When Should Retinal Hemorrhages be Considered Suspicious for Non-Accidental Head Injury?

Patient Presentation

A 6-month-old male came to the emergency room with a history of falling out of his mother’s arms onto a bed. The infant cried and mother placed him into the crib as it was time for his nap. About 1 hour later, the infant was crying, had vomitted and the mother felt he was lethargic. The radiologic evaluation showed frontal and interhemispheric acute subdural hematomas and the infant was transferred to a regional children’s hospital for neurosurgical care. The past medical history revealed a full-term, normal spontaneous vaginal delivery without complications. The patient had received routine care and immunizatons. The family history was negative for neurological or congenital abnormalities. There were no reported early or unexplained deaths or miscarriages in the families.

The pertinent physical exam showed normal vital signs. Weight was 10%, head circumference was 95% and length was 25%. The infant had an irritated cry. The anterior fontanelle was bulging. There was bruising from intravenous catheter placement attempts but no other bruising. The rest of the examination was normal. The work-up was negative including screening trauma labs, urine drug screen and hair studies, bleeding studies, urine organic acids, and skeletal survey. The ophthalmological consultant found superficial and deep bilateral retinal hemorrhages that were too numerous to count and covered most of the retinas. During the patient’s clinical course he was placed on anti-epileptic medication and did not have any seizures. Along with the child protection services team, the inpatient hospital physicians reported the child to the Department of Family Services as highly suspicious for a diagnosis of non-accidental trauma. The investigators agreed and the child was discharged to kinship foster care after two weeks of monitoring in the hospital for stabilization of the subdural hemorrhages. The child was to follow-up with neurosurgery in 2 weeks.

Case Image

Figure 88 – Axial image from an unenhanced computed tomography scan of the brain demonstrates high density right frontal and interhemispheric acute subdural hematomas. There is some associated mild swelling of the right cerebral hemisphere.

Discussion
Shaken baby syndrome (SBS) is a form of non-accidental head injury (NAHI) that occurs when someone violently shakes a child. It may result in brain, eye and/or skeletal injury. The long-term survival is poor with cognitive/behavioral problems, cognitive impairment, cerebral palsy, and/or epilepsy as common problems. In one report 19% of the children died as a direct result of SBS and only 22% had no sequelae at discharge. SBS can be misdiagnosed particularly if it is less severe, has no external bruising (21% of cases) and no history of previous abuse (40%).

SBS often occurs in infancy but can occur in children up to 8 years of age in the literature. Incomplete ophthalmological examination may under-estimate the presence and/or extent of retinal hemorrhages (RH). Complete examination of the entire retina is needed for proper evaluation, which usually means by an ophthalmologist.

Learning Point
Togioka states “[a]lthough the presence of RH [retinal hemorrhage] does not confirm the diagnosis of SBS. RHs are common in abused children and exceedingly rare in cases of accidental head injury.”

Injury type
RH presence is much more common in NAHI (53-80%) than in AHI (accidental head injury, 0-10%). The AHI that has RH associated with it is usually of significant force (e.g. motor vehicle accident). Short falls (< 4 feet) are extremely unlikely to cause RHs. In one study of 287 children, no children who had an accidental fall < 4 feet had RH, while 25% of those with a fall in the abused group had RHs.

Anatomy
Flame shaped RHs are the most common form of RH seen in SBS. RHs appear to generally start more centrally and superficially within the retina and then spread more peripherally and deeper with an increasing amount of force/trauma. Studies have shown peripheral RHs are seen in 27% of NAHI and 0% in AHI. Unilateral retinal hemorrhages can be seen in NAHI (14-21%). Bilateral RH are found in 58-100% with NAHI and in only 1.5% of accidental head injury. Other ophthalmological pathology has been linked to NAHI including hemorrhages in other parts of the eye, retinal folds, macular folds and Roth spots.

