Increased CSF concentrations of myelin basic protein after TBI in infants and children: absence of significant effect of therapeutic hypothermia.

BACKGROUND: The objectives of this study were to determine effects of severe traumatic brain injury (TBI) on cerebrospinal fluid (CSF) concentrations of myelin basic protein (MBP) and to assess relationships between clinical variables and CSF MBP concentrations. METHODS: We measured serial CSF MBP concentrations in children enrolled in a randomized controlled trial evaluating therapeutic hypothermia (TH) after severe pediatric TBI. Control CSF was obtained from children evaluated, but found not to be having CNS infection. Generalized estimating equation models and Wilcoxon Rank-Sum test were used for comparisons of MBP concentrations. RESULTS: There were 27 TBI cases and 57 controls. Overall mean (± SEM) TBI case MBP concentrations for 5 days after injury were markedly greater than controls (50.49 ± 6.97 vs. 0.11 ± 0.01 ng/ml, p < 0.01). Mean MBP concentrations were lower in TBI patients <1 year versus >1 year (9.18 ± 1.67 vs. 60.22 ± 8.26 ng/ml, p = 0.03), as well as in cases with abusive head trauma (AHT) versus non-abusive TBI (14.46 ± 3.15 vs. 61.17 ± 8.65 ng/ml, p = 0.03). TH did not affect MBP concentrations. CONCLUSIONS: Mean CSF MBP increases markedly after severe pediatric TBI, but is not affected by TH. Infancy and AHT are associated with low MBP concentrations, suggesting that age-dependent myelination influences MBP concentrations after injury. Given the magnitude of MBP increases, axonal injury likely represents an important therapeutic target in pediatric TBI.

Biomarkers of abnormally invasive placenta.

INTRODUCTION: Abnormally invasive placenta (AIP, aka placenta accreta spectrum; PAS) is an increasingly common pregnancy pathology, which, despite significant morbidity risk to the mother, is often undiagnosed prior to delivery. We tested several potential biomarkers in plasma from PAS mothers to determine whether any were sufficiently robust for a formal, diagnostic accuracy study. METHODS: We examined hyperglycosylated hCG (h-hCG), decorin and IL-8, based on biological plausibility and literature indications that they might be altered in PAS. These analytes were assayed by ELISA in maternal plasma from five groups, comprising (1) normal term controls, (2) placenta previa controls, and cases of (3) placenta increta/percreta without placenta previa, (4) placenta previa increta/percreta and (5) placenta previa accreta. RESULTS: There were no differences in h-hCG, ß-hCG or the h-hCG/ß-hCG ratio between the groups. Mean decorin levels were increased in previa controls (Group 2) compared to the other groups, but there was substantial overlap between the individual values. While an initial multiplex assay showed a greater value for IL-8 in the placenta previa increta/percreta group (Group 4) compared to placenta previa controls (Group 2), the subsequent validation ELISA for IL-8 showed no differences between the groups. DISCUSSION: We conclude that the absence of differences and the extent of overlap between cases and controls does not justify further assessment of these biomarkers.

Characterizing Lyme Disease Surveillance in an Endemic State.

Lyme disease (LD) is the most common vector-borne disease in Maryland and the United States. Surveillance for LD is valuable for understanding the burden of the disease, particularly to assess whether the disease is spreading and to appreciate who is affected. However, not all cases of LD in Maryland are reported, and surveillance practices vary across each of Maryland's 24 local health departments (LHDs). To better understand this variability and to systematically characterize the surveillance process, we surveyed Maryland's LHDs regarding LD surveillance. The Maryland Local Health Department Lyme Disease Surveillance Survey has been administered annually since 2011. Questions asked each year included whether all LD reports are investigated or only a subset, and how many reports are not entered into the surveillance database. Since 2011, Maryland has lost surveillance personnel for LD. Each year from 2009 to 2012, a median 3598 (range 2462 to 5722) reports were not entered into the surveillance database and hence not investigated. These reports represent 43-55% of all reports received for the year. Over time, more LHDs chose to streamline their LD investigation approach by investigating only those reports that met the criteria for laboratory evidence of infection: in 2008, 5 (21%) LHDs investigated only a subset of LD reports; by 2013, this increased to 15 (63%). There is wide variability across LHDs in how LD investigations are conducted. Maryland LHDs have experienced a loss of LD surveillance personnel with a concomitant increase in the number of LHDs adopting a streamlined approach to investigating cases. These findings underscore the tremendous burden of LD on the public health agencies and highlight the need for alternative approaches that can both reduce burden and preserve surveillance data quality.

