Zoe Frances Lawson

Patterns of burns and scalds in children

Objective To describe the characteristics of childhood burns and scalds, mechanisms and agents to inform prevention. Methods Prospective multicentred cross-sectional study of children (<16 years) with unintentional burns/scalds from five Emergency Departments (ED), a burns assessment unit and three regional childrens Burns Units. Data collected: site, severity, distribution of the burn/scald, age, motor development of the child, agent and mechanism of the injury. Comparative analysis for children <5 and 5–16 years. Results Of 1215 children, 58% (709) had scalds, 32% (390) contact burns and 116 burns from other causes, 17.6% (214/1215) were admitted to hospital and the remaining treated in ED or burns assessment centre. 72% (878) were <5 years, peak prevalence in 1-year-olds. Commonest scald agent (<5 years) was a cup/mug of hot beverage 55% (305/554), and commonest mechanism was a pull-down injury 48% (66/554). In 5–16-year-olds, scalds were from hot water 50% (78/155) and spill injuries 76% (118/155). Scalds affected the front of the body in 96% (680/709): predominantly to the face, arms and upper trunk in <5-year-olds, older children had scalds to the lower trunk, legs and hands. Contact burns (<5 years) were from touching 81% (224/277) hot items in the home, predominant agents: hair straighteners or irons 42% (117/277), oven hobs 27% (76/277), 5–16-year-olds sustained more outdoor injuries 46% (52/113). 67% (262/390) of all contact burns affected the hands. Conclusions Scalds to infants and toddlers who pull hot beverages over themselves or sustain burns from touching irons, hair straighteners or oven hobs are a high priority for targeted prevention.

A Timetable for the Radiologic Features of Fracture Healing in Young Children

OBJECTIVE Fracture dating significantly shapes decisions in child protection. With a dearth of primary evidence underpinning fracture dating in children, we examined the key radiologic features of fracture healing and their timelines. MATERIALS AND METHODS Digital radiographs of children younger than 72 months old with accidental long bone fractures of known timing were reviewed independently by three pediatric radiologists blinded to the age of the fractures. Six radiologic features of fracture healing were evaluated: soft-tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling. Interobserver agreement was assessed using kappa analysis. RESULTS Two hundred twenty-eight films of 82 fractures in 63 children (mean age, 4.8 years) were assessed. Soft-tissue swelling was identified by two or more radiologists in 59% of the radiographs at days 1-2 after fractures, and prevalence sharply declined thereafter. Periosteal reaction was first seen at day 5 and was present in 62% of the films obtained between 15 and 35 days after the fracture. Soft callus was first seen at day 12 and was prevalent in 41% between 22 and 35 days. Hard callus and bridging began at day 19, increasing to 60% prevalence from 36 days onward. Remodeling was observed only in fractures 45 days old or more. Kappa scores were between 0.55 and 0.80 overall, with greater agreement when there was no plaster cast. CONCLUSION The results of this study show that fractures in young children may be dated as acute (< 1 week), recent (8-35 days), or old (≥ 36 days) on the basis of the presence of six key radiologic features in combination. Furthermore, good interobserver agreement suggests these results are reproducible.

Which is the preferred image modality for paediatricians when assessing photographs of bruises in children

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.

When do children get burnt

Burns are a cause of more than 5000 paediatric hospital admissions per year in England and Wales. Injury prevention and service provision may be better planned with knowledge of burn timing. Prospectively collected records from 1st January 2010 to 31st December 2011 were analysed. All episodes involving patients less than 16 years of age reviewed by the South West Childrens Burns Centre were included. Data was collected from 1480 records to investigate seasonal, weekly, and daily variation. Day to day analysis showed significantly more burns occurred on Saturday and Sunday than Monday-Friday (p<0.001). Of all burns, 46% occurred within the time-period 08:00-15:59; however the mean hourly rate of burns was highest between 16:00 and 18:59. Of the larger burns (>10% body surface area), 38% occurred after 19:00. There was no statistically significant variation in the monthly (p=0.105) or seasonal (p=0.270) distribution of burns. Bank holidays did not cause a statistically significant increase in numbers. Injury prevention strategies are likely to have most volume impact by increasing awareness of the peak time for burns in children, enabling parents at home with young children to modify any risky behaviour and by targeting older children and their behaviour.

Development and validation of a standardized tool for reporting retinal findings in abusive Head trauma

PURPOSE To develop and validate a robust standardized reporting tool for describing retinal findings in children examined for suspected abusive head trauma. DESIGN A prospective interobserver and intraobserver agreement study. METHOD An evidence-based assessment pro forma was developed, recording hemorrhages (location, layer, severity) and additional features. Eight consultant pediatric ophthalmologists and 7 ophthalmology residents assessed a series of 105 high-quality RetCam images of 21 eyes from abusive head trauma cases with varying degrees of retinal hemorrhage and associated findings. The pediatric ophthalmologists performed a repeat assessment of the randomized images. The images were observed simultaneously with standardized display settings. Interobserver and intraobserver agreement was assessed using free-marginal multirater kappa, intraclass correlation coefficients, and concordance coefficients. RESULTS Almost-perfect interobserver agreement was observed for residents and pediatric ophthalmologists recording the presence and number of fundus hemorrhages (intraclass correlation coefficients 0.91 and 0.87, respectively) and the location of hemorrhages (concordance coefficients 0.86 and 0.85, respectively). Substantial agreement was observed by both groups regarding size of hemorrhage (concordance coefficients 0.73 and 0.76), moderate agreement for hemorrhage morphology (concordance coefficients 0.53 and 0.52), and other findings (concordance coefficients 0.48 and 0.59). Intraobserver agreement for pediatric ophthalmologists varied by question, ranging from substantial to perfect for the presence, number, location, size, and morphology of fundus hemorrhage. CONCLUSION We have developed and validated a standardized clinical reporting tool for ophthalmic findings in suspected abusive head trauma, which has excellent interobserver and intraobserver agreement among consultant specialists and residents. We suggest that its use will improve standardized clinical reporting of such cases.

