Showing posts with label trauma. Show all posts
Showing posts with label trauma. Show all posts

Monday, July 13, 2015

Checking for Occult Fractures in the Setting of Abuse: Not the Automatic One Might Expect


By: Lewis First, MD, MS; Editor-in-Chief  

     We have certainly seen studies in our journal and others strongly demonstrating the importance of checking for occult fractures in children who are victims of physical abuse or in infants who have non-accidental traumatic brain injuries given the yield of finding such fractures in these injured children. So does it happen as a standard of diagnostic evaluation?  
      Sadly no—at least as per the study results reported by Wood et al. (doi: 10.1542/peds.2014-3977) in a retrospective study of more than 2500 abused children from more than 350 hospitals released this week in our journal.  The authors looked at inter-hospital variations and identified a variety of factors at the child and hospital level that influence the probability that occult fractures are or are not sought after. 
      For example, a smaller hospital with less young injured patients may be less apt to think about checking for occult fractures than one that is larger and sadly sees more of these patients.  The bottom line is that many injured children as a result of abuse and non-accidental injury are not being evaluated for occult fractures despite the importance of doing so.   
     How important is this?  Dr. Kristine Campbell, a specialist in the prevention of child abuse and neglect further comments on the ramifications of what this study suggests in an accompanying commentary (doi: 10.1542/peds.2015-0694).Hopefully forgetting to think about and in turn diagnose occult fractures does not happen in your local emergency room or in your practice when patients with alleged abuse are being evaluated –and if for some reason, you need a reminder to get a skeletal survey, this study and commentary should provide the painful reminder you need.

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Tuesday, March 17, 2015

Isolated Linear Skull Fractures in Minor Blunt Head Trauma: A Fine Line Regarding the Need for Minimal Further Workup

By: Lewis First, MD, MS; Editor-in-Chief  

Bethesda Medical Center
      Skull fractures are scary and usually when detected on a plain film, lead to further imaging and possible hospitalization for observation. But how concerned should we really be with an isolated linear skull fracture in the setting of a minor head injury?  Powell et al. (doi: 10.1542/peds.2014-2858) elected to study 350 children who had isolated linear skull fractures after experiencing a minor head injury such as from a fall.     
      The good news is that despite CT and MRI imaging, reimaging, and hospitalization in a good number of these patients, none require neurosurgical intervention. 
     This was a prospective cohort (which can be more valid and reliable than a retrospective cohort) and the fact that complications were nonexistent, certainly prompts one to not do more than some initial imaging to diagnose the simple fracture.       
     Is that what you do, or do you hospitalize patients with skull fractures and/or reimage them in the days that follow the minor head injury? Share your approach to this problem by responding to this blog or sending in an e-letter or posting on our Facebook or Twitter sites.




Wednesday, January 7, 2015

Strict Rest Following a Concussion. Heads Up on An Interesting Study!

By: Lewis First, MD, MS; Editor-in-Chief
Bethesda Naval Medical Center
 
     We certainly have become familiar with the recommendations for strict rest following a concussion. Often we council families to rest for 5 days before considering return to school or return to play activity—but how much better is 5 days versus fewer days before a step-wise return to activity?
     Thomas et al. (doi:10.1542/peds.2014-0966) sought to answer that question through a methodologically sound randomized controlled trial involving 45 intervention subjects 11-22 years of age who received recommendations for 5 days of strict bed rest  and 43 control subjects told to return to normal activity following 1-2 days of rest. 
      The result will surprise you. The group that got the prolonged rest had more post-concussive symptoms and slower symptom recovery. Just why did this study showed findings that differ from others?  That is the subject of discussion by the authors as well as by Doctors William Meehan and Richard Bachur (doi:10.1542/peds.2014-3665in an accompanying commentary to this study.   
      Do you agree with the findings in this study or feel 5 days of bed rest is still the way to head off complications of a serious concussion? Share your thoughts on this article and commentary by responding to this blog, or via an e-letter, or by commenting on our Facebook or Twitter sites.

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Thursday, June 19, 2014

Abusive Head Trauma Medical Costs

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our July issue. To learn more about Dr. Schulte and her work in general pediatrics and preventive medicine, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by COD Newsroom via Flickr
When infants and children are abused, the long-term consequences are serious. Shaken baby syndrome or abusive head trauma can shape children’s futures negatively, and two-thirds of such children are left with significant disability, often requiring more medical care. Those children also incur significant medical expenses according to research published early released from the July issue of Pediatrics.

Using a case-control methodology, Cora Peterson and her co-authors (doi: 10.1542/ peds.2014-0117) estimated that a child who suffered abusive head trauma incurred medical expenses totaling $47,952 in the four years after the injury. For children covered by commercial insurance, estimated expenses were $38,321. Estimated expenses were higher for Medicaid patients at $56,691. Those estimated expenses did not include non-medical costs related to special education or disability.

The authors studied children aged 0 to 4 years and used regression modeling to simulate the direct medical costs. The cases and controls (five controls for each abused child) were identified in the Truven Health MarketScan database, which reports paid insurance claims and patient encounters, for the period of 2003 through 2011. Their modeling of direct medical costs was based on payments made for medical care.

Their study of the economic costs during a four-year period after abusive head trauma is a sobering analysis of the devastating consequences of what child abuse can produce.

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