Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
Child Abuse Negl. 2023 Oct;144:106371. doi: 10.1016/j.chiabu.2023.106371. Epub 2023 Aug 1.
Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists.
To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs).
Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career.
This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons.
There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example.
Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
虽然有关于虐待性头部外伤的诊断和时机的研究，但儿科专家之间的实践仍存在差异。
使用婴儿头部损伤的病例示例来检查儿科专家的诊断变异性。次要目标是检查专家之间的时间变化，以及儿科虐待儿童医师 (CAP) 之间的诊断和时间变化。
从儿科虐待儿童、医院医学、急诊医学、重症监护和神经外科招募儿科专家完成研究工具。如果他们在职业生涯中至少评估了 1 例可能的虐待性头部外伤，则符合研究条件。
这项多机构、混合方法研究使用了一个研究工具，其中包含 4 个婴儿头部损伤的病例示例：严重视网膜出血 (RH)、有肿块效应的硬膜下血肿 (SDH)、SDH 膜形成和败血症。大多数 CAP 选择的反应是参考，并在专业之间以及 CAP 之间使用卡方或 Fisher 精确检验进行比较。使用 Bonferroni 校正 (p < 0.01) 进行专业比较。
有 288 名参与者完成了至少 1 个病例示例。在所有病例示例中都观察到了诊断变异性。选择参考反应的医院医学 (34.9% vs. 57.9%，p < 0.01)、急诊医学 (28.0% vs. 57.9%，p < 0.0001) 和神经外科 (24.0% vs. 57.9%，p < 0.01) 参与者明显较少。对于有肿块效应的 SDH 病例示例，选择参考反应的参与者明显较少。所有病例示例的时间变化均具有统计学意义 (p < 0.01)。选择参考反应的年龄在 44-64 岁的 CAP 明显较少 (p < 0.01)，用于严重 RH 病例示例的时间。
对于虐待性头部外伤中的具有挑战性的问题，可能需要额外的同行审查过程和共识指南。
