Child Abuse Neglect the International Journal, Nov 1, 2010
Objective: The authors' objective is to describe the disparity between the case-fatality rates fo... more Objective: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. Method: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. Results: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. Conclusions: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. Practice implications: Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-healthoriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.
No standard management plan for infants with an apparent life-threatening event (ALTE) currently ... more No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. The study's objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Authors retrospectively reviewed records from a large children's hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.
No standard management plan for infants with an apparent life-threatening event (ALTE) currently ... more No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. The study's objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Authors retrospectively reviewed records from a large children's hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.
The primary aim of this study is to better define both the type and incidence of cranial computed... more The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury. This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006. Children's Hospital, San Diego. Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included. None. Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state. These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.
Objective: The authors' objective is to describe the disparity between the case-fatality rates fo... more Objective: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. Method: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. Results: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. Conclusions: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. Practice implications: Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-healthoriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.
Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of... more Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p = 0.046), fissure (p = 0.000), laceration (p = 0.000) and total anal dilatation (p = 0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.
Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic acces... more Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.
Child Abuse Neglect the International Journal, Nov 1, 2010
Objective: The authors' objective is to describe the disparity between the case-fatality rates fo... more Objective: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. Method: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. Results: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. Conclusions: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. Practice implications: Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-healthoriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.
No standard management plan for infants with an apparent life-threatening event (ALTE) currently ... more No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. The study's objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Authors retrospectively reviewed records from a large children's hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.
No standard management plan for infants with an apparent life-threatening event (ALTE) currently ... more No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. The study's objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Authors retrospectively reviewed records from a large children's hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.
The primary aim of this study is to better define both the type and incidence of cranial computed... more The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury. This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006. Children's Hospital, San Diego. Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included. None. Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state. These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.
Objective: The authors' objective is to describe the disparity between the case-fatality rates fo... more Objective: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. Method: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. Results: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. Conclusions: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. Practice implications: Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-healthoriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.
Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of... more Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p = 0.046), fissure (p = 0.000), laceration (p = 0.000) and total anal dilatation (p = 0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.
Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic acces... more Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.
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