AST and ALT Elevation in Suspected Physical Abuse: Can the Threshold to Obtain an Abdominal CT be Raised?

BACKGROUND: Identification of abdominal injury (AI) in children with concern for physical abuse is important as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines which use a cutoff of AST > 200 or ALT >125 IU/L. METHODS: This was a retrospective review of children ages 0-60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: mid-range (AST < 200 and ALT <125 IU/L) and high-range (AST > 200 and/or ALT >125 IU/L) LFTs. RESULTS: Abdominal CTs were performed in 55% (131/237) of subjects, 38% (50/131) with mid-range LFTs and 62% (81/131) with high-range LFTs. AI was identified in 19.8% (26/131) of subjects. Subjects with AI were older than those without AI [mean age (SD) 18.7 (12.5) vs. 11.6 (12.2) months, p = 0.009]. The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13/25; 95% CI: 31.3-72.2%). The negative predictive value of having mid-range LFTs and no signs or symptoms of AI was 100% (95% CI: 97.0-100%). CONCLUSIONS: Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST < 200 and ALT <125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. LEVEL OF EVIDENCE: Level IV, Diagnostic Test/Criteria.

Increased severity of abusive head trauma during the first year of the COVID-19 pandemic.

BACKGROUND: Abusive head trauma (AHT) is the leading cause of death from physical abuse in children. Reports regarding the impact of the COVID-19 pandemic on rates and severity of AHT are limited and with conflicting results. OBJECTIVE: To determine the number and clinical characteristics of AHT cases presenting to a pediatric tertiary care center during the first year of the COVID-19 pandemic compared to the two prior years. PARTICIPANTS AND SETTING: We performed a retrospective cohort study of patients <5 years old diagnosed with AHT at a single pediatric tertiary care center over a three-year period. METHODS: Data were obtained for the pandemic year and two years before, including demographics, length of stay, physical and retinal examination findings, radiologic studies, electroencephalogram results, and mortality. RESULTS: There were 27 cases of AHT during the first year of the pandemic and 55 during the two pre-pandemic years. Length of stay was similar for the two cohorts. The mortality rate was higher during the pandemic (29.6 % vs. 3.6 %; p < .01), as were the proportion of patients with retinal hemorrhages (84.6 % vs. 41.5 %; p < .01) and abnormal cervical spine imaging (52.6 % vs. 21.2 %; p = .02). There were no differences in age, sex, race, abnormalities on dermatological exam, skeletal surveys, and electroencephalograms. CONCLUSIONS: We did not observe an increase in the number of patients with AHT during the pandemic but did see an increase in mortality, patients with retinal hemorrhages, and patients with abnormalities on cervical spine imaging. These data suggest a higher severity of AHT presenting to a pediatric tertiary care center during the pandemic.

Improved Detection of Child Maltreatment with Routine Screening in a Tertiary Care Pediatric Hospital.

OBJECTIVES: To evaluate the impact of layering routine child abuse screening on top of a preexisting electronic health record-embedded Child Abuse Clinical Decision Support System (CA-CDSS) in a pediatric emergency department. STUDY DESIGN: The Pittsburgh Child Abuse Screening Tool (P-CAST) was performed in all children aged <13 years and in nonverbal children aged ≥13 years who presented to a pediatric tertiary care center over a 6-month period. The P-CAST was layered on top of a preexisting CA-CDSS that included passive triggers, alerts, and abuse-specific order sets. RESULTS: Of the 28 797 screens performed, 1.8% were positive in children aged <13 years and 1.6% were positive in nonverbal children aged ≥13 years. One-half of the children with a positive P-CAST also triggered the CA-CDSS; the other one-half triggered only because of the P-CAST. Nineteen percent of the patients with a positive P-CAST were reported to Child Protective Services (CPS). There was no relationship between race and the odds of a positive P-CAST or between race and the likelihood of a report being made to CPS. CONCLUSIONS: Active routine child abuse screening improves identification of suspected child maltreatment in a children's hospital above and beyond what is identified with a CA-CDSS, which depends on passive triggers. The lack of a relationship between race and a positive P-CAST or a report to CPS suggest that systematic child abuse screening may mitigate well-recognized racial disparities in identifying and reporting suspected child maltreatment.

Left-Sided Appendicitis: More Than Meets the Eye.

