cu-OCl was unable to exert any transmissible damage from sperm to the offspring in either species. The present study raises the case of possible discrepancies between toxicity of a technical mixture and of its analytical-grade components, also providing evidence for a loss of pesticide toxicity following dispersion in an environmental matrix such as sediment or soil.

The role of oxidative stress in developmental and reproductive toxicity of tamoxifen

The antiestrogen tamoxifen (TAM) is widely used as a drug against breast cancer and is currently being tested as a chemopreventive agent. However, a number of studies showed genotoxic and carcinogenic effects of TAM. These effects are thought to be related to oxygen radical overproduction which occurs during TAM metabolic activation. There is no evidence, thus far, on TAM toxicity to embryos and gametes. The present study was designed to elucidate the mechanisms of TAM-induced developmental, reproductive and cytogenetic toxicity towards sea urchin (SU) embryos with regard to the possibility of TAM-initiated oxidative stress. Embryo cultures from SU were subjected to long-term (throughout embryogenesis) or short-term (two hours) incubation with TAM at concentrations from 10(-8) to 10(-5) M. The experiments on TAM-induced toxicity to gametes were carried out with SU sperm, or unfertilized eggs, suspended in TAM (10(-8) to 10(-6) M). To assess the effects of TAM to embryos or to gametes, developmental defects, embryonic mortality, fertilization success, and cytogenetic abnormalities were scored. Oxidative damage to DNA and lipids was detected by measurements of 8OHdG levels and lipid peroxidation, respectively. Reactive oxygen species (ROS) production by eggs and embryos was recorded by luminol-dependent chemiluminescence (LDCL) and cytochrome c reduction methods. The changes in activities of SU superoxide dismutase (SOD) and catalase were also evaluated. TAM exerted: a) early embryonic mortality to exposed embryos and to the offspring of exposed eggs; b) developmental defects to the offspring of exposed sperm; c) decrease in sperm fertilization success, and d) cytogenetic effects in the offspring of exposed sperm or eggs. These morphological effects corresponded to the state of oxidative stress in SU embryos (increased oxidative damage to DNA and lipids and induction of antioxidant enzymes). Since TAM did increase significantly ROS production by embryos, it is suggested that TAM may be metabolically activated by SU embryonic oxidases and peroxidases, which in turn could be induced by TAM. The present study provides further support to the utilization of the SU system as a useful model to help elucidate mechanisms of chemical teratogenesis and carcinogenesis.

Child abuse in Turkey: an experience in overcoming denial and a description of 50 cases

OBJECTIVE

To share the experiences of the first clinical multidisciplinary child abuse and neglect (CAN) team in Turkey with international child abuse community.

METHODS

The authors established the first Turkish CAN follow-up team at Dr. Behcet Uz Children's Hospital. Following a training program in five teaching hospitals in Izmir, the authors kept a record of every case diagnosed with CAN from these hospitals between 1996 and 1998. The demographic, epidemiologic, and medical features of this case series are summarized.

RESULTS

Fifty cases were diagnosed and followed-up. Seventy-six percent of patients were reported from Dr. Behcet Uz Children's Hospital. Age and sex distribution was 9.2 +/- 6.7 years and 46% male, 54% female, respectively. The offenders were only father in 38%, only mother in 28%, and multiple in 34%. More than three CAN risk factors were present in 94%. Of the children reported 44% survived, 14% died, and 42% were lost to follow-up. Sixteen percent were free of reabuse, and 42% survived with handicaps.

CONCLUSIONS

Child abuse and neglect is a reality in Turkey. The team's work increased pediatricians' awareness of CAN. Reporting these cases to Social Affairs Bureau was established for the first time in Turkey. Physicians in Turkey need training to diagnose and properly report CAN. The implemen tation of a national CAN prevention program is an urgent need for Turkey.

Diaper burn: accident, abuse, or neglect

A 7-year-old, female with mental retardation and seizure disorder was admitted with burns. Reportedly, her brother who was 12 years old was cooking dinner for himself. A towel caught fire. He threw the towel over his head, and the patient's diaper ignited. She had partial thickness second-degree burns over her right elbow, upper abdomen, both inner thighs, and buttocks with multiple blistering, which was estimated to be 7% of the total body surface. The child abuse team took a diaper similar to the one the child was wearing at the time of injury and found that it easily ignited and melted in several seconds. This is the first medically reported burn case due to a disposable diaper.

