School Nurses on the Front Lines of Healthcare: Red Flags and Red Herrings: Improving the Recognition of Bruises and Burns Associated With Physical Abuse in School-Age Children.

Through a series of case scenarios, this article describes the assessment and management of suspected physical child abuse presenting as bruises and burns. Although it is not uncommon for school-age children to have accidental injuries, recognizing patterns associated with physical child abuse and understanding red flags for abuse is vital. Failure to recognize injury patterns suspicious for physical child abuse, and thus failure to intervene appropriately, may leave children at risk for more serious injury or death.

When Medical Care and Parents Collide-Parents Who Refuse Testing and or Treatment for Children.

Medical Neglect is a challenging diagnosis. Physicians and parents may clash over what they both perceive to be in the best interest of the child. Cultural, religious, financial, or philosophical differences between the health care providers and families can be difficult to negotiate. This paper reviews the definition of medical neglect and describes barriers that can prevent families from following medical recommendations for their child. Involvement of statutory authorities to intervene in cases of medical neglect may be helpful, but also may result in increased friction between parents and the health system, often without a satisfactory outcome for the child. Recognizing and then overcoming such barriers, as well as improving communication can help the family to begin to cooperate with medical recommendations. The paper will present an approach to families, parameters for reporting when all other options have failed, and the child remains at risk for harm due to the failure of the parent or caregiver to follow medical advice. The ultimate goal of any intervention is to ensure that children can achieve their full potential, in a nurturing and caring environment.

Racial and Ethnic Disparities and Bias in the Evaluation and Reporting of Abusive Head Trauma.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P <.001 [aOR, 4.1] and P <.001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians' implicit bias.

A tunable hydrogel system for long-term release of cell-secreted cytokines and bioprinted in situ wound cell delivery.

For many cellular therapies being evaluated in preclinical and clinical trials, the mechanisms behind their therapeutic effects appear to be the secretion of growth factors and cytokines, also known as paracrine activity. Often, delivered cells are transient, and half-lives of the growth factors that they secrete are short, limiting their long-term effectiveness. The goal of this study was to optimize a hydrogel system capable of in situ cell delivery that could sequester and release growth factors secreted from those cells after the cells were no longer present. Here, we demonstrate the use of a fast photocross-linkable heparin-conjugated hyaluronic acid (HA-HP) hydrogel as a cell delivery vehicle for sustained growth factor release, which extends paracrine activity. The hydrogel could be modulated through cross-linking geometries and heparinization to support sustained release proteins and heparin-binding growth factors. To test the hydrogel in vivo, we used it to deliver amniotic fluid-derived stem (AFS) cells, which are known to secrete cytokines and growth factors, in full thickness skin wounds in a nu/nu murine model. Despite transience of the AFS cells in vivo, the HA-HP hydrogel with AFS cells improved wound closure and reepithelialization and increased vascularization and production of extracellular matrix in vivo. These results suggest that HA-HP hydrogel has the potential to prolong the paracrine activity of cells, thereby increasing their therapeutic effectiveness in wound healing. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1986-2000, 2017.

Experimental testicular tissue banking to generate spermatogenesis in the future: A multidisciplinary team approach.

Spermatogonial stem cell (SSC) loss due to cancer treatment, developmental disorder or genetic abnormality may cause permanent infertility. Cryopreservation of ejaculated sperm is an effective method of fertility preservation in adult males at risk of infertility. However this is not an option in pre-pubertal boys because spermatogenesis has not yet started, and it is difficult in adolescents who are not sexually mature. Therefore testicular tissue cryopreservation to preserve SSCs for future generation of spermatogenesis, either in vivo or in vitro, could be an option for these groups of patients. Although SSC transplantation has been successful in several species including non-human primates, it is still experimental in humans. There are several remaining concerns which need to be addressed before initiating trials of human SSC autotransplantation. Establishment of a testicular tissue banking system is a fundamental step towards using SSC technology as a fertility preservation method. It is important to understand the consultation, harvesting the testicular tissue, histological evaluation, cryopreservation, and long term storage aspects. We describe here a multidisciplinary approach to establish testicular tissue banking for males at risk of infertility.

Mandated reporting thresholds for community professionals.

This study examines how community-based mandated reporters understand and interpret reasonable suspicion, the standard threshold for mandated reporting of suspected child abuse. Respondents were asked to identify the probability necessary for "suspicion of child abuse" to constitute reasonable suspicion. Data were analyzed for internal consistency, evidence of a group standard, and associations with professional and educational demographics. There was a 90.4% response rate (1,233/1,364). On both ordinal probability and estimated probability scales, respondents demonstrated wide variability in the thresholds they identified for what constitutes reasonable suspicion. Comparing individual responses for the two scales, 83% were inconsistent. Responses on the estimated probability scale were correlated with frequency of reporting child abuse, professional background, and prior education on child abuse. Lack of consensus in how community professionals interpret reasonable suspicion raises the question of whether more specific training is needed for this threshold to be understood, interpreted, and applied in a consistent manner.

Child abuse experts disagree about the threshold for mandated reporting.

CONTEXT: Though reasonable suspicion serves as the standard threshold for when to report suspected child abuse, there is little guidance how to interpret the term. OBJECTIVE: To examine how experts on child abuse interpret reasonable suspicion using 2 probability frameworks. PARTICIPANTS: Anonymous survey of clinical and research experts on child abuse. MAIN OUTCOME MEASURES: Responses on ordinal and visual analog scales quantifying the probability needed for "suspicion of child abuse" to rise to reasonable suspicion. RESULTS: A total of 81 of 117 experts completed the survey (69% response rate, mean age 47 years, 69% female). On both the ordinal probability scale (rank order on a differential diagnosis) and the estimated probability scale (1% to 99% likelihood), experts demonstrated wide variability in defining reasonable suspicion, with no statistically significant differences found for age, race, gender, professional training, seniority, or prior education on reasonable suspicion. CONCLUSIONS: This study found no consensus in how experts on child abuse interpret reasonable suspicion.

Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents.

OBJECTIVES: To determine whether the commonly used over-the-counter medications dextromethorphan and diphenhydramine are superior to placebo for the treatment of nocturnal cough and sleep difficulty associated with upper respiratory infections and to determine whether parents have improved sleep quality when their children receive the medications when compared with placebo. METHODS: Parents of 100 children with upper respiratory infections were questioned to assess the frequency, severity, and bothersome nature of the nocturnal cough. Their answers were recorded on 2 consecutive days, initially on the day of presentation, when no medication had been given the previous evening, and then again on the subsequent day, when either medication or placebo was given before bedtime. Sleep quality for both the child and the parent were also assessed for both nights. RESULTS: For the entire cohort, all outcomes were significantly improved on the second night of the study when either medication or placebo was given. However, neither diphenhydramine nor dextromethorphan produced a superior benefit when compared with placebo for any of the outcomes studied. Insomnia was reported more frequently in those who were given dextromethorphan, and drowsiness was reported more commonly in those who were given diphenhydramine. CONCLUSIONS: Diphenhydramine and dextromethorphan are not superior to placebo in providing nocturnal symptom relief for children with cough and sleep difficulty as a result of an upper respiratory infection. Furthermore, the medications given to children do not result in improved quality of sleep for their parents when compared with placebo. Each clinician should consider these findings, the potential for adverse effects, and the individual and cumulative costs of the drugs before recommending them to families.