Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma.

OBJECTIVE: To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated 4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR. STUDY DESIGN: We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR. RESULTS: Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% (P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% (P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation. CONCLUSIONS: Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.

Derivation of a clinical prediction rule for pediatric abusive head trauma.

OBJECTIVES: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that-if validated-can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN: Prospective, multicenter, cross-sectional, observational. SETTING: Fourteen PICUs. PATIENTS: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity-to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform-not dictate-their early decisions to launch (or forego) an evaluation for abuse.

Scaling and root planing treatment for periodontitis to reduce preterm birth and low birth weight: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The aim of this study is to perform an updated systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy of scaling and root planing (SRP) in reducing the preterm-birth and low-birth-weight risks to analyze important subgroups and to further explore heterogeneity and bias risks in the pooled studies. METHODS: The entire Cochrane Library was searched (from 1990 to September 2011), MEDLINE (from 1950 to September 2011), CINAHL (from 1980 to September 2011), University of Michigan School of Dentistry "Dentistry and Oral Sciences" database (from 1990 to September 2011), conference proceedings, and the ClinicalTrials.gov database. Authors were contacted when clarification was needed. Selection criteria included the following: 1) RCTs that reported preterm-birth risk (<37 weeks) outcomes, 2) compared SRP treatment to either placebo or no treatment in pregnant patients with periodontitis, and 3) had a probing depth >4 mm or clinical attachment loss >2 mm for ≥ 1 site. Reviewers independently extracted data from each included study using a standardized, piloted form and assessed quality using a risk-of-bias tool modeled after Cochrane, and discrepancies were resolved. A random-effects model was used to calculate relative risks and 95% confidence intervals (CIs) for pooled data. For subgroup analysis with heterogeneity <50%, a fixed-effects model was used. RESULTS: After abstract review, 12 studies were identified by the search, and 11 were included in the main meta-analysis (preterm birth <37 weeks). Overall quality and design of included studies was fair or good. For the main meta-analysis, results ranged from risk ratio with periodontal treatment 0.14 (95% CI = 0.01, 2.55) to 1.24 (95% CI = 0.93, 1.67) for an overall risk ratio of 0.81 (95% CI = 0.64, 1.02). When analyzed separately by subgroup for excess prematurity risk, the high-risk group (overall prematurity of 22.2% to 62.8%) showed combined risk ratios of 0.66 (95% CI = 0.54, 0.80). Remaining studies (overall prematurity of 4.0% to 10.4%) showed combined risk ratio of 0.97 (95% CI = 0.75, 1.24). CONCLUSIONS: This systematic review and meta-analysis indicates statistically significant effect in reducing risk of preterm birth for SRP in pregnant women with periodontitis for groups with high risks of preterm birth only. Future research should attempt to confirm these findings and further define groups in which risk reduction may be effective.