Other diseases that can cause RH include:

  • Glutaric aciduria type 1
  • Hemorrhage disease of the newborn
  • Hermansky-Pudlak Syndrome
  • Osteogenesis imperfecta
  • Protein C deficiency (homozygous) and other coagulopathies
  • Terson syndrome

Data shows that forceful emesis, forceful coughing, seizures and prolonged chest compressions basically do not cause the RHs seen in SBS. RH can be seen after birth in up to 30-40% of deliveries but most are resolved in 3-9 days after birth.
While alternative explanations for NAHI can be hypothesized, Moran noted that “[t]here is no disease or condition that fully mimics the complete diagnostic picture of SBS.”

Questions for Further Discussion
1. What are some of the clinical presentation of non-accidental trauma?
2. What are the local laws regarding mandatory reporting of suspected non-accidental trauma?
3. What types of testing should be included in an evaluation for suspected non-accidental trauma?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Child Abuse

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Makoroff K. Child Abuse Identification Toolkit for Professionals. Cincinnati Children’s Hospital.
Available from the Internet at http://www.cincinnatichildrens.org/svc/alpha/c/child-abuse/tools/retinal-hemorrhage.htm (cited 8/5/10).

Moran KT. National Australian conference on shaken baby syndrome. Med J Aust. 2002 Apr 1;176(7):310-1.

Reece RM, Sege R. Childhood Head Injuries: Accidential or Inflicted. Arch Pediatr Adolesc Med. 2000;154:11-15.

Togioka BM, et.al. Retinal hemorrhages and shaken baby syndrome: an evidence-based review. J Emerg Med. 2009 Jul;37(1):98-106.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Is This An Epidermal Cyst?

    Patient Presentation
    A 15-year-old female came to clinic for a round lesion on the anterolateral right neck that was slowly increasing in size over several months. She had noted it being 1/2 a pea-size and now it was almost pea-sized. She had squeezed it and a small amount of whitish, thick material had come out of it. Afterwards the size had decreased for a while but then increased. She also noted that there seemed to be a dark spot over the lesion’s center. It was not painful or erythematous. She denied additional lesions. The family history was positive for other family members with similar lesions.

    The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters. The mass was ~12 mm wide and made the skin slightly elevated but appeared to be part of the skin and not subcutaneous tissue. It was freely mobile, without pain or erythema. There was a punctum noted with brownish coloring of what appeared to be dried material. The rest of her skin examination found freckling of her nose and cheeks and one cafe-au-lait lesion on her left ankle. The rest of her examination was normal. The diagnosis of an epidermal cyst was made. The patient and parents were told about the natural history of the lesion including that they may spontaneously drain, become infected, and rupture causing an inflammatory response. They were also counseled that more lesions can occur. The patient initially decided to monitor, but when the lesion continued to increase in size she decided to have it excised. She had no complications, but did develop another lesion 3 years later on her back that she also had excised.

    Discussion
    Epidermal cysts (sometimes called sebaceous, pilar, or epidermoid cysts) are common lesions. They often appear round, firm and are mobile, and a pore may be seen over the mass. They are closed sacs with a definite wall that are intradermal or subcutaneous in location, and occur because of epidermal cell proliferation. Spontaneous drainage of cheesy whitish material (possibly foul-smelling) from the pore may occur. Aspirates may show keratin but usually are highly cellular. They can be singular or multiple and are commonly seen on the head, neck and trunk. Breast and bone sites have also been reported. The lesions are benign and usually cause more cosmetic problems. Potentially however, a lesion’s location or size could make excision necessary for functional reasons.

    Rupture of the cyst’s wall may set up an inflammatory reaction where the mass becomes red, swollen and tender and may look like a staphylococcal furuncle. Furuncles usually occur abruptly and drain pus and therefore the difference is usually made based upon the timing of the lesion’s appearance and the drainage material if present. Inflamed cysts have a higher rate of bacteria (aerobic and anaerobic) than uninflamed cysts and therefore may be treated with antibiotics. A tetracycline-type antibiotic may be used for its antibiotic activity and to decrease the inflammatory reaction. Ruptured cysts are also treated with local heat and drainage if necessary. Inflamed cysts often fragment if excision is attempted so usually they are monitored until the inflammation has abated and then excision can be attempted. Surgical excision of the entire cyst wall is necessary so there is no recurrence.

