Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico / Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Medicolegal analysis of physical violence toward physicians in Egypt.

This study analyzed physical violence against physicians in Egypt from a medicolegal perspective. 88%, 42%, and 13.2% of participants were exposed to verbal, physical, and sexual violence. Concerning the tools of violence, 75.2% of attackers used their bodies. Blunt objects (29.5%), sharp instruments (7.6%), and firearm weapons (1.9%) were used. The commonest manners of attacks were pushing/pulling (44.8%), throwing objects (38.1%), and fists (30.5%). Stabbing (4.8%) and slashing (2.9%) with sharp instruments were also reported. Traumas were mainly directed towards upper limbs (43.8%), trunks (40%), and heads (28.6%). Considering immediate effects, simple injuries were reported that included contusions (22.9%), abrasions (16.2%), and cut wounds (1.9%). Serious injuries included firearm injuries (4.8%), internal organs injuries (3.8%), fractures (2.9%), and burns (1.9%). Most (90.5%) of injuries healed completely, whereas 7.6% and 1.9% left scars and residual infirmities, respectively. Only 14.3% of physicians proceeded to legal action. The current study reflects high aggression, which is disproportionate to legal actions taken by physicians. This medicolegal analysis could guide protective measures for healthcare providers in Egypt. In addition, a narrative review of studies from 15 countries pointed to violence against physicians as a worldwide problem that deserves future medicolegal analyses.

Prevalence, predictors, and consequences of workplace violence among female healthcare workers in tertiary care hospitals: A cross-sectional study in Pakistan.

OBJECTIVE: To determine the prevalence, predictors and perpetrators of violence, and its impact on the mental health of female healthcare workers. METHODS: The cross-sectional study was conducted from June to October 2022 at three tertiary care hospitals after approval from the ethics review board of Rawalpindi Medical University, Rawalpindi, Pakistan, and comprised female healthcare workers, including doctors, nurses and paramedical staff. Data was collected regarding workplace violence using a structured questionnaire adopted from literature. The incidence of verbal, physical and sexual violence in the preceding 12 months was noted, and predictors were analysed. Data was analysed using SPSS 25. RESULTS: Of the 140 subjects with an age range of 16-60 years, verbal violence was experienced by 102(72.9%) and physical violence by 26(18.6%), while verbal and physical forms of sexual violence were reported by 33(23.6%) and 13(9.3%), respectively. Those in the Medicine department had significantly lower odds of experiencing verbal violence compared to those from the Surgery department (adjusted odds ratio=0.223; 95% confidence interval: 0.078-0.036; p=0.005). Those in the Emergency department had significantly greater odds of experiencing physical violence compared to those in Surgery (adjusted odds ratio=8.716; 95% confidence interval: 1.693-44.87; p=0.01). Violence had a significant detrimental impact on the mental health of female healthcare workers (p<0.05). CONCLUSIONS: Violence was found to be prevalent in the healthcare sector, specifically in stressful and critical-care departments, like Emergency and Surgery.

Association between threat-related adverse childhood experiences and chronic lung diseases in a middle and older aged population: A cross-sectional and longitudinal study in China.

OBJECTIVES: We investigated the association between threat-related adverse childhood experiences (ACEs) and the risk of chronic lung diseases (CLDs). METHODS: The data used for this study were extracted from the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative survey of respondents recruited from 450 villages/urban communities in 28 provinces. Threat-related ACEs were constructed using five adverse factors: household substance abuse, physical abuse, domestic violence, unsafe neighbourhood, and bullying). Participants were divided into three groups according to their number of threat-related ACEs at baseline and at follow-up. The association between threat-related ACEs and CLD prevalence in the cross-sectional study was calculated using logistic regression models. The association between threat-related ACEs and CLD onset was evaluated using Cox proportional regression models in the cohort study. Potential confounders were considered in both the cross-sectional and cohort studies. RESULTS: The CLD prevalence in the total population, no exposure group, exposure to one threat-related ACE, and exposure to at least two threat-related ACEs were 10.07% (1320/13104), 9.20% (665/7232), 10.89% (421/3865), and 11.66% (234/2007), respectively. Exposure to one threat-related ACE (OR: 1.23, 95% CI: 1.07-1.41) and exposure to at least two threat-related ACEs (OR: 1.31, 95% CI: 1.11-1.55) were significantly associated with higher CLD prevalence rates. The cohort study included 11,645 participants. During the 7-year follow-up, 738 CLD incidents were identified. Similarly, exposure to one threat-related ACE (HR: 1.20, 95% CI: 1.01-1.43) and at least two threat-related ACEs (HR: 1.64, 95% CI: 1.35-2.00) were significantly associated with a higher CLD incidence risk. CONCLUSIONS: Exposure to threat-related ACEs was significantly associated with a higher CLD prevalence risk and onset. It is crucial to identify individuals who have encountered childhood threats and prioritise the monitoring of their pulmonary function.