Exploring an alternative approach to Lyme disease surveillance in Maryland.

In Maryland, Lyme disease (LD) is a reportable disease and all laboratories and healthcare providers are required to report to the local health department. Given the volume of LD reports and effort required for investigation, surveillance for LD is burdensome and subject to underreporting. We explored the utility of International Classification of Diseases, 9th Revision, Clinical Modification (administrative) codes for use with LD surveillance. We aimed to collect the administrative codes for a 10% sample of 2009 LD reports (n = 474) from 292 facilities stratified by case classification (confirmed, probable, suspected and not a case). Sixty-three per cent (n = 184) of facilities responded to the survey, and 341 different administrative codes were obtained for 91% (n = 430) of sampled reports. The administrative code for Lyme disease (088.81) was the most commonly reported code (133/430 patients) among sampled reports; while it was used for 62 of 151 (41%) confirmed cases, it was also used for 48 of 192 (25%) not a case reports (sensitivity 41% and specificity 73%). A combination of nine codes was developed with sensitivity of 74% and specificity of 37% when compared to not a case reports. We conclude that the administrative code for LD alone has low ability to identify LD cases in Maryland. Grouping certain codes improved sensitivity, but our results indicate that administrative codes alone are not a viable surveillance alternative for a disease with complex manifestations such as LD.

Lyme disease surveillance in the United States: Looking for ways to cut the Gordian knot.

Current surveillance methods have been useful to document geographic expansion of Lyme disease in the United States and to monitor the increasing incidence of this major public health problem. Nevertheless, these approaches are resource-intensive, generate results that are difficult to compare across jurisdictions, and measure less than the total burden of disease. By adopting more efficient methods, resources could be diverted instead to education of at-risk populations and new approaches to prevention. In this special issue of Zoonoses and Public Health, seven articles are presented that either evaluate traditional Lyme disease surveillance methods or explore alternatives that have the potential to be less costly, more reliable, and sustainable. Twenty-five years have passed since Lyme disease became a notifiable condition - it is time to reevaluate the purpose and goals of national surveillance.

Assessing diagnostic coding practices among a sample of healthcare facilities in Lyme disease endemic areas: Maryland and New York - A Brief Report.

The value of using diagnostic codes in Lyme disease (LD) surveillance in highly endemic states has not been well studied. Surveys of healthcare facilities in Maryland (MD) and New York (NY) regarding coding practices were conducted to evaluate the feasibility of using diagnostic codes as a potential method for LD surveillance. Most respondents indicated that their practice utilized electronic medical records (53%) and processed medical/billing claims electronically (74%). Most facilities were able to search office visits associated with specific ICD-9-CM and CPT codes (74% and 73%, respectively); no discernible differences existed between the healthcare facilities in both states. These codes were most commonly assigned by the practitioner (82%), and approximately 70% of respondents indicated that these codes were later validated by administrative staff. These results provide evidence for the possibility of using diagnostic codes in LD surveillance. However, the utility of these codes as an alternative to traditional LD surveillance requires further evaluation.

Pet ownership increases human risk of encountering ticks.

We examined whether pet ownership increased the risk for tick encounters and tickborne disease among residents of three Lyme disease-endemic states as a nested cohort within a randomized controlled trial. Information about pet ownership, use of tick control for pets, property characteristics, tick encounters and human tickborne disease were captured through surveys, and associations were assessed using univariate and multivariable analyses. Pet-owning households had 1.83 times the risk (95% CI = 1.53, 2.20) of finding ticks crawling on and 1.49 times the risk (95% CI = 1.20, 1.84) of finding ticks attached to household members compared to households without pets. This large evaluation of pet ownership, human tick encounters and tickborne diseases shows that pet owners, whether of cats or dogs, are at increased risk of encountering ticks and suggests that pet owners are at an increased risk of developing tickborne disease. Pet owners should be made aware of this risk and be reminded to conduct daily tick checks of all household members, including the pets, and to consult their veterinarian regarding effective tick control products.

Human interaction in the NICU and its association with outcomes on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA).