    Learning Point
    The differential diagnosis of an epidermal cyst includes:

    • Brachial cleft cyst (in the neck)
    • Ganglion cyst
    • Lipoma
    • Lymph nodes
    • Neoplasm of skin
    • Neoplasm of adjacent structure

    Occasionally history and physical examination may still leave a lesion to be indeterminant. Dermal ultrasound may assist in differentiating between some of the common lesions. A nice image of the ultrasonic appearances of a lipoma, ganglion cyst and epidermal cyst can be seen here. A brief overview of ganglion cysts can be found here. Ganglion cysts are not true cysts because they do not have a true wall. A ganglion cyst is an outpouching of the tendon sheath.

    Questions for Further Discussion
    1. What are indications for referral to a dermatologist?
    2. What other common benign “lumps and bumps” come to a pediatrician’s attention?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Benign Tumors and Skin Conditions.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Pariser RJ. Benign neoplasms of the skin. Med Clin North Am. 1998 Nov;82(6):1285-307, v-vi.

    Handa U, Chhabra S, Mohan H. Epidermal inclusion cyst: cytomorphological features and differential diagnosis. Diagn Cytopathol. 2008 Dec;36(12):861-3.

    Kuwano Y, Ishizaki K, Watanabe R, Nanko H. Efficacy of diagnostic ultrasonography of lipomas, epidermal cysts, and ganglions. Arch Dermatol. 2009 Jul;145(7):761-4.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Criteria Could Be Used for Outpatient Treatment of Bacterial Meningitis?

    Patient Presentation
    A 13-year-old female came to the emergency room with fever, headache and lethargy that were increasing over a few hours. On physical examination she was noted to have nuchal rigidity. A head computed tomography examination showed no mass and a lumbar puncture was performed that showed white blood cell pleocytosis, increased protein and decreased glucose. She was given ceftriaxone and vancomycin, and was transferred to a regional children’s hospital with a diagnosis of bacterial meningitis which the laboratory confirmed was caused by Streptococcus pneumoniae.

    The patient’s clinical course showed that by day 4 of admission that patient was back to her clinical baseline and feeling well. The parents asked if she could be sent home on intravenous antibiotics. After discussion with an infectious disease expert, a plan was made to discharge the patient if appropriate care could be coordinated at home and if the child’s laboratory inflammatory markers had returned to normal. As the local community was rural, it was not possible to have consistent care for emergencies nor for replacement of her peripheral intravenous catheter if needed. Therefore, it was decided to stop her inpatient intravenous antibiotics between 10-14 days treatment if she continued to be well and her inflammatory markers returned to normal. This occurred on day 11 of treatment and the patient was discharged home. She did well long-term with no sequelae.

    Discussion
    Fortunately, vaccination against Haemophilus influenza type b, Streptococcus pneumoniae and Neisseria meningitidis has decreased the rates of bacterial meningitis but still it is an important cause of morbidity and mortality.

    Common pathogens by age:

    • For neonates < 1 month of age – Streptococcus agalactiae, Escherichia coli, Klebsiella species, Listeria monocytogenes
    • For infants and toddlers 1-23 months – Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus agalactiae, Haemophilus influenzae, Escherichia coli
    • For children > 2 years – Neisseria meningitidis, Streptococcus pneumoniae,

    Learning Point

    Criteria for considering initiating outpatient antibiotic treatment for patients with bacterial meningitis includes:

    • Inpatient antibiotic therapy for at least 6 days
    • No fever for at least 24-48 hours before beginning outpatient therapy
    • No significant neurologic dysfunction, focal findings, or seizures
    • Clinically stable or improving condition
    • Ability to maintain hydration orally
    • Established plan for physician and/or nursing visits, laboratory testing, monitoring, and emergencies
    • Access to home health nursing or other consistent, reliable place for antibiotic administration
    • Reliable intravenous access device if needed, along with reliable location for replacing such a device if needed
    • Daily availability of a physician and/or daily visits to a physician
    • Patient and family consent and compliance with the plan
    • Appropriately safe environment with access to a telephone, utilities, food, refrigerator, and transportation

    It should be noted that each patient with bacterial meningitis needs to be treated individually, and these criteria are only guides. Consultation with an infectious disease expert should also be considered as part of the patient’s overall management.