Does parental use of harsh discipline and punishment in response to ambiguous child situations vary by child physical abuse risk?

BACKGROUND/OBJECTIVES: The present study investigated the extent to which fathers and mothers at high-risk and low-risk for child physical abuse (CPA) differed in their use of harsh discipline and punishment when presented ambiguous child situations (situations where differences in positive and negative valences are close to zero). PARTICIPANTS/METHODS: High-risk for CPA parents (N = 74: fathers, n = 41; mothers, n = 33) and low-risk parents (N = 178: fathers, n = 91; mothers, n = 87) were asked to indicate their likelihood of using harsh verbal discipline (HVD), harsh physical discipline (HPD), and punishment (i.e., retributive harm separate from HVD and HPD) after viewing each of eighteen ambiguous child situations. RESULTS: As expected, high-risk, compared to low-risk, for CPA parents were significantly (ps < 0.001) more likely to use HVD (d = 0.546), HPD (d = 0.595), and punishment (d = 0.564). Overall, fathers, relative to mothers, were significantly more likely to use HVD (d = 0.261) and HPD (d = 0.238). For punishment, however, there was no significant parental role (father, mother) difference (d = 0.136). CONCLUSIONS: Since in everyday living situations many child behaviors are ambiguous, the findings that parents, especially high-risk for CPA parents, use harsh discipline and punishment when encountering ambiguous child situations suggest that non-contingent harsh child-related parental behaviors may be frequent in the lives of some children. The findings that parents may use non-contingent discipline and punishment suggest the need to explore whether, when these parenting behaviors occur, they increase the likelihood of negative child outcomes.

Explaining how childhood physical abuse and physical neglect influence adult depression: An analysis with multiple sequential mediators.

BACKGROUND: Substantial evidence indicates that experiencing physical abuse and neglect during childhood significantly elevates the likelihood of developing depression in adulthood. Nevertheless, there remains a dearth of understanding regarding the mechanisms underpinning this correlation. OBJECTIVE: In this study, we aimed to examine the associations of childhood physical abuse and physical neglect with depression using follow-up data from UK Biobank and quantified the contribution of smoking, insomnia, and BMI in these associations. PARTICIPANTS AND SETTINGS: This study included 144,704 participants (64,168 men and 80,536 women) from UK Biobank, most of whom were white (97 %). METHODS: Physical abuse and physical neglect were measured using two items of Childhood Trauma Screener (CTS). Data on the incidence of depression were obtained from primary care, hospital inpatient records, self-reported medical conditions, and death registries. We used a sequential mediation analysis based on the "g-formula" approach to explore the individual and joint effects of potential mediators. RESULTS: The depression incidence rate was 1.85 per 1000 person-years for men and 2.83 per 1000 person-years for women, respectively. Results of Cox proportional risk regression showed that physical abuse (HRs: 1.39-1.53, P < 0.001) and physical neglect (HRs: 1.43-1.60, P < 0.001) are associated with depression. Smoking, insomnia, and BMI together mediated 3 %-26 % of the associations. CONCLUSIONS: These findings contribute to our understanding of how physical abuse and physical neglect influence depression. Furthermore, a more effective reduction in the burden of depression can be achieved by managing modifiable mediators.

Prevalence and associated factors of sexual, psychological, and physical violence among physical therapists in their clinical role in Spain: a national web-based cross-sectional survey.

OBJECTIVES: To determine the extent of career-long and 12-month exposure to sexual, physical, and psychological/verbal violence committed by patients or their companions among physical therapists in Spain. Additionally, to identify the factors associated with such exposure. METHODS: This study employed an observational cross-sectional approach. Initially, a questionnaire was developed and validated using a convenience sample. Subsequently, it was distributed via email to all physical therapists registered in Spain in the first quarter of 2022. Individual risk models were created for each type of violence experienced within the past 12 months. RESULTS: The prevalence of violence encountered by physical therapists throughout their careers was 47.9% for sexual violence, 42.7% for psychological/verbal abuse, and 17.6% for physical abuse. Lower values were observed within the last 12 months (13.4%, 15.8%, and 5.2%, respectively). Statistical risk modeling for each type of violence experienced in the past 12 months indicated that the common precipitating factor for all forms of violence was working with patients with cognitive impairment. Working part-time appeared to be a protective factor. Other factors, such as the practitioners' gender, practice setting, or clinic location showed variations among the diverse types of violence. CONCLUSIONS: The exposure to type II workplace violence within the last 12 months among physical therapists in Spain (Europe) is not so high as in some other world regions. Various individual, clinical, and professional/organizational risk factors have been identified in connection with type II workplace violence. Further research is warranted to compare the violence experienced once the COVID pandemic has subsided.