Redox-dependent toxicity of diepoxybutane and mitomycin C in sea urchin embryogenesis

The effects and mechanisms of action of diepoxybutane (DEB) and mitomycin C (MMC) were investigated on sea urchin embryogenesis, (Sphaerechinus granularis and Paracentrotus lividus). DEB- and MMC-induced toxicity was evaluated by means of selected end-points, including developmental defects, cytogenetic abnormalities and alterations in the redox status [oxygen-dependent toxicity, Mn-superoxide dismutase (MnSOD) and catalase activities and glutathione (GSH) levels]. Both DEB and MMC exhibited developmental toxicity (at concentrations ranging from 3 x 10(-5) to 3 x 10(-4) M and 3 x 10(-6) to 3 x 10(-5) M, respectively) expressed as larval abnormalities, developmental arrest and mortality. The developmental effects of both compounds were significantly affected by oxygen at levels ranging from 5 to 40%. These results confirmed previous evidence for oxygen-dependent MMC toxicity and are the first report of oxygen dependence for DEB toxicity. Both DEB and MMC exerted significant cytogenetic abnormalities, including mitotoxicity and mitotic aberrations, but with different trends between the two chemicals, at the same concentrations as exerted developmental toxicity. The formation of reactive oxygen species was evaluated using: (i) luminol-dependent chemiluminescence (LDCL); (ii) reactions of the main antioxidant systems, such as GSH content and MnSOD and catalase activities. The results point to clear-cut differences in the effects induced by DEB and MMC. Thus, DEB suppressed GSH content within the concentration range 10(-7)-3 x 10(-5) M. The activity of catalase was stimulated at lower DEB levels (10(-7)-10(-6) M) and then decreased at higher DEB concentrations (> or =10(-5) M). Increasing MMC concentrations induced LDCL and MnSOD activity (> or =10(-6) M) greatly and modulated catalase activity (10(-7) - 10(-6) M). GSH levels were unaffected by MMC. The results suggest that oxidative stress contributes to the developmental and genotoxic effects of both toxins studied, although through different mechanisms.

Serum lipid and lipoprotein composition in infants of diabetic mothers

Diabetes mellitus (DM) alters carbohydrate and lipid metabolism to a great extent. This study was planned to determine whether infants of insulin dependent and gestational diabetic mothers have abnormal lipid metabolism. Three groups of newborns were included in the study; group I consisted of 7 infants of diabetic mothers (IDM) with insulin dependent DM (Type 1 DM), group II of 18 infants of gestational diabetic mothers and group III of 20 control neonates whose mothers had no history of DM. Total cholesterol (TC), triglyceride (TG) and high density lipoprotein-cholesterol (HDL-C) values in groups I and II were no different compared to those in group III (p > 0.05). However, low density lipoprotein-cholesterol (LDL-C) and LDL-C/HDL-C ratio were similar between groups I and II (p > 0.05) but significantly higher in both infants of type 1 diabetic mothers and gestational diabetic mothers compared to control infants (p < 0.05). Apolipoprotein A-I (Apo A-1) and apolipoprotein B (Apo B) levels, Apo A-I/Apo B and HDL-C/Apo A-I ratios were similar in between groups. However, Apo B/LDL-C ratio was significantly lower in groups I and II compared to control group (p < 0.05). In conclusion, diabetes in pregnant women causes a tendency to LDL hypercholesterolemia in the offspring. These infants should be longitudinally followed up to assess whether this observation imposes an increased risk for atherosclerosis for advanced ages.

A multicenter child maltreatment study: twenty-eight cases followed-up on a multidisciplinary basis

Twenty-eight maltreated cases were presented in this multicenter study. Hospital distribution was as follows: Dr. Behçet Uz Children's Hospital, 54 percent; Dokuz Eylül University Hospital, 21 percent; Ege University Hospital, 14 percent; Tepecik Social Security Hospital, 7 percent; Atatürk State Hospital, 4 percent. Age and sex distribution was two months to 25 years and 43 percent male, 57 percent female. The offender was the father in 71 percent, the mother in 32 percent and multiple in 25 percent of the cases. More than three child maltreatment risk factors were present in 93 percent. Nineteen patients (68%), nine of which were effectively followed-up were reported to the Social Affairs Bureau. Sixty-four percent gained acceptable health with the support of our team, 14 percent died, and 21 percent failed to comply with follow-up. A multidisciplinary group may interfere both medically and socially with these cases to interrupt the course of maltreatment. Every children's hospital needs such a team to increase diagnosis establishment necessary to initiate social support.