BACKGROUND: Extremely preterm infants represent one of the highest risk categories for impairments in social competence. Few studies have explored the impact of the neonatal intensive care unit (NICU) environment on social development. However, none have specifically analyzed the effects of the care structure the infant receives during hospitalization on later social competence indicators. OBJECTIVE: To identify associations between the care structures received by extremely preterm infants in the NICU and scores on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) post-discharge. PARTICIPANTS: 50 extremely preterm infants (mean gestational age: 25 weeks during hospitalization; mean chronological age during follow-up assessment: 2 years, 4 months). METHODS: A secondary analysis of BITSEA data was performed exploring its relation to care structure data we extracted from electronic medical records (i.e., how much time infants were engaged in human interaction during their first thirty days of hospitalization and what types of interaction they were exposed to). RESULTS: Extremely preterm infants spend a considerable amount of time alone during hospitalization (80%) with nursing care comprising the majority of human interaction. Infants who experienced greater human interaction scored significantly higher on the Social Competence (p = 0.01) and lower on the Dysregulation (p = 0.03) BITSEA subscales. CONCLUSION: Human interaction and isolation in the NICU is associated with social competence and dysregulation outcomes in extremely preterm infants. Further research is needed to understand how various NICU care structures including centralized nursing teams, parental skin-to-skin care, and early therapy may synergistically play a positive role in developing social competence.

Perceptions and Practices of Mass Bat Exposure Events in the Setting of Rabies Among U.S. Public Health Agencies.

Current guidelines in the setting of exposures to potentially rabid bats established by the Advisory Committee on Immunization Practices (ACIP) address post-exposure prophylaxis (PEP) administration in situations where a person may not be aware that a bite or direct contact has occurred and the bat is not available for diagnostic testing. These include instances when a bat is discovered in a room where a person awakens from sleep, is a child without an adult witness, has a mental disability or is intoxicated. The current ACIP guidelines, however, do not address PEP in the setting of multiple persons exposed to a bat or a bat colony, otherwise known as mass bat exposure (MBE) events. Due to a dearth of recommendations for response to these events, the reported reactions by public health agencies have varied widely. To address this perceived limitation, a survey of 45 state public health agencies was conducted to characterize prior experiences with MBE and practices to mitigate the public health risks. In general, most states (69% of the respondents) felt current ACIP guidelines were unclear in MBE scenarios. Thirty-three of the 45 states reported prior experience with MBE, receiving an average of 16.9 MBE calls per year and an investment of 106.7 person-hours annually on MBE investigations. PEP criteria, investigation methods and the experts recruited in MBE investigations varied between states. These dissimilarities could reflect differences in experience, scenario and resources. The lack of consistency in state responses to potential mass exposures to a highly fatal disease along with the large contingent of states dissatisfied with current ACIP guidance warrants the development of national guidelines in MBE settings.

Strangulation in childhood: epidemiology and clinical course.

A review of 233 cases of childhood strangulation was made to determine injury epidemiology. Consistent patterns of injury were observed. Crib and playground equipment strangulations are already the subject of Consumer Product Safety Commission (CPSC) preventative regulations. High chair-, playpen mesh-, pacifier cord-, and clothing-related injuries would be amenable to prevention by improved product safety regulation. The CPSC has been petitioned to remedy the first two of these hazards. Many crib and rope strangulations can only be prevented by direct patient counseling. Although Congress empowered and required the CPSC to recognize and correct unsafe products, its surveillance systems may obscure the very design defects that cause injury. Likewise, political considerations may slow enactment of new design regulations. Physicians who treat childhood accident victims are in a position to recognize hazardous products and lobby for their improvement. Of the 233 cases 38 were further evaluated to delineate the clinical course of childhood strangulation. Victims who fail to resume normal cardiopulmonary function by the time of hospitalization have a poor prognosis for neurologic recovery with current modes of therapy. Improved treatment of hypoxic and ischemic cerebral injury might prevent some of the deaths and handicaps resulting from strangulation.

Psychologic morbidity of children subjected to Munchausen syndrome by proxy.

Munchausen syndrome by proxy is being recognized and reported with increasing frequency, which suggests that it is more common and occurs with a wider spectrum of severity than was previously suspected. In past reports, the difficulties of detecting and documenting the syndrome have been emphasized, as well as its physical morbidity and mortality. The psychologic morbidity of Munchausen syndrome by proxy in six children is described. The children reacted with developmentally appropriate behavior problems ranging from feeding disorders in infants, withdrawal and hyperactivity in preschool-aged children, to hysterical disorders and personal adoption of Munchausen syndrome behavior in adolescents. Parental psychologic and behavioral styles, family dynamics, and responses from legal and children's protective services systems make protection of the child within the home difficult, if not impossible. Even with protection from further physical injury, severe psychologic trauma remains likely. Extreme caution is suggested in allowing these children to remain in the family.

