Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
Department of Pediatrics, UMass Chan Medical School-Baystate Health, 759 Chestnut Street, Springfield, MA 01199, USA.
Child Abuse Negl. 2022 Jul;129:105666. doi: 10.1016/j.chiabu.2022.105666. Epub 2022 May 11.
Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms.
To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT.
Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021.
Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values.
Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96.
The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
医师对虐待性头部外伤 (AHT) 的诊断一直受到循环推理和过度依赖“三联征”发现的批评。在没有金标准的情况下，对 AHT 和非 AHT 应用严格参考标准的分析可以证实或反驳这些批评。
比较有目击/入院 AHT 与有目击/入院非 AHT 患者的临床表现和损伤，以及有目击/入院 AHT 与无目击/入院医师诊断 AHT 患者的临床表现和损伤。测量三联征在有目击/入院 AHT 与有目击/入院非 AHT 患者中的 AHT 检测性能。
2010 年至 2021 年间，18 个地点的急性头部受伤 <3 岁住院接受重症监护的患者。
对现有、合并的横断面数据集进行二次分析。概率值和优势比用于识别和描述差异。测试性能指标包括敏感性、特异性和预测值。
与有目击非 AHT 的患者（n=100）相比，有目击/入院 AHT 的患者（n=58）更常出现呼吸窘迫（OR 2.94，95%CI：1.50-5.75）；延长的脑病（OR 5.23，95%CI：2.51-10.89）；躯干、耳朵或颈部瘀伤（OR 11.87，95%CI：4.48-31.48）；双侧硬膜下血肿（OR 8.21，95%CI：3.94-17.13）；弥漫性脑缺氧、缺血或肿胀（OR 6.51，95%CI：3.06-13.02）；和密集、广泛的视网膜出血（OR 7.59，95%CI：2.85-20.25）。所有差异均具有统计学意义（p≤.001）。在有目击/入院 AHT（n=58）与未目击/入院诊断 AHT（n=438）患者之间未观察到显著差异。三联征表现出 AHT 特异性和阳性预测值≥0.96。
在有目击/入院 AHT 与有目击非 AHT 患者中观察到的差异证实了先前的报告。在有目击/入院 AHT 与未目击/入院诊断 AHT 患者之间没有差异，这支持了一种印象，即医生应用诊断推理是基于先前报告的损伤模式的知识。在出现“三联征”的患者中，对虐待的担忧是合理的。