ABSTRACT: Classic appendicitis is a common condition easily diagnosed by emergency care providers. However, atypical cases represent a diagnostic challenge and can contribute to increased morbidity from a delay in definitive care. It is important to recognize that atypical presentations have an increased risk for underlying anatomic variants, which may require additional imaging as part of management. We present a case of a 13-year-old previously healthy adolescent boy with acute onset of left-sided abdominal pain who was found to have appendicitis in the setting of underlying malrotation.

Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department.

OBJECTIVES: Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. METHODS: We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. RESULTS: There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. CONCLUSIONS: Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.

Design, Implementation, and Evaluation of a Simulation-Based Clinical Correlation Curriculum as an Adjunctive Pedagogy in an Anatomy Course.

PROBLEM: Because reported use of simulation in preclinical basic science courses is limited, the authors describe the design, implementation, and preliminary evaluation of a simulation-based clinical correlation curriculum in an anatomy course for first-year medical students at Perdana University Graduate School of Medicine (in collaboration with Johns Hopkins University School of Medicine). APPROACH: The simulation curriculum, with five weekly modules, was a component of a noncadaveric human anatomy course for three classes (n = 81 students) from September 2011 to November 2013. The modules were designed around major anatomical regions (thorax; abdomen and pelvis; lower extremities and back; upper extremities; and head and neck) and used various types of simulation (standardized patients, high-fidelity simulators, and task trainers). Several methods were used to evaluate the curriculum's efficacy, including comparing pre- versus posttest scores and comparing posttest scores against the score on 15 clinical correlation final exam questions. OUTCOMES: A total of 81 students (response rate: 100%) completed all pre- and posttests and consented to participate. Posttest scores suggest significant knowledge acquisition and better consistency of performance after participation in the curriculum. The comparison of performance on the posttests and final exam suggests that using simulation as an adjunctive pedagogy can lead to excellent short-term knowledge retention. NEXT STEPS: Simulation-based medical education may prove useful in preclinical basic science curricula. Next steps should be to validate the use of this approach, demonstrate cost-efficacy or the "return on investment" for educational and institutional leadership, and examine longer-term knowledge retention.

Disparities in osteoporosis screening between at-risk African-American and white women.

BACKGROUND: Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist. OBJECTIVE: To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women. METHODS: We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age > or = 65 years and weight < or = 127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis. RESULTS: Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns. CONCLUSIONS: Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.

Apoptosis-inducing factor substitutes for caspase executioners in NMDA-triggered excitotoxic neuronal death.

The profound neuroprotection observed in poly(ADP-ribose) polymerase-1 (PARP-1) null mice to ischemic and excitotoxic injury positions PARP-1 as a major mediator of neuronal cell death. We report here that apoptosis-inducing factor (AIF) mediates PARP-1-dependent glutamate excitotoxicity in a caspase-independent manner after translocation from the mitochondria to the nucleus. In primary murine cortical cultures, neurotoxic NMDA exposure triggers AIF translocation, mitochondrial membrane depolarization, and phosphatidyl serine exposure on the cell surface, which precedes cytochrome c release and caspase activation. NMDA neurotoxicity is not affected by broad-spectrum caspase inhibitors, but it is prevented by Bcl-2 overexpression and a neutralizing antibody to AIF. These results link PARP-1 activation with AIF translocation in NMDA-triggered excitotoxic neuronal death and provide a paradigm in which AIF can substitute for caspase executioners.

Mediation of poly(ADP-ribose) polymerase-1-dependent cell death by apoptosis-inducing factor.

Poly(ADP-ribose) polymerase-1 (PARP-1) protects the genome by functioning in the DNA damage surveillance network. PARP-1 is also a mediator of cell death after ischemia-reperfusion injury, glutamate excitotoxicity, and various inflammatory processes. We show that PARP-1 activation is required for translocation of apoptosis-inducing factor (AIF) from the mitochondria to the nucleus and that AIF is necessary for PARP-1-dependent cell death. N-methyl-N'-nitro-N-nitrosoguanidine, H2O2, and N-methyl-d-aspartate induce AIF translocation and cell death, which is prevented by PARP inhibitors or genetic knockout of PARP-1, but is caspase independent. Microinjection of an antibody to AIF protects against PARP-1-dependent cytotoxicity. These data support a model in which PARP-1 activation signals AIF release from mitochondria, resulting in a caspase-independent pathway of programmed cell death.