Salbutamol or mist in acute bronchiolitis

BACKGROUND

The role of bronchodilators in the treatment of bronchiolitis remains controversial.

METHODS

A double-blind, placebo controlled trial was performed to evaluate the clinical response to nebulized salbutamol. One hundred and fifty-six infants aged between 7 weeks and 24 months who had had an episode of wheezing and other signs and symptoms of bronchiolitis were randomized to three groups as follows: (i) nebulized salbutamol was administered to 52 patients in group I at a dose of 0.15 mg/kg in 2 mL saline; (ii) saline was nebulized to 52 patients in group II and (iii) in group III 52 patients received mist in a tent. All three groups were administered oxygen during the procedures. Treatment was repeated with the same agent after 30 min if the respiratory score was 5 or more. Respiratory rate, heart rate, oxygen saturation and presence of cyanosis, wheezing, retractions were recorded before and after each treatment.

RESULTS

The decrease in the respiratory score was 5.2 +/- 1.8, 0.82 +/- 2.4 and 1.7 +/- 1.3 in group I, II and III, respectively. The decrease in group I was significantly higher than in the other groups. Heart rate was similar between groups. Oxygen saturation decreased in group I without reaching statistical significance.

CONCLUSIONS

Salbutamol was shown to be effective and safe in the treatment of acute bronchiolitis.

Neonatal Klebsiella pneumonia sepsis and imipenem/cilastatin

Efficacy and safety of imipenem/cilastatin in neonatal Klebsiella pneumonia sepsis was investigated in 45 infants compared to 39 control infants on conventional antibiotic regimen. Sensitivity to imipenem was 94% followed by cephoxitin (88%), quinolons (80%), and amikacin (52%) according to susceptibility results in the study group. Treatment duration of surviving infants was 16.5 +/- 4.6 and 20.3 +/- 6.4 days in the study and control groups respectively (p < 0.05). Five infants (11%) vs 27 (69%) were unresponsive (septic deaths) to treatment in the study and control groups respectively (p < 0.001). The cure rates were 73% and 28% respectively (p < 0.001). Sequelae free discharge rates were 67% and 23% respectively (p < 0.001). The most frequent adverse effects of imipenem/cilastatin were Candida albicans superinfection (20%); Candida albicans colonisation (10%); impairment of liver and renal functions (19% and 10% respectively); seizures (5%); thrombocytosis (3%); thrombophlebitis (3%); urine discoloration (3%); and Staphylococcus epidermidis colonisation (2%). Imipenem is considered a good alternative for neonatal Klebsiella pneumonia sepsis with these results, however, one must be aware of the increased risk of Candida albicans superinfection.

L-methionine induces stage-dependent changes of differentiation and oxidative activity in sea urchin embryogenesis

This study was to investigate developmental toxicity of some selected low molecular weight antioxidants, by utilising sea urchin embryos and gametes as model system. Sea urchin embryos or sperm were exposed at different developmental stages to L-methionine or some selected low molecular weight antioxidants: a) N-acetylcysteine; b) L-carnosine; c) L-homocarnosine, and d) L-anserine. L-methionine displayed developmental toxicity at levels > or = 10(-5) M, whereas the other agents tested were mostly active at levels > or = 10(-4) M. When embryos were exposed to 10(-4) M L-methionine or N-acetylcysteine at different developmental stages, the most severe effects were exerted by early exposures (0 to 2 hr after fertilisation), whereas later exposures turned to lesser or no effects. Cytogenetic analysis of L-methionine-exposed embryos showed a significant mitogenic effect and increase of mitotic aberrations. Fertilisation success was decreased by L-methionine (10(-6) M to 10(-3) M) added at the moment of fertilisation, with increasing developmental and cytogenetic abnormalities in the offspring. The formation of reactive oxygen species in embryos and gametes was determined by: a) analysing the DNA oxidative product, 8-hydroxy-2'-deoxyguanosine (8-OHdG), and b) luminol-dependent chemiluminescence. The results showed that: 1) 8-OHdG levels were increased during embryogenesis; 2) fertilisation was associated with a double-wave luminol-dependent chemiluminescence emission; 3) luminol-dependent chemiluminescence was maximal in cleavage, declining down to zero in plutei, and 4) an embryotoxic L-methionine or N-acetylcysteine level (10(-4) M) turned to a decrease in reactive oxygen species formation. The data suggest that L-methionine- or N-acetylcysteine-induced developmental toxicity is confined to early stages. A role for oxidative activity is suggested in modulating cell differentiation and embryogenesis, consistent with antioxidant-induced damage to early life stages.