Relationship of domestic violence with pregnancy symptoms and pregnancy experience in Iranian pregnant women: a cross-sectional study.

OBJECTIVE: Violence has had adverse effects on the physical and psychological dimensions of pregnant women. This study was conducted with the aim of determining the relationship of domestic violence with pregnancy symptoms and pregnancy experience. DESIGN: In this cross-sectional study, pregnant women were selected through two-stage cluster sampling method. Data were collected using the domestic violence questionnaire of the WHO, pregnancy symptoms inventory (PSI) and pregnancy experience scale (PES). To determine the relationship between domestic violence with pregnancy symptoms and pregnancy experience, adjusted general linear model was used in multivariate analysis. SETTING: Health centres in Urmia-Iran in 2022. PARTICIPANTS: 415 pregnant women. RESULTS: The frequency of emotional, physical and sexual violence was 86.0%, 67.7% and 79.5%, respectively. The mean (SD) of PSI was 49.45 (14.38) with attainable score of 0-123 and PES including happiness and worry was 14.32 (6.48) and 16.21 (2.51) with attainable score of 0-30, respectively. Based on the adjusted general linear model, the mean score of PSI in women who experienced physical violence (mild (p<0.001) and moderate (p<0.001)); sexual violence (mild (p<0.001), moderate (p<0.001) and severe (p<0.001)); and emotional violence (mild (p<0.001), moderate (p=0.002) and severe (p<0.001)) was significantly higher than women without experiencing violence. The mean score of happiness during pregnancy in women who experienced physical violence (moderate (p=0.011)) and emotional violence (mild (p<0.001), moderate (p=0.002) and severe (p<0.001)) was significantly lower than women without experience of violence. Also, the mean score of worry scores in women with experience of sexual violence (mild (p=0.001) and moderate (p=0.012)) and emotional violence (mild (p<0.001), moderate (p<0.001)) and severe (p<0.001)) was significantly higher than women without experiencing violence. CONCLUSION: Considering the relationship between violence and pregnancy symptoms and pregnancy experiences, it is necessary to use appropriate strategies to prevent violence in pregnant women.

Alexithymia as a mediator of the associations between child maltreatment and internalizing and externalizing behaviors in adolescence.

Child maltreatment is a global concern that profoundly affects individuals throughout their lives. This study investigated the relationships between various forms of child maltreatment and behavior problems involving internalization and externalization during adolescence. Data obtained from a diverse sample of 1802 Canadians aged 14-18 years was used to examine the mediating role of alexithymia-a difficulty in recognizing and expressing emotions-in these associations. Results indicated that adolescents who experienced sexual abuse, emotional abuse, and exposure to intimate partner violence (IPV) in their childhood exhibited higher levels of alexithymia, which was correlated with elevated levels of both internalizing and externalizing problems. Physical abuse and parental neglect were only associated with externalizing problems. Gender differences also emerged, with gender-diverse adolescents reporting a higher prevalence of maltreatment, alexithymia, and behavior problems compared with their peers. However, alexithymia's mediating role was consistent across genders. Overall, this study highlights the intricate relationships between child maltreatment, alexithymia, and adolescent behavior problems. The findings of this study how different forms of child maltreatment significantly shape behavioral outcomes and indicate the importance of interventions in enhancing emotional awareness and expression in adolescents with a childhood history of maltreatment.

Prevalence of physical violence against people in insecure migration status: A systematic review and meta-analysis.