Child abuse, cardiopulmonary resuscitation, and rib fractures.

Rib fractures have occasionally been described in children receiving cardiopulmonary resuscitation (CPR). Because child abuse is sometimes suspected in these cases, it is both medically and legally important to establish whether the rib fractures are secondary to abuse or CPR. One hundred thirteen children, including 41 victims of child abuse, 50 patients who had CPR, and 22 patients who had rib fractures, were studied. Twenty-nine patients had rib fractures; 14/29 (48%) were abusive. Other causes of fracture were: motor vehicle accidents (four), rickets/osteoporosis (five), surgery (five), and osteogenesis imperfecta (one). In spite of prolonged resuscitation performed with variable degrees of skill, no fractures could be attributed to CPR. On the other hand, rib fractures occurred frequently in abused children (6/41 or 15%). Abusive fractures were often multiple, of different ages, and affected multiple adjacent ribs. Patients with abusive rib fracture also had other physical and radiologic signs of abuse or neglect.

Tap water scald burns in children.

Tap water scald burns account for 7% to 17% of all childhood scald burns that require hospitalization. Often the burns are severe and disabling. Toddlers and preschool children are the most frequent victims. In 45% of the injuries, the unsupervised victim or peer turned on the tap water; in 28% the cause was abuse. Eighty percent of the homes tested had unsafe bathtub water temperatures of 54 C (130 F) or greater, exposing the occupants to the risk of full-thickness scald with 30-second exposure to hot water. Such burns may be prevented passively by limiting household water temperatures to less than 52 C (125 F). New water heaters could be preset at this temperature and families could be taught to turn down the temperature on existing units.

Tap water burn prevention: the effect of legislation.

Five years after a 1983 Washington State law required new water heaters to be preset at 49 degrees C (120 degrees F), 77% of homes (84% of homes with postlaw and 70% of homes with prelaw water heaters) had tap water temperatures of less than 54 degrees C. In 1977, 80% of homes had tap water temperatures greater than 54 degrees C. Mean temperature in 1988 was 50 degrees C compared with 61 degrees C in 1977. Both changes were significant compared with 1977 temperatures. Few people increased their heater temperature after installation. Eighteen burn victims were identified from July 1979 through May 1988, for an average admission rate of 2.4 per year, compared with 5.5 per year in the 1970s. Compared with the 1970s, total body surface area burned, mortality, grafting, scarring, and length of hospital stay were all reduced, while the likelihood that scald burns were the result of child abuse increased to 50%. Both education campaigns and legislation have resulted in significantly safer water temperatures. Further, this change seems to have resulted in a reduction in frequency, morbidity, and mortality of tap water burn injuries in children. Lower water heater settings proved acceptable to the consumer.

Epidural hemorrhage: is it abuse?

OBJECTIVE: To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH). DESIGN: Retrospective chart review. SETTING: Level I regional trauma center and a regional children's hospital. PATIENTS: All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991. MEASUREMENT AND RESULTS: Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality. CONCLUSIONS: Our data are consistent with current biomechanical concepts of intracranial injury. EDHs results from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.

Alkynyliodonium salts in organic synthesis. Preparation of 2-substituted-3-p-toluenesulfonyldihydrofurans from 1-hydroxybut-3-ynyliodonium ethers via a formal Stevens shift of a carbon group.

[reaction: see text]p-Toluenesulfinate addition to 1-hydroxybut-3-ynyliodonium ethers triggers a sequence of reactions which ultimately delivers 2-substituted-3-p-toluenesulfonyldihydrofuran products along with 3-p-toluenesulfonyldihydrofuran as a major byproduct. A putative 1,2-alkyl shift within an unsaturated oxonium ylide (Stevens rearrangement) accounts for the oxygen-to-carbon transfer of the alkyl group.

Inflicted submersion in childhood.

OBJECTIVE: To improve characterization and recognition of inflicted pediatric submersions. DESIGN: Retrospective case series, records review. SETTING: A regional children's hospital and the King County (Washington) Medical Examiner's office. PATIENTS: Children younger than 19 years who sustained submersion injury between 1983 and 1991 and were hospitalized or autopsied. OUTCOME MEASURES: Two pediatricians, using preestablished criteria, categorized abstracted case scenarios as either inflicted or unintentional events. The two groups were compared. RESULTS: Of 205 submersions, 16 (8%) were judged to have been inflicted. Objective physical signs of abuse and incompatibilities between the history and the child's stage of development or physical findings were common (69% and 50%, respectively). Inflicted submersion victims were likely to be young (median age, 2.1 years). They tended to be the youngest sibling in a large (three or more children) household. Social and demographic attributes of inflicted and unintentional submersion victims did not differ significantly. Bathtubs were the most common site for inflicted submersions (9/16 [56%]), and submersions in bathtubs were frequently inflicted (9/34 [26%]). Compared with unintentional submersion victims, children who were inflicted submersion victims were less likely to be revived by bystanders (relative risk, 0.10; confidence interval, 0.01 to 0.72) and were more likely to die (relative risk, 4.32; confidence interval, 1.40 to 21.43). CONCLUSIONS: Enough childhood submersions are inflicted to warrant careful case evaluation. Bathtub submersion victims and children with physical and historical findings common to other forms of abuse are most likely to be the victims of inflicted submersion.

Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network.

OBJECTIVES: To determine the frequency and location of bruises in normal infants and toddlers, and to determine the relationship of age and developmental stage to bruising. DESIGN: Cross-sectional survey. SETTING: Community primary care pediatric offices. SUBJECTS: Children younger than 36 months attending well-child care visits. METHODS: Prospective data collection of demographics, developmental stage, and presence and location of bruises. Any medical condition that causes bruises as well as known or suspected abuse was also recorded. A chi2 test or Fisher exact test was used to determine the significance of differences. MAIN OUTCOME MEASURES: Presence and location of bruises as related to age and developmental stage. RESULTS: Bruises were found in 203 (20.9%) of 973 children who had no known medical cause for bruising and in whom abuse was not suspected. Only 2 (0.6%) of 366 children who were younger than 6 months and 8 (1.7%) of 473 children younger than 9 months had any bruises. Bruises were noted in only 11 (2.2%) of 511 children who were not yet walking with support (cruising). However, 17.8% of cruisers and 51.9% of walkers had bruises (P<.001). Mean bruise frequency ranged from 1.3 bruises per injured child among precruisers (range, 1-2 bruises) to 2.4 per injured child among walkers (range, 1-11). The most frequent site of bruises was over the anterior tibia and knee. Bruises on the forehead and upper leg were common among walkers, but bruises on the face and trunk were rare, and bruises on the hands and buttocks were not observed at any age. There were no differences in bruise frequency by sex. African American children were observed to have bruises much less frequently than white children (P<.007). CONCLUSIONS: Bruises are rare in normal infants and precruisers and become common among cruisers and walkers. Bruises in infants younger than 9 months and who are not yet beginning to ambulate should lead to consideration of abuse or illness as causative. Bruises in toddlers that are located in atypical areas, such as the trunk, hands, or buttocks, should prompt similar concerns.

Inadequate history as a barrier to immunization.

OBJECTIVES: To evaluate how lack of immunization history contributes to missed opportunities for immunization and to document the effort required to obtain immunization history. DESIGN: Cross-sectional. SETTING: Urban, inner-city primary care pediatric clinic serving a low-income, multiethnic population. PATIENTS: Ninety-five new patients seen for either well-child care (53 patients) or acute illnesses (42 patients) during a 4-month period in 1993. Fifty-nine patients were aged 3 to 59 months and 36 were aged 5 to 15 years. MEASUREMENTS: Efforts to obtain immunization history were documented by means of a standardized data collection form. RESULTS: Immunization history was obtained for only 26 (27%) of 95 patients during the initial visit. Caregivers of 74 (78%) of 95 patients did not bring immunization records to the initial visit; they were no more likely to bring records for well-child care than for acute care or for younger vs older children. Parents brought immunization records more often than did nonparents. A total of 145 telephone calls were made and 30 letters were sent in an attempt to obtain immunization histories. Immunization records were never found for 10 new patients (11%). Thirty-two patients (34%) were found to be lacking immunizations. Of these, only three patients had contraindications to immunization at the initial visit. Therefore, in one third of our new patients, opportunities to immunize were missed solely because their immunization records were unavailable at the initial visit. In another one third of cases, caregivers had incorrectly believed their child's immunizations to be up to date. CONCLUSIONS: Opportunities to immunize children were often missed because of a lack of immunization history. Our experience supports the need for improved documentation of immunization histories.