Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments.

OBJECTIVES: Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months. METHODS: We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). RESULTS: Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. CONCLUSION: Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.

Impact of a state concussion law on pediatric emergency department visits.

OBJECTIVE: Many states have passed concussion laws that mandate that players undergo medical clearance before returning to play. Few data have been collected on the impact of such laws on emergency department (ED) visits. This study measures the impact of Rhode Island concussion legislation on sports-related concussion visits to a pediatric ED. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes with injury mechanism-associated E-codes were extracted from hospital databases from 2004 to 2011 for both sports-related concussions and sports-related ankle ligamentous injuries (comparison group). Visit rates for sports-related concussions were compared before and after the passage of the state concussion law.Secondary outcome measures included rates of head imaging per ED visit for concussion before and after passage of the law. Times series analysis was used to analyze season-to-season count and rate changes. RESULTS: Overall rate of sports-related concussion visits more than doubled (2.2-fold increase; 95% confidence interval, 1.3-3.6; adjusted P = 0.01) during the fall sports season following the implementation of legislation (2010) relative to the previous year (3.6% vs 1.4%). Rates of sports-related ankle sprain visits tended to increase during the fall sports season but did not achieve statistical significance. Rates of computed tomography scan imaging of the head did not change over time. CONCLUSIONS: The data from this study revealed an increase in pediatric ED visits for sports-related concussions, without a corresponding increase in head imaging, suggesting that the passage of a state concussion law has led to increased vigilance in evaluation of sports-related concussions, without an increase in diagnostic computed tomography scans.

The use of alternate light sources in the clinical evaluation of child abuse and sexual assault.

Alternate light sources are devices that produce visible and invisible light at specific wavelengths to allow for enhanced visualization of fluorescent substances. These devices (which include Wood's lamp and blue light) are often used in forensics for evidence collection and can be quite useful to physicians in the medical evaluation of suspected physical or sexual assault. An understanding of the proper applications, as well as the limitations, of each alternate light source is imperative to correctly performing and interpreting medical evaluations in the emergency department. This review discusses the evidence from prospective trials in children and adults on the ability of specific alternate light sources to identify evidence of physical or sexual assault and also highlights some promising new technological adjuncts to alternate light sources that may allow for accurate dating of bruising.

Molecular basis of the time-dependent inhibition of cyclooxygenases by indomethacin.

Cyclooxygenases (COXs) are the therapeutic targets of nonsteroidal antiinflammatory drugs. Indomethacin (INDO) was one of the first nonsteroidal antiinflammatory drugs to be characterized as a time-dependent, functionally irreversible inhibitor, but the molecular basis of this phenomenon is uncertain. In the crystal structure of INDO bound to COX-2, a small hydrophobic pocket was identified that surrounds the 2'-methyl group of INDO. The pocket is formed by the residues Ala-527, Val-349, Ser-530, and Leu-531. The contribution of this pocket to inhibition was evaluated by altering its volume by mutagenesis of Val-349. The V349A mutation expanded the pocket and increased the potency of INDO, whereas the V349L mutation reduced the size of the pocket and decreased the potency of INDO. Particularly striking was the reversibility of INDO inhibition of the V349L mutant. The 2'-des-methyl analogue of INDO (DM-INDO) was synthesized and tested against wild-type COX-1 and COX-2, as well as the Val-349 mutants. DM-INDO bound to all enzymes tested, but only inhibited wt mCOX-2 and the V349I enzyme. Without the 2'-methyl group anchoring DM-INDO in the active site, the compound was readily competed off of the enzyme by arachidonic acid. The kinetics of inhibition were comparable to the kinetics of binding as evaluated by fluorescence quenching. These results highlight binding of the 2'-methyl of INDO in the hydrophobic pocket as an important determinant of its time-dependent inhibition of COX enzymes.