OBJECTIVES: This study summarised evidence on the prevalence of interpersonal, community and state physical violence against people in insecure migration status. METHODS: We conducted a systematic review and meta-analysis of primary studies that estimated prevalence of physical violence against a population in insecure migration status. We searched Embase, Social Policy and Practice, Political Science Complete, SocINDEX and Web of Science Social Sciences Citation Index for reports published from January 2000 until 31 May 2023. Study quality was assessed using an adapted version of the Joanna Briggs assessment tool for cross-sectional studies. Two reviewers carried out screening, data extraction, quality assessment and analysis. Meta-analysis was conducted in Stata 17, using a random effects model and several exploratory subgroup analyses. RESULTS: We retrieved 999 reports and included 31 retrospective cross-sectional studies with 25,997 migrants in insecure status. The prevalence estimate of physical violence was 31.16% (95% CI 25.62-36.70, p < .00). There was no statistically significant difference in the estimates for prevalence of violence for men (35.30%, 95% CI 18.45-52.15, p < .00) and for women (27.78%, 95% CI 21.42-34.15, p < .00). The highest point estimate of prevalence of violence was where insecure status was related to employment (44.40%, 95% CI 18.24-70.57, p < .00), although there were no statistically significant difference in the subgroup analysis. The prevalence of violence for people in undocumented status was not significantly different (29.13%, 95% CI 19.86-38.41, p < .00) than that for refugees and asylum seekers (33.29%, 95% CI 20.99-45.59, p < .00). The prevalence of violence in Asia was 56.01% (95% CI 22.47-89.55, p < .00). Europe had the lowest point prevalence estimate (17.98%, 95% CI 7.36-28.61, p < .00), although the difference was not statistically significant. The prevalence estimate during the migration journey was 32.93% (95% CI 24.98-40.88, p < .00). Intimate partner violence attached to insecure status was estimated at 29.10%, (95% CI 8.37-49.84, p = .01), and state violence at 9.19% (95% CI 6.71-11.68, p < .00). CONCLUSIONS: The prevalence of physical violence is a concern among people in a range of insecure migration statuses. Prevalence of violence is not meaningfully higher for people in undocumented status than for people in other types of insecure status. REVIEW REGISTRATION: PROSPERO (CRD42021268772).

Workplace violence against Chinese licensed doctors: a cross-sectional study.

Introduction: China has issued and implemented a series of policies aimed at preventing and controlling workplace violence (WPV) against licensed doctors. However, the prevalence of WPV has not been fundamentally curbed. The aim of this study was to present the prevalence of WPV, identify its influencing factors and propose responsive measures. Method: The online Chinese Physician Practice Survey was conducted with purposive sampling method among licensed doctors in China from January 2022 to June 2022. Data covered licensed doctors' sociodemographic characteristics, occupational characteristics, prevalence of WPV, and perception of effective countermeasures. Results: A total of 74,305 licensed doctors participated in this study. A total of 44.88% of respondents had experienced WPV, among them, either physical violence only (1.06%) or non-physical violence only (89.91%) or encountered both of them (9.03%). Age, gender, marital status, education level, professional title and registration type were all associated with WPV, being younger, non-married, more educated, and higher professional title are all risk factors for WPV. Male (OR = 1.396, 95CI%: 1.355 to 1.439), clinicians (OR = 1.342,95%CI: 1.177 to 1.529), who were single (OR = 1.174, 95%CI: 1.111 to 1.241), with master's degree (OR = 2.021, 95%CI: 1.739 to 2.349) and professional title were subsenior (OR = 1.194, 95%CI: 1.125 to 1.267) were most likely to occur WPV. WPV occurred mostly in provincial capitals, public hospitals, primary and community hospitals, and departments of internal medicine, surgery, pediatrics, emergency medicine and mental health. Overall, 44.24% of doctors perceived that strengthening crackdowns on criminal behaviors was the most effective measure to prevent WPV against healthcare staff. Conclusion: The frequency of WPV decreased after the implementation of relevant laws and policies. Future efforts should be made to strengthen crackdowns on illegal and criminal activities and to issue specific legal provisions on the prevention and control of WPV against doctors.

The reciprocal relationship between child maltreatment and children's bullying victimization in China.

Children who experience physical and psychological maltreatment within their family are more likely to become victims of abuse outside the family. In Chinese culture, children's victimization may also be a precursor to parenting behaviors. Nevertheless, the reciprocal relationship between child maltreatment and children's bullying victimization remains unclear, particularly in Chinese culture. This study aimed to evaluate the reciprocal association between child maltreatment and children's bullying victimization in China, as well as its gender differences. A total of 891 children aged 8-11 years in China participated in the study at four time points. The potential reciprocal link was examined using a cross-lagged model. The results indicated that physical abuse predicted children's bullying victimization across four time points, while physical neglect predicted children's bullying victimization during the first three time points. The effects of emotional abuse and neglect were negligible. Conversely, children's bullying victimization consistently predicted various types of parental maltreatment over time. Some gender differences in the relationship were found. The findings emphasized a reciprocal relationship between child maltreatment within the family and children's bullying victimization at school. Understanding the cyclical patterns between child maltreatment and bullying victimization may help improve family education approaches and reduce children's bullying victimization.

Does it add up? Educational achievement mediates child maltreatment subtypes to allostatic load.