Cytogenetic, developmental, and biochemical effects of aluminum, iron, and their mixture in sea urchins and mussels

The present study was undertaken to evaluate the toxicity of aluminum sulfate, ferric chloride and their 1:1 mixture (Mix) on early development, fertilization and offspring quality in three sea urchins species (Sphaerechinus granularis, Paracentrotus lividus, Psammechinus microtuberculatus) and in mussels (Mytilus galloprovincialis). The endpoints were the following: a) larval malformations; b) developmental arrest; c) embryonic mortality; d) fertilization success; e) cytogenetic effects, and f) luminol-dependent chemiluminescence (LDCL). Overall data point to the induction of developmental defects in both sea urchin and mussel embryos following exposure of embryos to Al(III) or Fe(III) (10(-7) to 10(-6) M), whereas Mix caused varied effects vs. Al(III) or Fe(III) alone, from scarce or no additive effects (M. galloprovincialis and P. lividus) to a dramatic rise in embryolethality even at nominal levels of 10(-8) M (Ps. microtuberculatus).S. granularis sperm underwent a dose-dependent decrease in fertilization success following exposure to Al(III), or Fe(III), or Mix at levels ranging from 10(-8) to 10(-5) M. A significant increase of developmental defects was observed in the offspring of S. granularis sperm exposed to micromolar levels of the agents, suggesting an Al(III)- and Fe(III)-related transmissible damage to sperm. The cytogenetic analysis of Al(III)-, Fe(III)-, or Mix-exposed S. granularis embryos showed a significant increase in mitotic aberrations. A relevant feature of the observed cytogenetic damage included scattered chromosomes, suggesting cytoskeleton damage. The LDCL emission in S. granularis embryos showed a dose-related inhibition by agent levels ranging from 10(-7) to 10(-5) M; this held true for both spontaneous and, to a larger extent, for horseradish peroxidase (HRP)-activated LDCL. LDCL associated with fertilization was affected by Al(III), Fe(III) and Mix, with a time- and dose-related shift from stimulation to inhibition. The changes observed in LDCL emission suggested that the observed damage to embryogenesis, fertilization and mitotic activity may be related, at least partly, to alterations of the embryo prooxidant state. The present data point to developmental, cytogenetic and biochemical changes related to realistic levels of Al(III), Fe(III) and their mixtures, raising concern as to their environmental, occupational and iatrogenic exposures.

Agenesis of the corpus callosum in Schinzel-Giedion syndrome associated with 47,XXY karyotype

The Schinzel-Giedion syndrome is a rare autosomal recessive condition with typical facial features, skeletal manifestations and congenital hydronephrosis and/or hydroureter. We report a male infant with Schinzel-Giedion syndrome, also showing the karyotypic abnormality 47,XXY. Agenesis of the corpus callosum and laryngeal stenosis were determined at autopsy. Besides typical Schinzel-Giedion syndrome, our propositus was found to be affected by Klinefelter syndrome. This represents a fortuitous anomaly, which is probably of no importance in the phenotype of the patient.

Spondylocostal dysplasia and cardiac anomalies in one dizygotic twin

A 13-day-old, preterm, male infant was referred for respiratory distress syndrome (RDS) and jaundice. His twin sister had died of RDS on the second day of life in another hospital. The patient had typical features of spondylocostal dysplasia. Ventricular septal defect (VSD) and patent ductus arteriosus (PDA) were also diagnosed by echocardiographic evaluation. Parental consanguinity was not reported. There were no other similar cases in the family, and his twin sister and five-year-old living sister were free of deformities. Therefore, autosomal-recessive transmission may be considered first; however, because the patient was the only affected individual in this family, second denovo autosomal-dominant mutation should also be considered. This is the first reported case of spondylocostal dysplasia with VSD and PDA to our knowledge.

Antenatally diagnosed neonatal craniopharyngioma

A case of neonatal craniopharyngioma diagnosed by fetal ultrasonography at 29 weeks and by magnetic imaging at 35 weeks of gestation is presented with clinical and neuroradiologic findings. This is a rare tumor and only 10 cases of neonatal craniopharyngioma have been previously reported .