    Questions for Further Discussion
    1. What antibiotics are recommended for empiric administration for suspected bacterial meningitis?
    2. At what ages do you consider treating for possible herpes simplex meningitis?
    3. What is the role of adjuvant dexamethasone in suspected bacterial meningitis?
    4. What are the possible sequelae of bacterial meningitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Meningitis and Streptococcal Infections.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Waler JA, Rathore MH. Outpatient management of pediatric bacterial meningitis. Pediatr Infect Dis J 1995; 14:89-92.

    Tice AD, Strait K, Ramey R, Hoaglund PA. Outpatient parenteral antimicrobial therapy for central nervous system infections. Clin Infect Dis. 1999 Dec;29(6):1394-9.

    Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.

    Kim KS. Acute bacterial meningitis in infants and children. Lancet Infect Dis. 2010 Jan;10(1):32-42.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Tests Are the Most Helpful As Screening Tests for Inflammatory Bowel Disease?

    A 15-year-old female came for a second opinion to the general pediatrics clinic because of a 3 month history of abdominal pain described as more in the right upper quadrant but also left upper quadrant. The pain was described as crampy and would occur most days and also at night. She had 5-10 times/day stools that were described as loose without blood or mucous. Intermittently she had emesis. She was not able to participate in school or other activities because of the pain. She had a decreased appetite and had lost 3-5 pounds over the 3 months. The past medical history was negative. The family history was positive for possible inflammatory bowel disease (IBD) in the mother but she was not sure and didn’t take any medication. The review of systems showed no fever, cold intolerance, skin or visual changes, and no changes in flatulence or belching. She reported normal menses and no recent travel.

    The pertinent physical exam showed an unhappy appearing teenager who said her pain was 7/10 but appeared comfortable. Her documented weight loss was 1.8 kilograms and other vital signs were normal. She complained of pain anywhere with palpation but no masses, organomegaly, ascites or rebound tenderness was noted. She had a dilated rectal vault and the stool was guiac negative. The work-up locally showed a hemoglobin of 11.3 g/dl, and platelets of 417 x 1000/mm2. She had normal electrolytes, blood urea nitrogen, creatinine, transaminases, bilirubin, albumin and total protein, lipase, amylase, urinalysis and erythrocyte sedimentation rate. An ultrasound and computer tomography examination of her abdomen and pelvis were normal. The diagnosis of possible inflammatory bowel disease and/or irritable bowel syndrome was made. The pediatrician felt with the history of no hematochezia over this time period that inflammatory bowel disease was less likely. However the patient did have a mild anemia and thrombocytosis which could be consistent with it and also the possible family history. She elected to start the patient on a high fiber diet and to refer to the pediatric gastroenterologist for possible endoscopy. Although the daughter was not excited about endoscopy, she thought that this was a good idea to be able to decide if she did have IBD and then could possibly start treatment. The patient’s clinical course showed she did have some improvement in her symptoms when she went to the gastroenterologist, and additional history revealed a cousin with Crohn’s Disease. Therefore the decision was made to perform endoscopy which was scheduled in 2 weeks.

    Discussion
    Inflammatory bowel disease (IBD) is made up of two major diseases: Crohn’s Disease (CD) and Ulcerative Colitis (UC). CD is more common than UC in children. Extraintestinal manifestations are less common in children (6%) but increase to 25% in adulthood. Children with IBD have problems with growth and often have delayed puberty. Despite the delayed puberty, many may not reach predicted adult height.