BACKGROUND: Childhood maltreatment (CM) has been linked to higher levels of allostatic load (AL) and educational achievement is a possible pathway and may differ across gender. It is also critical to determine if CM severity or specific subtypes of CM are more or less influential. OBJECTIVE: This study examined educational achievement as a mediator linking cumulative and individual types of CM to AL and examined gender as a moderator. PARTICIPANTS AND SETTING: Using two waves of data, 897 adults from the study Midlife in the United States were analyzed. METHODS: Multiple group structural equation models stratified across gender to test were used cumulative maltreatment and maltreatment subtypes to AL and test gender as a moderator. RESULTS: Overall CM was associated with educational achievement (ß = -0.12, p < .01) and AL (ß = 0.11, p < .05) and education was inversely associated with AL (ß = -0.17, p < .001) in men but not women. The subtypes model revealed that physical abuse predicted lower level of education achievement (ß = -0.20, p < .001) and among men. Educational achievement, in turn, was associated with lower levels of AL (ß = -0.02, p = .002). Educational achievement was a possible pathway linking physical abuse to AL (ß = 0.02, 95 % CI [0.001, 0.040]) among men but was non-significant in women. Gender did not moderate any of the pathways. CONCLUSIONS: Educational achievement is a potentially modifiable social determinant of health that can be a focus of prevention and intervention efforts among men who were maltreated, particularly for those who experienced physical abuse.

Pilot study using machine learning to improve estimation of physical abuse prevalence.

BACKGROUND: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes have been shown to underestimate physical abuse prevalence. Machine learning models are capable of efficiently processing a wide variety of data and may provide better estimates of abuse. OBJECTIVE: To achieve proof of concept applying machine learning to identify codes associated with abuse. PARTICIPANTS AND SETTING: Children <5 years, presenting to the emergency department with an injury or abuse-specific ICD-10-CM code and evaluated by the child protection team (CPT) from 2016 to 2020 at a large Midwestern children's hospital. METHODS: The Pediatric Health Information System (PHIS) and the CPT administrative databases were used to identify the study sample and injury and abuse-specific ICD-10-CM codes. Subjects were divided into abused and non-abused groups based on the CPT's evaluation. A LASSO logistic regression model was constructed using ICD-10-CM codes and patient age to identify children likely to be diagnosed by the CPT as abused. Performance was evaluated using repeated cross-validation (CV) and Reciever Operator Characteristic curve. RESULTS: We identified 2028 patients evaluated by the CPT with 512 diagnosed as abused. Using diagnosis codes and patient age, our model was able to accurately identify patients with confirmed PA (mean CV AUC = 0.87). Performance was still weaker for patients without existing ICD codes for abuse (mean CV AUC = 0.81). CONCLUSIONS: We built a model that employs injury ICD-10-CM codes and age to improve accuracy of distinguishing abusive from non-abusive injuries. This pilot modelling endeavor is a steppingstone towards improving population-level estimates of abuse.

Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse. / Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Racial and ethnic disparities in diagnostic imaging for child physical abuse.

IMPORTANCE: Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES: To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN: In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING: The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS: We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES: For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS: In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE: We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims.

OBJECTIVE: The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening. METHODS: Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ 2 analysis are reported. RESULTS: Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments. CONCLUSIONS: Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Consequences of the lack of clinical forensic medicine in emergency departments.

Most victims of physical violence sooner or later will access a hospital or medical cabinet because of that violence, and in particular emergency departments (EDs). This paper aims to analyze the performance of emergency ward clinicians in the forensic management of such victims by examining the activities carried out and the data reported. A total of 991 medical records were extrapolated from the database of the ED of the Policlinico of Milan in an average pre-pandemic 1-year activity. For each medical record, 16 parameters were analyzed in-depth including epidemiological data, information on the type of violent actions, injuries, and time between the infliction of the lesion and access to the ED. In the vast majority of cases, all the actions with medicolegal implications had been neglected by health professionals causing loss of data not only for the justice system but especially for correctly interpreting what happened and taking appropriate measures to protect the patient/victim. Hence, given that clinicians in EDs are busy with non-forensic clinical tasks (and rightly so), it should be ensured that there be specific forensic clinical personnel. However, it is crucial that when unfortunately there can be no forensic staff, at least the clinicians who work in the ED are properly trained to correctly apply essential medicolegal measures. Overall, timely and informed medical and forensic intervention is possible and necessary for the improvement and maintenance of the mental and physical health of victims of violence.

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse.

OBJECTIVES: Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury. METHODS: Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity. RESULTS: A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27). CONCLUSIONS: Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.