Focussing on the future: Survey results on the image capture of patterned cutaneous injuries

An investigator who is involved in assessing the likelihood of physical abuse must make a decision as to whether the injury seen matches the explanation given. In some instances the pattern of these injuries can give the investigator a possible link to the cause of the injury. Photographic imaging is used to record the patterned cutaneous injuries (PCI) and to facilitate forensic interpretation. The current method of capturing PCI often results in some form of distortion that causes a change to the shape of the patterned injury. The Dermatological Patterned Injury Capture and Analysis (DePICA) research group was formed to assess current image capture methods and practices. An online survey was set up to assess the value of localised imaging protocols and training specific to imaging PCI and was made available to law enforcement professionals, forensic investigators and hospital staff. 80 participants responded to the survey. The majority of the survey participants have had training in medical or forensic photography, however 66 (83%) have not had specific training in how to photograph PCI. 41 (51%) of the participants responded that they always use a rigid scale and 34 (43%) position the camera so that it is perpendicular to the scale and injury. Comments made about the quality of images obtained and produced raises concerns about how much knowledge those initiating such images have about image relevance in criminal cases. It is evident that a clear and comprehensive guide to photographing PCIs is required to improve the quality of the photographic evidence that is collected.

Contrast Enhancement of Bite Mark Images Using the Grayscale Mixer in ACR in Photoshop

Enhanced images may improve bite mark edge definition, assisting forensic analysis. Current contrast enhancement involves color extraction, viewing layered images by channel. A novel technique, producing a single enhanced image using the grayscale mix panel within Adobe Camera Raw®, has been developed and assessed here, allowing adjustments of multiple color channels simultaneously. Stage 1 measured RGB values in 72 versions of a color chart image; eight sliders in Photoshop® were adjusted at 25% intervals, all corresponding colors affected. Stage 2 used a bite mark image, and found only red, orange, and yellow sliders had discernable effects. Stage 3 assessed modality preference between color, grayscale, and enhanced images; on average, the 22 survey participants chose the enhanced image as better defined for nine out of 10 bite marks. The study has shown potential benefits for this new technique. However, further research is needed before use in the analysis of bite marks.

Reducing Error in Spreadsheets: Example Driven Modeling Versus Traditional Programming

This article presents experimental data supporting an alternative approach to developing decision support spreadsheets using a Programming by Demonstration paradigm. This technique is coined “Example Driven Modeling” and uses example data (attribute classifications) in combination with inductive machine learning to create decision support models as an alternative to spreadsheet programming. This experiment examines whether participants can define attribute classifications (“example-giving”) satisfactorily and describe benefits and limitations this method offers through statistical analysis of the experimental results. The article then considers the wider implications of this research in traditional programming.

Clinical photography of bruises: measurement variability and image modality preference

Aims Bruise photographs serve as a clinical record and may facilitate forensic analysis if physical child abuse is suspected. Currently, only conventional (unfiltered visible light) imaging is employed; however, alternative imaging modalities may provide additional information. Observer variation in interpretation of colour and age of bruises, using conventional imaging techniques, is considerable. Findings from two pilot studies will be presented: (1) Within- and between-observer variation when measuring bruises on printed and digital conventional images; (2) Image modality preference of paediatricians when assessing bruise photographs, and between-observer agreement therein. Methods Study (1) 45 observers recorded the greatest lengths of six bruises on two occasions. All completed manual and electronic measurements, using a paper tape-measure for printed images and ImageJ software on a lap-top for digital images. Study (2) Nine Child Protection paediatricians independently ranked five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared), for four bruises, by completing a questionnaire. Results Study (1) Widespread observer variation existed for both manual and electronic measurements; within-observer SD ranged from 2.1 to 4.7, between-observer SD from 2.1 to 5.2. Observers were found to be prone to rounding bias (digit preference to nearest 5 mm) upon manual assessment. Paired t tests showed mean bruise sizes were smaller for manual measurements than for electronic, this difference was significant 10 of 12 times. Study (2) Paediatricians almost unanimously preferred cross-Polarised for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the last two positions. Between-observer agreement on preference was high, with coefficients of concordance between 0.76 and 0.96. Image modality combinations, chosen to give the most complete picture of the bruise, predominantly consisted of cross-Polarised and conventional (colour and grey-scale). Conclusions In order to increase consistency and reliability of recordings, a standardised automated method for bruise assessment is sought. Cross-polarised imaging is not currently requested from medical photographers within the context of bruising, but would appear to have the potential to better assess size and boundary. More extensive research to define the optimal imaging protocol is vital.