Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages.

OBJECTIVE: The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist. METHODS: This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls. RESULTS: Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises. CONCLUSIONS: These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.

Missed opportunities to diagnose child physical abuse.

OBJECTIVES: This study aimed to determine the incidence of missed opportunities to diagnose abuse in a cohort of children with healing abusive fractures and to identify patterns present during previous medical visits, which could lead to an earlier diagnosis of abuse. METHODS: This is a retrospective descriptive study of a 7-year consecutive sample of children diagnosed with child abuse at a single children's hospital. Children who had a healing fracture diagnosed on skeletal survey and a diagnosis of child abuse were included. We further collected data for the medical visit that lead to the diagnosis of child abuse and any previous medical visits that the subjects had during the 6 months preceding the diagnosis of abuse. All previous visits were classified as either a potential missed opportunity to diagnose abuse or as an unrelated previous visit, and the differences were analyzed. RESULTS: Median age at time of abuse diagnosis was 3.9 months. Forty-eight percent (37/77) of the subjects had at least 1 previous visit, and 33% (25/77) of those had at least 1 missed previous visit. Multiple missed previous visits for the same symptoms were recorded in 7 (25%) of these patients. The most common reason for presentation at missed previous visit was a physical examination sign suggestive of trauma (ie, bruising, swelling). Missed previous visits occurred across all care settings. CONCLUSIONS: One-third of young children with healing abusive fractures had previous medical visits where the diagnosis of abuse was not recognized. These children most commonly had signs of trauma on physical examination at the previous visits.

Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma.

INTRODUCTION: This study aims to evaluate the capability of magnetic resonance imaging (MRI) susceptibility weighted images (SWI) in depicting retinal hemorrhages (RH) in abusive head trauma (AHT) compared to the gold standard dilated fundus exam (DFE). METHODS: This is a retrospective, single institution, observational study on 28 patients with suspected AHT, who had a DFE and also underwent brain MRI-SWI as part of routine diagnostic protocol. Main outcome measures involved evaluation of patients to determine whether the RH could be identified on standard and high-resolution SWI sequences. RESULTS: Of the 21 subjects with RH on DFE, 13 (62%) were identified by using a standard SWI sequence performed as part of brain MRI protocols. Of the 15 patients who also underwent an orbits SWI protocol, 12 (80%) were positive for RH. None of the seven patients without RH on of DFE had RH on either standard or high-resolution SWI. Compared with DFE, the MRI standard protocol showed a sensitivity of 75% which increased to 83% for the orbits SWI protocol. CONCLUSIONS: Our study suggests the usefulness of a tailored high-resolution orbits protocol to detect RH in AHT.

The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors.

CONTEXT: Advance provision of emergency contraception (EC) may increase timely access and improve effectiveness, but the impact on adolescent sexual and contraceptive behaviors is not known. OBJECTIVE: To determine whether adolescents given advance EC have higher sexual and contraceptive risk-taking behaviors compared to those obtaining it on an as-needed basis. DESIGN AND SETTING: Randomized trial conducted at urban, hospital-based adolescent clinic in Pittsburgh, PA, from June 1997 to June 2002. PARTICIPANTS: 301 predominantly minority, low-income, sexually active adolescent women, age 15-20 years, not using long-acting contraception. INTERVENTIONS: Advance EC vs instruction on how to get emergency contraception. OUTCOME MEASURES: Self-reported unprotected intercourse and use of condoms, EC, and hormonal contraception ascertained by monthly 10-minute telephone interviews for 6 months post-enrollment. Reported timing of EC use after unprotected intercourse. RESULTS: At both 1- and 6-month followup interviews, there were no differences between advance EC and control groups in reported unprotected intercourse within the past month or at last intercourse. At 6 months, more advance EC participants reported condom use in the past month compared to control group participants (77% vs 62%, P=0.02), but not at last intercourse (advance EC 83% vs control 78%, P=0.34). There were no significant differences by group in hormonal contraception use reported by advance EC or control groups in the past month (44% vs 53%, P=0.19) or at last intercourse (48% vs 58%, P=0.20). At the first followup, the advance group reported nearly twice as much EC use as the control group (15% vs 8%, P=0.05) but not at the final followup (8% vs 6%, P=0.54). Advance EC group participants began their EC significantly sooner (11.4 hours vs 21.8 hours, P=0.005). CONCLUSIONS: Providing advance EC to adolescents is not associated with more unprotected intercourse or less condom or hormonal contraception use. In the first month after enrollment, adolescents provided with advance EC were nearly twice as likely to use it and began EC sooner, when it is known to be more effective.

Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors.

OBJECTIVES: To describe doctors' emotional reactions to the recent death of an "average" patient and to explore the effects of level of training on doctors' reactions. DESIGN: Cross sectional study using quantitative and qualitative data. SETTING: Two academic teaching hospitals in the United States. PARTICIPANTS: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital. MAIN OUTCOME MEASURES: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions. RESULTS: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support. CONCLUSIONS: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.

Improving children's mental rotation accuracy with computer game playing.

The authors investigated the relation between mental rotation (MR) and computer game-playing experience. Third grade boys (n = 24) and girls (n = 23) completed a 2-dimensional MR test before and after playing computer games (during 11 separate 30-min sessions), which either involved the use of MR skills (the experimental group) or did not involve the use of MR skills (the control group). The experimental group outperformed the control group on the MR posttest but not on the pretest. Boys outperformed girls on the pretest but not on the posttest. Children whose initial MR performance was low improved after playing computer games that entailed MR skills. The findings imply that computer-based instructional activities can be used in schools to enhance children's spatial abilities.