Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces

OBJECTIVEChildren who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.METHODSThe authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.RESULTSOf 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.CONCLUSIONSThe high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.

Abstract 11159: Prolonged QRS Duration Predicts Outcomes in Heart Failure With Preserved Ejection Fraction

Introduction: QRS widening on the surface electrocardiogram (ECG) is a marker of disease progression in heart failure (HF) with reduced ejection fraction. We hypothesized that prolonged QRS duration would similarly identify patients with HF with preserved ejection fraction (HFPEF) at high risk for cardiovascular (CV) events. Methods: We examined the relationship of baseline QRS duration to primary outcome [composite of CV death, aborted cardiac arrest, or HF hospitalization (HFH)] and HFH alone in TOPCAT, a multicenter, randomized, placebo-controlled trial of spironolactone in HFPEF. QRS duration was analyzed as a dichotomous variable (≥ 120 ms or < 120 ms). Multivariable analyses were conducted including variables that were significantly associated with QRS duration ≥ 120 ms (Table 1). Analyses were conducted in the entire study cohort as well as in separate analyses for only subjects enrolled from the Americas or from Russia/Georgia independently. Results: QRS duration was known in 3426 of 3445 TOPCAT patients. Compared to those with QRS duration < 120ms, 613 (17.9%) subjects had a QRS duration ≥ 120 ms and were older (72.9 years vs. 67.8 years; p < 0.0001) and more likely to be men (62% vs. 45%; p<0.0001). A QRS duration ≥ 120 ms was independently associated with an increased risk of primary outcome and HFH in the entire study cohort and in the subset of patients enrolled in the Americas but was of borderline statistical significance in Russia/Georgia (Table 1). No statistical interaction was observed between treatment with spironolactone and QRS duration (p value for interaction= 0.33). Conclusions: QRS duration identifies HFPEF subjects at a higher risk of adverse clinical outcomes; spironolactone had a similar effect on outcomes independent of QRS duration. This easily obtainable marker may be an important component of risk stratification in this syndrome.

Feasibility of Screening for Lynch Syndrome Among Patients With Colorectal Cancer

Purpose Identifying individuals with Lynch syndrome (LS) is highly beneficial. However, it is unclear whether microsatellite instability (MSI) or immunohistochemistry (IHC) should be used as the screening test and whether screening should target all patients with colorectal cancer (CRC) or those in high-risk subgroups. Patients and Methods MSI testing and IHC for the four mismatch repair proteins was performed on 500 tumors from unselected patients with CRC. If either MSI or IHC was abnormal, complete mutation analysis for the mismatch repair genes was performed. Results Among the 500 patients, 18 patients (3.6%) had LS. All 18 patients detected with LS (100%) had MSI-high tumors; 17 (94%) of 18 patients with LS were correctly predicted by IHC. Of the 18 probands, only eight patients (44%) were diagnosed at age younger than 50 years, and only 13 patients (72%) met the revised Bethesda guidelines. When these results were added to data on 1,066 previously studied patients, the entire study cohort (N = 1,566) showed an overall prevalence of 44 of 1,566 patients (2.8%; 95% CI, 2.1% to 3.8%) for LS. For each proband, on average, three additional family members carried MMR mutations. Conclusion One of every 35 patients with CRC has LS, and each has at least three relatives with LS; all of whom can benefit from increased cancer surveillance. For screening, IHC is almost equally sensitive as MSI, but IHC is more readily available and helps to direct gene testing. Limiting tumor analysis to patients who fulfill Bethesda criteria would fail to identify 28% (or one in four) cases of LS.

Equipment-independent reference values for dopamine transporter imaging with 123I-FP-CIT

Summary Aim: Reliable reference values are helpful to interpret and compare the results of dopamine transporter imaging with SPECT. Since semi-quantitative reference values cannot be easily transferred between imaging equipments, this study aimed to establish equipment independent normal values for the true striatal binding of 123I-FP-CIT. Patients, methods: Specific striatal FP-CIT binding of 6 healthy volunteers and 26 patients with essential tremor were used to generate a reference range by applying an equipment specific resolution dependent factor to compensate for recovery effects. This factor has been determined previously by a series of standardized phantom measurements of an anthropomorphic basal ganglia phantom. Herewith, the resulting DAT binding values represent the expected true specific binding in the striatum. Results: On average, true specific striatal binding was 5.83 ± 0.96 in healthy controls, 5.25 ± 0.67 in patients with essential tremor and 5.36 ± 0.75 in the entire study cohort. Conclusion: These preliminary results may serve as a basis for the generation of a generally accepted equipment independent reference range for dopamine transporter imaging with 123I-FP-CIT. By a simple phantom measurement that can be accomplished within one day factors related to specific imaging equipment and processing can be corrected for, resulting in specific binding values which may enable a more standardized interpretation of dopamine transporter scans.