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1.
Child Abuse Negl ; 144: 106371, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37536244

RESUMEN

BACKGROUND: Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES: To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING: Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS: This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS: There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS: Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.


Asunto(s)
Maltrato a los Niños , Traumatismos Craneocerebrales , Pediatría , Humanos , Lactante , Maltrato a los Niños/diagnóstico , Traumatismos Craneocerebrales/diagnóstico , Hematoma Subdural/diagnóstico , Pediatras , Hemorragia Retiniana , Estudios Retrospectivos
2.
Pediatrics ; 150(4)2022 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-36120799

RESUMEN

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.


Asunto(s)
Trastornos de la Coagulación Sanguínea , Maltrato a los Niños , Contusiones , Trastornos de la Coagulación Sanguínea/diagnóstico , Niño , Maltrato a los Niños/diagnóstico , Contusiones/diagnóstico , Contusiones/etiología , Diagnóstico Diferencial , Hemorragia/diagnóstico , Humanos
3.
Pediatrics ; 150(4)2022 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-36180615

RESUMEN

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.


Asunto(s)
Trastornos de la Coagulación Sanguínea , Maltrato a los Niños , Contusiones , Niño , Maltrato a los Niños/diagnóstico , Contusiones/diagnóstico , Contusiones/etiología , Hemorragia/diagnóstico , Hemorragia/etiología , Humanos , Prevalencia
4.
Acad Pediatr ; 22(5): 833-841, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35259548

RESUMEN

OBJECTIVES: Child protective services (CPS) reporting for families experiencing intimate partner violence (IPV) is complex. The goal of this study was to develop expert-driven best practices for pediatric providers filing CPS reports in the context of IPV. METHODS: We conducted a Delphi study with experts in IPV and child abuse and neglect (CAN) through 3 rounds of surveys. In Round 1, participants selected clinical scenarios for which they would file, as well as best practices when CPS reporting is indicating. In Round 2, participants described how strongly they agreed that a provider should file for each clinical scenario and how important each best practice was on a 5-point Likert scale. Finally, in Round 3 participants reviewed Round 1 and 2 results, then reported their final determination by selecting yes or no for each option. Consensus was achieved in Round 3 if >80% of participants agreed. In each round, participants could provide further detail via free-text answers. RESULTS: Twenty-three (40%) of the invited experts participated. Consensus was not achieved for children directly witnessing IPV or experiencing health symptoms due to IPV exposure. Participants were in consensus regarding need for CPS reporting when CAN was present and that reporting should not occur for exposure to IPV only. Best practices included supporting IPV survivors, developing healthcare-based IPV advocacy programs, and optimizing the child welfare system. CONCLUSION: This study provides expert-driven recommendations for filing CPS reports in the context of IPV and highlights the inherent complexity of filing and the need for further guidelines.


Asunto(s)
Maltrato a los Niños , Violencia de Pareja , Niño , Servicios de Protección Infantil , Protección a la Infancia , Humanos , Encuestas y Cuestionarios
5.
Pediatr Emerg Care ; 34(9): 665-670, 2018 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-30180101

RESUMEN

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.


Asunto(s)
Maltrato a los Niños/diagnóstico , Traumatismos Craneocerebrales/complicaciones , Hemorragia Retiniana/diagnóstico , Niño , Diagnóstico Diferencial , Humanos , Lactante , Hemorragia Retiniana/etiología
6.
Child Abuse Negl ; 52: 102-9, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26746111

RESUMEN

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p<0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.


Asunto(s)
Abuso Sexual Infantil/diagnóstico , Análisis de Varianza , Niño , Competencia Clínica/normas , Femenino , Psiquiatría Forense , Humanos , Variaciones Dependientes del Observador , Pediatras/normas , Fotograbar , Examen Físico , Estudios Prospectivos , Grabación en Video
7.
Acad Med ; 88(10): 1478-84, 2013 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-23969350

RESUMEN

PURPOSE: To describe patterns of clinical Spanish use by pediatric residents, and to compare self-assessment of language proficiency against an objective language test. METHOD: In 2010, the authors e-mailed a survey to all 247 pediatric residents at three institutions, inviting those with any level of Spanish language ability to participate. Participants completed a survey reporting Spanish proficiency, interpreter use, and comfort using Spanish in a range of clinical scenarios. Clinical scenarios were grouped and analyzed by degree of complexity. Self-reported Spanish proficiency was compared with tested proficiency, as measured by a 20-minute telephone assessment of general language ability. Scores were categorized as "not proficient," "proficient," and "highly proficient." RESULTS: Of the 247 residents, 78 (32%) participated, self-reporting a range of Spanish skills; 23% of those reported spoken proficiency ("proficient" or "fluent"). Participants at all levels of proficiency reported using Spanish without interpretation, including 63% of those who were not proficient. The majority (56%) of nonproficient residents reported comfort using Spanish in straightforward clinical scenarios, and 10% reported comfort in clinical scenarios with legal implications. Self-reported proficiency had a positive predictive value of 67% for testing at a proficient level and 22% for testing at a highly proficient level. CONCLUSIONS: Regardless of level of Spanish proficiency, pediatric residents provide clinical care to patients in Spanish. Self-reported Spanish proficiency does not reliably predict tested ability, especially when using stringent criteria to define proficiency. Provider language "credentialing" is an important step in implementing a policy to improve care for limited English proficiency patients.


Asunto(s)
Barreras de Comunicación , Hispánicos o Latinos , Internado y Residencia , Multilingüismo , Pediatría , Adulto , Estudios Transversales , Femenino , Humanos , Pruebas del Lenguaje , Masculino , Autoevaluación (Psicología) , Encuestas y Cuestionarios
8.
Pediatrics ; 130(1): e80-7, 2012 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-22689864

RESUMEN

OBJECTIVE: To measure the impact of an objective evaluation of provider Spanish-language skills on self-reported language proficiency and comfort using Spanish in a range of clinical scenarios. METHODS: We enrolled pediatric residents with any self-reported Spanish language ability from 3 residency programs. Participants completed a baseline survey, objective language testing, and a posttest survey. We gathered demographics, self-reported Spanish ability, and comfort using Spanish in various clinical scenarios, which were grouped and analyzed by degree of complexity. Between surveys, a language testing service administered a 20-minute, telephone-based assessment of general Spanish proficiency. Scores were reported on a scale from 1 to 12, with scores ≥ 9 designated "proficient." Participants received a numeric score and brief qualitative feedback on their language ability. RESULTS: Following testing, residents (n = 76) were significantly less likely to report comfort using Spanish in straightforward clinical scenarios, from 64% to 51% (P = .007). That difference was accounted for entirely by residents who tested at a non-proficient level (56% to 39%, P = .006). Testing had no impact on comfort using Spanish in complex or medical-legal scenarios, at any proficiency level. We found no change in self-reported Spanish proficiency in any resident group. CONCLUSIONS: Objective Spanish-language testing decreased nonproficient resident comfort using Spanish in straightforward clinical encounters, but it did not change comfort in complex or legal scenarios. In combination with education and enforceable policies, language testing may play an important role in decreasing nonproficient Spanish use and improving care for patients with limited English proficiency.


Asunto(s)
Actitud del Personal de Salud , Barreras de Comunicación , Competencia Cultural , Pruebas del Lenguaje , Multilingüismo , Pediatría , Adulto , Femenino , Humanos , Internado y Residencia , Masculino , Pediatría/educación , Estudios Prospectivos , Calidad de la Atención de Salud , Autoinforme , Traducción , Estados Unidos
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