    • Crohn’s Disease
      • 2.1-3.7 cases per 100,000 population
      • Gender: Males > females until puberty then about the same rate
      • Location:
        • Ileocolonic or colonic location predominance in children (more terminal ileum and less colonic in adults). Note bene: any area of the gastrointestinal tract can be affected from mouth to anus.
        • Involves entire thickness of the gastrointestinal tract wall
        • Skipped areas of colonic involvement are common
        • Granulomas are seen clinically and histologically
      • Presentation:
        • Nonstricturing, nonpenetrating colonic wall disease usually initially that over time becomes more stricturing/fistulizing and penetrating in many children
        • Abdominal pain, diarrhea, hematochezia, malnutrition, growth failure, weight loss, demineralization of bone are common
      • Genetics and cancer risk: Highly inheritable and has increased cancer risk

    • Ulcerative Colitis
      • 2 cases per 100,000 persons
      • Gender: Males = females at all ages
      • Location:
        • Pancolitis in children (more left-sided, proctitis in adults)
        • Involves the mucosa only
        • Continuous colonic involvement (no skipped areas)
        • No granulomas
      • Presentation:
        • Pancolitis with a shorter timespan to colectomy (if needed) in children than adults
        • Hematochezia, abdominal pain and diarrhea are common. Weight loss, fatigue, fever, and problems with growth may also occur
      • Genetics and cancer risk: Highly inheritable and has increased cancer risk

    Learning Point
    Serological testing for possible IBD has become available recently. Two recent studies that compared this panel to routine laboratory testing found better predictive values for routine laboratory testing (specifically hemoglobin, platelet count and erythrocyte sedimentation rate (ESR), one study also evaluated albumin). The authors of these papers recommend a complete blood count (evaluating for anemia and thrombocytosis) and ESR (evaluating for evidence of inflammation) as screening tests to help determine the necessity for more additional invasive/expensive testing.

    It is important to note that children with IBD may have totally normal screening tests. In 2007, Mack et. al., showed that normal values were obtained for ESR (26% and 18%, for all patients and moderate/severe disease patients respectively), hemoglobin level (32% and 24%), platelet count (50% and 43%), and albumin (60% and 50%). Hypoalbuminemia may be seen in IBD. The frequency of having all four laboratory tests being normal was 9% for CD and 19% for UC. The authors point out that if all laboratory testing is normal that other diseases such as irritable bowel syndrome are more likely however, “…normal laboratory tests cannot be relied on as an adequate screening tool to exclude mild IBD….children with more-severe IBD only rarely have all 4 of the laboratory tests yield normal rests at presentation.” They also point out that hematochezia is a common compliant for many children diagnosed with IBD, and in UC hematochezia is more common the more severe the symptoms.

    A differential diagnosis of gastrointestinal bleeding can be found here.

    Questions for Further Discussion
    1. What clinical indications warrant radiological testing or endoscopy?
    2. What treatments are currently available for IBD?
    3. Because of the increased risk of cancer, what screening is recommended?
    4. What extraintestinal manifestations are common in IBD?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Crohn’s Disease and Ulcerative Colitis.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Mack DR, et al., Pediatric Inflammatory Bowel Disease Collaborative Research Group. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics. 2007 Jun;119(6):1113-9.

    Sabery N, Bass D. Use of serologic markers as a screening tool in inflammatory bowel disease compared with elevated erythrocyte sedimentation rate and anemia. Pediatrics. 2007 Jan;119(1):e193-9.

    Sauer CG, Kugathasan S. Pediatric inflammatory bowel disease: highlighting pediatric differences in IBD. Gastroenterol Clin North Am. 2009 Dec;38(4):611-28.

    Grossman AB, Mamula P. Crohn’s Disease. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/928288-overview (rev. 10/8/2009, cited 6/1/2010).

    Markowitz JE, Mamula P. Ulcerative Colitis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/930146-overview (rev. 9/11/2009, cited 6/1/2010).

    Benor S, Russell GH, Silver M, Israel EJ, Yuan Q, Winter HS. Shortcomings of the Inflammatory Bowel Disease Serology 7 Panel. Pediatrics. 2010 May 3.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital