Analysis of Missed Cases
of Abusive Head Trauma
Carole Jenny, MD, MBA
Context Abusive head trauma (AHT) is a dangerous form of child abuse that can be
difficult to diagnose in young children.
Lt Col Kent P. Hymel, MD, USAF, MC Objectives To determine how frequently AHT was previously missed by physicians
Alene Ritzen, MD, JD in a group of abused children with head injuries and to determine factors associated Steven E. Reinert, MS with the unrecognized diagnosis.
Thomas C. Hay, DO Design Retrospective chart review of cases of head trauma presenting between Janu-
ary 1, 1990, and December 31, 1995.
a dangerous form of childabuse. More child abuse Patients One hundred seventy-three children younger than 3 years with head in-
juries caused by abuse.
deaths occur from head inju- ries than any other type of injury.1 In- Main Outcome Measures Characteristics of head-injured children in whom diag-
fants and toddlers who survive AHT of- nosis of AHT was unrecognized and the consequences of the missed diagnoses.
ten have serious neurologic sequelae.2,3 Results Fifty-four (31.2%) of 173 abused children with head injuries had been seen
Head injury in infants and toddlers can by physicians after AHT and the diagnosis was not recognized. The mean time to cor- be difficult to diagnose because symp- rect diagnosis among these children was 7 days (range, 0-189 days). Abusive head toms are often nonspecific. Vomiting, fe- trauma was more likely to be unrecognized in very young white children from intactfamilies and in children without respiratory compromise or seizures. In 7 of the chil- ver, irritability, and lethargy are com- dren with unrecognized AHT, misinterpretation of radiological studies contributed to mon symptoms of a variety of conditions the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diag- seen in children, including head trauma.
nosis. Twenty-two (40.7%) experienced medical complications related to the missed When caretakers do not give a history of diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been pre- injury and the victim is preverbal, an abu- vented by earlier recognition of abuse.
sive head injury can be mistakenly di- Conclusion Although diagnosing head trauma can be difficult in the absence of a
agnosed as a less-serious condition.
history, it is important to consider inflicted head trauma in infants and young children In March 1995, we evaluated a 14- presenting with nonspecific clinical signs.
month-old child who had sustained an abusive head injury 4 months previ-ously. Shortly after his initial injury, he been previously missed. We also exam- a referral center for Colorado, Wyoming, had been examined by his physician and ined factors that may have contributed Montana, and western Nebraska.
his new-onset seizures were attributed to the unrecognized diagnosis of AHT.
The children in this study were evalu- to his history of prematurity. During the ated by the hospital's Child Advocacy and next 4 months, the child had 7 physi- Protection Team (CAP Team). The CAP cian visits and 2 cranial imaging stud- We studied cases of AHT in children Team is a multidisciplinary group that con- ies. At each visit, the diagnosis of AHT younger than 3 years evaluated at the Chil- sults on cases of suspected child abuse and was not recognized. When we exam- dren's Hospital, Denver, Colo, from Janu- neglect. The team is led by pediatricians ined him 4 months later, he had mul- ary 1, 1990, through December 31, 1995.
whose clinical focus is child abuse. Social tiple old and new fractures and healing The Children's Hospital is an academic workers, nurses, psychologists, child psy- brain injuries, including extensive brain medical center affiliated with the Univer- chiatrists, and attorneys also participate.
atrophy and healing brain infarctions.
sity of Colorado School of Medicine. It is The team routinely interviews caretakers This case encouraged us to review ourexperience with AHT cases to deter- Author Affiliations: Department of Pediatrics, Brown
(Dr Ritzen); and the Department of Radiology, Univer- mine if the appropriate diagnosis had University School of Medicine (Dr Jenny), and Lifespan sity of Colorado School of Medicine, Denver (Dr Hay).
Medical Computing (Mr Reinert), Providence, RI; De- Corresponding Author and Reprints: Carole Jenny,
partment of Pediatrics, National Naval Medical Center, MD, MBA, Hasbro Children's Hospital, MOC-140, Bethesda, Md (Dr Hymel); Department of Pediatrics, Uni- For editorial comment see p 657.
593 Eddy St, Providence, RI 02903 (e-mail: versity of Oregon Health Sciences Center, Portland 1999 American Medical Association. All rights reserved.
JAMA, February 17, 1999—Vol 282, No. 7 621
UNRECOGNIZED CASES OF ABUSIVE HEAD TRAUMA and impact cause the signs and symp- the period of diagnostic delay were clas- Table 1. Types of Injuries Sustained
toms commonly referred to as shaken sified as reinjured. Study patients whose by Study Population baby syndrome.4-6 The mechanism of in- medical records after their inflicted head Types of Injury
jury cannot always be accurately deter- trauma revealed abnormal head growth, mined in child abuse cases. Because shak- recurrent seizures, psychomotor de- Subdural hematoma ing, impact to the head, or both are all lays, chronic anemia, vomiting, weight Diffuse parenchymal brain injury potentially harmful to infants and tod- loss, and/or sensory deficits were classi- Localized brain contusions or shearing injuries dlers, we grouped all head injuries caused fied as having medical complications by abuse into the single category of AHT.
Epidural hemorrhages Factors considered by the multidisci- We examined data to determine what Retinal hemorrhages plinary team in reaching the diagnosis of factors were associated with a missed vs Facial or scalp trauma AHT (rather than nonintentional head in- recognized diagnosis. We used x2 test- Trauma to parts of body other jury) included (1) confession of inten- ing to assess the independence of 10 vari- than head or face tional injury by an adult caretaker; (2) in- ables on the outcome variable of a cor- Fractures other than skull fractures consistent or inadequate histories given by rect diagnosis of head trauma. Variables caretakers (the history given did not ex- resulting in x2 P#.25 or less were en- to document medical history and the his- plain the nature and severity of the inju- tered into an initial multivariate logistic tory of the acute injury, review previous ries); (3) associated unexplained inju- regression model. We then used Wald and medical and social service records, re- ries, such as fractures or intra-abdominal likelihood ratio testing to iteratively re- view prior radiological studies, perform a injuries; and (4) delay in seeking care.
move noncontributory variables from the careful physical examination, and order Cases of AHT were defined as missed if model.7 Analysis was performed using appropriate new diagnostic studies. In all review of medical records and radiologi- Stata software, Version 5.0 (Stata Corp, cases, organic illnesses that mimic AHT are cal studies confirmed the following pre- College Station, Tex).
ruled out. Confirmation that head trauma defined criteria: (1) Prior to the diagnosis was inflicted requires multidisciplinary of AHT, a physician evaluated the child team consensus.
(on $1 occasions) for nonspecific clini- A total of 232 children with suspected Head trauma cases were identified cal sign(s) compatible with head trauma head injuries were evaluated by the CAP from the log records of the CAP Team (ie, recurrent vomiting, irritability, facial Team from January 1990 through De- and charts were reviewed in depth. To and/or scalp injury, altered mental sta- cember 1995. Fifty-nine children did not ensure concurrence, study cases were re- tus, abnormal respiratory status, and/or sei- meet study criteria. Of these, 8 were viewed by at least 2 of the authors (in- zures). (2) The medical evaluation(s) for eliminated because they were aged 3 cluding C.J.) and radiological imaging these nonspecific clinical sign(s) did not years or older. It was determined that 38 studies were reviewed by a pediatric ra- result in a diagnosis of AHT. (3) Thereaf- were not abused. The medical records of diologist (T.C.H.). Permission for the ter, 1 or more of the following scenarios 13 children could not be located. The re- anonymous chart review was granted by occurred: (a) The child improved clini- maining study sample included 173 the hospital's human subjects commit- cally, later experienced (repeat) acute abused children with head injuries.
tee. Information gathered included de- trauma confirmed as abusive, and under- The mean age of the 173 children was mographics, social and family data, de- went diagnostic imaging that revealed old 247 days (range, 10 days to 2.9 years).
tails of the children's injuries, presenting cranial injuries and other new injuries.
Ninety-five (55%) of the children were complaints, clinical course, and details (b) The child remained symptomatic or ex- male and 78 (45%) were female. The boys' of previous medical visits related to head perienced worsening clinical signs until ages at the time they were first seen for trauma, if applicable.
head trauma was recognized, verified by symptoms of AHT were not significantly We limited the study to children with cranial imaging studies, and confirmed as different than the girls' ages. In our study head injuries who were younger than 3 abusive. (c) The person who injured the sample, minorities were overrepre- years for 2 reasons. First, children older child later admitted to abusing the child sented (33.5% minority) compared with than 3 years are not as likely to sustain shortly before the onset of the child's non- the racial distribution of the Denver met- severe injury when struck in the head or specific clinical sign(s). In all cases, the es- ropolitan area (19.7% minority).8 shaken. Second, children older than 3 timated age of the cranial injuries docu- The types of injuries noted in the chil- years are more likely to be able to ar- mented by imaging studies was consistent dren are shown in TABLE 1. Many of the
ticulate their experiences. Hence, AHT with the prior time of onset of the child's children sustained more than 1 type of is much less likely to be missed as the nonspecific clinical sign(s).
injury. Eighty-nine children (51.4%) All remaining cases of AHT evalu- were covered by Medicaid-funded in- Abusive head trauma was defined as ated during the study period were con- surance programs. Twenty-seven chil- inflicted cranial injury. Researchers de- sidered recognized. Children who sus- dren (15.6%) were uninsured. The re- bate whether shaking alone or shaking tained any new inflicted injuries during mainder had private health insurance.
622 JAMA, February 17, 1999—Vol 282, No. 7
1999 American Medical Association. All rights reserved.
to be recognized as having head trauma were transformed to dichotomous vari- In the 173 children with AHT, 54 cases at first visit to the physician. TABLE 2
ables and entered into a logistic regres- (31.2%) were classified as missed. For summarizes the number and percent- sion model. They included age younger children with missed AHT, the mean age of children who were missed and rec- than 6 months, minority race, parents not number of physician visits before the ognized as having AHT compared with living together, and 6 signs and symp- trauma was recognized was 2.8 (range, their symptoms and signs. At the first toms noted at the first visit, including fa- 2-9 visits).
visit, children who were comatose, whose cial injury, seizures, decreased mental sta- For children in whom the diagnosis of breathing was compromised, who were tus, abnormal respiratory status, vomiting, AHT was missed, the mean length of time having seizures, or who had facial bruis- and irritability. Of these 9 variables, 4 were to diagnosis of head trauma from the day ing were more likely to be accurately di- retained in the multivariate logistic model.
of the first visit was 7 days (range, 0- agnosed. Conversely, children who pre- These 4 independent variables predict- 189 days). In 5 cases, the children were sented with irritability or vomiting at the ing the correct diagnosis of AHT at the first seen twice in the same day and the di- first visit were less likely to be identi- visit included (1) abnormal respiratory sta- agnosis was made on the second visit; fied as having AHT.
tus (odds ratio [OR], 7.23; 95% CI, 2.4- hence, the designation of 0 days until di- 21.3; P,.001); (2) seizures present (OR, agnosis in some cases of missed AHT.
Factors Not Significantly Different
6.67; 95% CI, 2.5-17.3; P,.001); (3) fa- When missed cases were compared Several factors were found not to differ be- cial and/or scalp injury present (OR, 4.81; with recognized cases, several factors tween children with missed vs recog- 95% CI, 2.1-11.0; P,.001); and (4) par- were found to be significantly different.
nized AHT. These included whether the ents not living together (OR, 2.49; 95% parents were employed, whether the par- CI, 1.1-5.7; P = .03).
ents had private insurance coverage, the Applying the logistic regression model Children with missed AHT were much sex of the child, the birth weight of the constructed from the data, we found that younger than those in whom the diagno- child, and whether the child had been born if none of these 4 factors were present, sis was recognized on the first physician prematurely (,37 weeks' gestation).
the probability that a physician would visit. The mean age of missed AHT cases make the correct diagnosis of AHT was at the time of their first medical visit for P = .20. That is, if a child had normal res- head injury symptoms was 180 days (95% With Missed Diagnosis of AHT
pirations, had no seizures, had no facial confidence interval [CI], 125-236). The Nine variables were found to be signifi- or scalp injury, and came from an intact mean age of the recognized cases was 278 cantly associated with missing the diag- family, the probability that AHT would days (95% CI, 228-328). The mean ages nosis of AHT by univariate analysis. These be recognized was less than 1 in 5.
of children with missed and recognizedAHT were significantly different (inde-pendent samples t test, P = .02).
Table 2. Missed and Recognized Abusive Head Trauma Cases: Severity of Presenting Symptoms
Abusive head trauma was missed signifi- Facial and/or scalp injuries cantly more often in white children than Other bodily trauma (not head children of minority races. In white chil- dren, 43 (37.4%) of 115 cases of AHT were missed and in minority children, 11 (19%) of 58 were missed (Pearson x2, P = .01).
Sleepy and/or lethargic Comatose and responsive to pain Comatose and unresponsive to pain Abusive head trauma was more likely to Mental status by group be missed in families in which both par- ents lived with the child. Thirty-seven Depressed or comatose Respiratory status (40.2%) of 92 cases were missed in in- tact families. In families in which the mother and father of the child were not Requiring resuscitation or ventilation living together, 14 (18.7%) of 75 cases Respiratory status by group were missed (Pearson x2, P = .003).
Abnormal (compromised or requiring Severity of Symptoms
resuscitation or ventilation) at Initial Visit
Seizures at first visit Not surprisingly, the more severely Vomiting at first visit symptomatic children were more likely Irritable at first visit 1999 American Medical Association. All rights reserved.
JAMA, February 17, 1999—Vol 282, No. 7 623
UNRECOGNIZED CASES OF ABUSIVE HEAD TRAUMA cases, 5 (9.3%) of 54 children died. The missed for longer than 7 days involved to Children With AHT
percentage of children in the missed AHT radiological misreadings. TABLE 5 sum-
The 54 children with missed AHT re- group who died was not statistically dif- marizes the nature of the errors made and ceived 98 diagnoses other than AHT dur- ferent than in the recognized AHT group ing their 98 patient visits. TABLE 3 lists
(x2 = 1.712; P = .19). In our estimation, Table 3. Frequent Erroneous Diagnoses Made
the diagnoses applied to the children with 4 of the 5 deaths in the missed AHT group in Cases of Missed Abusive Head Trauma* missed AHT. The most common diag- might have been prevented by earlier rec- No. of Times
noses made were for viral gastroenteri- ognition of abuse (TABLE 4).
Viral gastroenteritis or tis and accidental head injury. In some Of the missed AHT cases, 15 (27.8%) cases, the diagnoses were correct, even of the 54 children were known to have Accidental head injury though coexistent head trauma was not been reinjured because of the delay in diag- recognized. For example, in 1 case an in- nosis. Twenty-two children (40.7%) had Increasing head size fant was accurately assessed to have a ret- medical complications related to the delay Nonaccidental trauma ropharyngeal abscess, but the accompa- in diagnosis. These conditions included (not head injury) nying subdural hematoma, retinal seizure disorders, chronic vomiting, and hemorrhages, and skull fracture were not increasing head size because of increas- recognized. In other cases, the symp- ing untreated subdural hematomas.
toms of head trauma were attributed to Upper respiratory tract conditions other than AHT. In 10 cases, the wrong diagnosis was applied more In 7 of the children whose diagnosis of Urinary tract infection or than once to the same child. We did not AHT was missed, radiological errors con- count these repeated diagnoses on our tributed to the delay. These 7 children Bruising of unknown origin frequency table.
had 8 studies in which trauma was missed, including 6 computed tomog- Outcome and Consequences
raphy scans of the head, 1 skeletal sur- *Incorrect diagnoses made only once included anxiety, bronchiolitis, colic, complications of prematurity, Twenty-five (14.5%) of the 173 children vey, and 1 long-bone radiograph of the constipation, failure to thrive, fever of unknown cause, died as a result of their head injuries. Of arm. The 2 longest delays in diagnosis hemiparesis, milk allergy, myositis, pneumonia,postmeningitic subdural effusion, retropharyngeal the recognized AHT cases, 20 (16.8%) of (141 days and 174 days) and 6 of 25 abscess, rule out osteomyelitis, sudden infant deathsyndrome, torticollis, urticaria, viral encephalitis, and 119 children died. In the missed AHT cases in which the diagnosis of AHT was vomiting of unknown cause.
Table 4. Clinical Presentations of 4 Potentially Preventable Deaths With Missed AHT*
Time Between
Documented Clinical Signs
Vomiting, sleepy, normal respirations, facial Vomiting, alert and responsive, normal respiration, new bruising Vomiting, coma, unresponsive to pain, Retinal hemorrhages, subdural hemorrhage, respiratory arrest focal brain injury, diffuse brain injury,noncranial trauma Failure to thrive, vomiting, alert and responsive, Normal computed tomography result with normal respiration, bruising to face and missed subdural hemorrhage and brain Seizures, coma, unresponsive to pain, Retinal hemorrhages, skull fracture, subdural respiratory arrest hemorrhage, diffuse brain injury, noncranialtrauma, old cranial trauma Vomiting, irritability, sleepiness, normal Anxiety secondary respiration, "went limp" Vomiting, diarrhea, irritability, alert and Acute gastroenteritis responsive, normal respiration Vomiting, irritability, coma, unresponsive to pain, Retinal hemorrhages, subdural hemorrhages, seizures, cardiorespiratory arrest diffuse brain injury Vomiting, irritability, alert and responsive, normal Acute gastroenteritis respiration, dehydration Coma, unresponsive to pain Retinal hemorrhage, subdural hemorrhage, diffuse brain injury, old brain injury, oldcranial trauma *In all cases of missed abusive head trauma (AHT), the estimated age of cranial injuries documented by imaging studies was consistent with the time of onset of the child's nonspecific clinical sign(s) before his/her first physician visit.
624 JAMA, February 17, 1999—Vol 282, No. 7
1999 American Medical Association. All rights reserved.
UNRECOGNIZED CASES OF ABUSIVE HEAD TRAUMA the time in delay of diagnosis attributed sodes of shaking that led to the infant's ognized. The fact that they were not as to the radiological misreading.
various illnesses.
ill made the diagnosis of AHT difficult.
In the current study, we found that Also, the children whose AHT was 31.2% of children who were clinically missed were, as a group, younger. The It is difficult to study the cases of child symptomatic after AHT were misdiag- difficulty of diagnosing serious illness or abuse that clinicians do not recognize.
nosed as having other conditions. Infants injury in young infants is complicated by In 1972, Jackson9 reviewed traumatic in- have few ways to demonstrate illness or the limited range of their normal behav- juries in children at King's College Hos- injury. Nonspecific signs, such as vomit- ior. With less-sophisticated behavioral pital in London, England, and found 18 ing, fever, and irritability, are seen in a and neurologic signs to assess, the of 100 cases to have been missed cases myriad of conditions, including many be- changes in young infants with head in- of child abuse. O'Neill et al10 reported a nign, self-limited illnesses. The diffi- juries are more difficult to detect.
series of 110 battered children in 1973.
culty, then, is to be able to discern when Striking differences were seen in the race Eighty percent of those children had signs these signs and symptoms indicate poten- and family composition of infants with of prior injury. Alexander et al11 found tially serious or fatal pathology.
missed and recognized injuries. Infants physical evidence of previous head The possibility exists that in some of with recognized AHT were more likely to trauma in 8 of 24 children evaluated for the visits we classified as missed, the be minority children or children whose head injury due to shaking. Ewing- child had not yet been injured. How- mothers and fathers were not living to- Cobbs et al12 discovered signs of preex- ever, in another study by our group, we gether. We speculate that this may repre- isting brain injury in 45% of children found that patients became symptom- sent a subtle bias in decision making based with inflicted traumatic brain injury com- atic immediately after their injuries in on the physician's assessment of risk. A pared with none in children with acci- 37 cases in which perpetrators admit- physician examining a white child from dental traumatic brain injury.
ted to causing head injuries in infants.16 an intact family may be less likely to think Incidental cases of missed child abuse To guard against misclassification, we about the possibility of child abuse. An- have been published.13 In their study of examined the medical records ex- other hypothesis is that perhaps minor- abusive head injuries, Benzel and Had- tremely carefully to correlate clinical ity and single-parent families were more den mention that 9 of 23 abused chil- and radiological findings.
likely to obtain care from public clinics or dren with head injuries ". . were known Not surprisingly, the infants and tod- hospital emergency departments, where to have been seen by other physicians be- dlers in our study whose head injuries physicians may be more attuned to abuse cause of similar problems or other inju- were misdiagnosed were overall less ill issues. In the current study, the children ries consistent with child abuse."14 Since than those whose head injuries were rec- of intact, 2-parent households were much then, an increased awareness of childabuse has occurred, but similar studieshave not been reported.
Table 5. Radiological Errors in Cases of Missed Abusive Head Trauma*
We do not know how many cases of Visit No. in Which
Length of Delay in
Case Radiological Error
Diagnosis Due to
AHT are never detected. Surely, the inju- Nature of Misdiagnosis
Radiological Error, d
ries occurring from impact or shaking rep- Result of CT of head read as normal; CT resent a range of severity, from no inju- showed subdural hemorrhage and shearingtears of the parenchyma ries to mild concussion or small subdural Result of CT of head read as consistent with hemorrhage, severe brain damage, exten- internal hydrocephalus; CT showed subdural sive intracranial bleeding, and cerebral edema. Caffey15 speculated in 1972 that Second visit of 3 Result of CT of head read as normal; CT showed subdural hemorrhage many children who are found to have mild Result of skeletal survey read as normal; child neurologic abnormalities and learning dis- had a metaphyseal fracture of the tibia and abilities may have been victims of AHT.
unilateral periosteal elevation of the same Parents who confess to shaking or hitting the heads of their children fre- Second visit of 3 Result of CT of head read as normal; CT showed subdural hemorrhage quently report doing the same thing Result of CT of head read as normal; CT previously. In 1 study case, an infant showed subdural hemorrhage was hospitalized 3 times before some- Second visit of 9 Result of CT of head read as normal; CT one witnessed the child being shaken showed subdural hemorrhage and shearingtears of the parenchyma violently. On 1 occasion, he was evalu- Long-bone radiographs of both arms read as ated and treated for possible sepsis.
consisent with myositis; x-ray film showed The other 2 hospitalizations were for extensive periosteal reaction of both humeriand metaphyseal fractures of proximal apnea and reflux, respectively. The humeri bilaterally child's father admitted to multiple epi- *CT indicates computed tomography.
1999 American Medical Association. All rights reserved.
JAMA, February 17, 1999—Vol 282, No. 7 625
UNRECOGNIZED CASES OF ABUSIVE HEAD TRAUMA more likely to have private insurance (Pear- agnosis. Perform a head-to-toe physical simple blood test possibly could be son x2, 23.953; P,.001). In addition, examination, palpate the fontanelles, done to detect occult trauma. In a re- white families were much more likely to measure the head circumference, and be cent study by Hymel and colleagues,22 have private insurance than minority fami- alert for signs of trauma.
children with traumatic parenchymal lies (Pearson x2, 5.148; P = .02). How- 3. When collecting spinal fluid in brain injury were frequently noted to ever, we did not collect data on the prac- cases of suspected infantile sepsis, ex- have prolonged prothrombin and par- tice setting in which missed and recognized amine any bloody cerebrospinal fluid for tial thromboplastin times. These tests diagnoses were made.
xanthochromia. A supernatant of a spi- are generally available and inexpensive Are missed cases of AHT inevitable? nal fluid contaminated by blood second- to run. Their sensitivity and specificity If a child's caretakers cannot or will not ary to a traumatic procedure should be as screening tests for head trauma in in- give an accurate history, making the cor- clear in color if the specimen is exam- fants are not known.
rect diagnosis is extremely difficult. Phy- ined shortly after it is collected. Xantho- There are other ways for AHT to pre- sicians cannot obtain cranial computed chromic spinal fluid can represent old sent clinically that we did not see in this tomographic scans for every infant and blood in the cerebrospinal fluid from pre- group of patients. The list of signs and toddler who presents with vomiting, ir- vious trauma, although it is not specific symptoms we examined is not univer- ritability, and fever. Based on this study for an intracranial bleed.18-20 sally inclusive. Another limitation of our and on our experience with these cases, 4. Pediatrically trained radiologists method is that the study was done ret- we make the following suggestions to fa- should be consulted to interpret x-ray rospectively through record review.
cilitate the diagnosis of AHT.
film and computed tomographic im- However, this seems to be the only op- 1. Be alert for bruises or abrasions on ages in cases of suspected child abuse.
tion we currently have for examining di- the faces or heads of children presenting In addition to these suggestions, agnostic errors. Finally, information con- with nonspecific symptoms. In 20 of 54 other as yet unvalidated strategies to cerning the training, experience, or missed AHT cases in this study, facial or detect occult abuse could be consid- practice setting of the physicians evalu- head bruising was attributed to acciden- ered. Dilated retinal examinations in ating these patients was not obtained.
tal injury unrelated to the presenting ill- infants and children with nonspecific Although it is difficult to detect all se- ness symptoms. One study of bruising in symptoms of illness could increase the rious AHT in the clinical setting, an healthy, nonabused children found no recognition of retinal hemorrhages.
awareness of the nonspecific nature of the bruises on children who were not yet Retinal hemorrhages have been re- signs and symptoms of AHT, particu- strong enough to pull to standing.17 The ported in the majority of children who larly in less-serious cases, could in- presence of bruises in infants raises the are victims of AHT.21 Other possibili- crease the likelihood that more cases will possibility of inflicted injury.
ties need further research. Some mark- be detected.
2. When evaluating infants and tod- ers of brain trauma are known to cross Disclaimer: The opinions and conclusions in this ar-
dlers with nonspecific symptoms, such the blood-brain barrier, such as the BB ticle are those of the authors and are not intended to as vomiting, fever, or irritability, con- fraction of creatine kinase. If rapid tests represent the official positions of the US Air Force, USDepartment of Defense, or any other governmental sider head trauma in the differential di- were available for such markers, a 1. Levitt CJ, Smith WL, Alexander RC. Abusive head
8. US Bureau of the Census. 1990 Census of Popu-
damage and mental retardation. AJDC. 1972;124: trauma. In: Reece RM, ed. Child Abuse: Medical Di- lation and Housing, Summary Tape File 1. Washing- agnosis and Management. Philadelphia, Pa: Lea & Fe- ton, DC: US Government Printing Office; 1991.
16. Starling SP, Holden JR, Jenny C. Abusive head
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17. Wedgwood J. Childhood bruising. Practitioner.
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18. Kortbeek LH, Booij AC. Bilirubin excess, eryth-
3. Sinal SH, Ball MR. Head trauma due to child abuse:
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19. Resurreccion EC, Rosenblum JA. Common causes
Marguilies SS, Wiser R. The shaken baby syndrome: Neuroimaging, physical, and developmental of spurious xanthochromia in cerebrospinal fluid. An- a clinical, pathological, and biomechanical study. J Neu- findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics. 1998;102:300- 20. Spear RM, Chadwick D, Peterson BM. Fatalities
5. Alexander R, Sato Y, Smith W, Bennett T. Inci-
associated with misinterpretation of bloody cerebro- dence of impact trauma with cranial injuries ascribed 13. Diamond P, Hansen CM, Christofersen MR. Child
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abuse presenting as a thoracolumbar spinal fracture 6. Duhaime AC, Christian CW, Rorke LB, Zimmer-
dislocation: a case report. Pediatr Emerg Care. 1994; 21. Smith WL, Alexander RC, Judisch GF, Sato Y, Kao
man RA. Nonaccidental head injury in infants: the SC. Magnetic resonance imaging evaluation of neo- "shaken baby syndrome." N Engl J Med. 1998;338: 14. Benzel EC, Hadden TA. Neurologic manifesta-
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22. Hymel KP, Abshire TC, Luckey DW, Jenny C. Co-
Regression. New York, NY: John Wiley & Sons Inc; 15. Caffey J. On the theory and practice of shaking
agulopathy in pediatric abusive head trauma. Pedi- infants: its potential residual effects of permanent brain 626 JAMA, February 17, 1999—Vol 282, No. 7
1999 American Medical Association. All rights reserved.
also were receiving non–Chinese drug treatments. Based on Table. Transaminase Values of Patients at Discharge*
these findings, we recommend that liver function be moni- Patients With Normal Transaminase Levels
tored in patients receiving traditional Chinese drugs, espe- at Admission
cially in patients with possible previous liver disease or risk of decreased liver function.
Dieter Melchart, MD
Klaus Linde, MD
g-GT (n = 1248) 1210 (96.9) Patients With Elevated Transaminase Levels
at Admission
Stefan Hager, MD
Hospital for Traditional Chinese Medicine

2-Fold of
.2-Fold of
Debbie Shaw, BSc
Guy's & St Thomas' Hospital Trust
London, England

*ALT indicates alanine aminotransferase; AST, aspartate aminotransferase; and g-GT, g-glutamyltransferase. All data are presented as number (percentage) of patients.
Disclosure: Dr Hager is the chief physician at Hospital for Traditional Chinese Medi-
cine, where the study was performed. Dr Melchart of Technische Universitat, and
of the 1507 patients consuming Chinese herbs. Two of the Dr Bauer of Heinrich-Heine-University, are members of the scientific advisory board.
14 patients also had temporary clinical symptoms (nausea 1. Chan TY, Critchley JA. Usage and adverse effects of Chinese herbal medicines.
and vomiting in 1 patient, itching in the second patient).
Hum Exp Toxicol. 1996;15:5-12.
Based on assessments by 2 independent physicians review- 2. Perharic L, Shaw D, Leon C, De Smet PA, Murray VS. Possible association of
liver damage with the use of Chinese herbal medicine for skin disease. Vet Hum
ing the records, a causal relationship of elevated ALT levels with Chinese drug therapy seemed possible in 13 patients 3. Kane JA, Kane SP, Jain S. Hepatitis induced by traditional Chinese herbs: pos-
and likely in 1. All patients were also receiving non– sible toxic components. Gut. 1995;36:146-147.
4. Rote Liste Service GmbH. Rote Liste 1997. Aulendorf, Germany: Editio Can-
Chinese drug treatment, and, for some of the drugs used (for example, minocycline, mesalazine, and diclofenac), liverenzyme elevations are listed as possible adverse effects.4 Thir-teen patients had started these treatments with non–Chinese drugs before their hospital stays, and the dosages had been kept constant or diminished.
Follow-up values of ALT obtained within 8 weeks of Incorrect Description: In the Editorial entitled "Understanding Parkinson Disease"
hospital discharge were normal in 11 patients (6 of them published in the January 27, 1999, issue of THE JOURNAL (1999;281:376-378), sele-giline was identified as an MAO type A inhibitor rather than a type B inhibitor. On had continued to take traditional Chinese drugs) and page 377, the sentence should have read, "Selegiline is a monoamine oxidase type nearly normal in the remaining 3. In 5 patients there were B inhibitor that limits the formation of free radicals derived from oxidation of do- indications of previous liver function abnormalities. The pamine, and application of this agent in clinical trials suggests an effect on diseaseprogression consistent with a neuroprotective action.23-25" 14 patients with increased ALT levels had received a totalof 115 different traditional Chinese drugs. When the fre- Incorrect Byline and Affiliation: In the Original Contribution entitled "Analysis
of Missed Cases of Abusive Head Trauma," published in the February 17, 1999,
quency of drugs used in these cases was compared with issue of THE JOURNAL (1999;281:621-626), the third author's name was mis- the frequency in patients who had normal liver enzyme spelled in the byline on page 621. It should have read "Arlene Ritzen, MD, JD."Additionally, in the author affiliations on the same page, Dr Ritzen's affiliation should values, an increased risk was observed for formulas con- have read "Department of Pediatrics, Oregon Health Sciences University, Port- taining Glycyrrhizae radix and Atractylodis macrocephalae Author Omitted: In the Reply Letter entitled "Talking With Patients About Screen-
Comment. In the population and setting studied, clini-
ing for Prostate Cancer" published in the January 13, 1999, issue of THE JOURNAL cally relevant liver enzyme elevations occurred in about 1 (1999;281:133), the first author was inadvertently omitted. Scott Stern, MD, shouldhave been listed above Wendy Levinson, MD. Both authors are affiliated with the in 100 patients treated with traditional Chinese drugs who University of Chicago.
1999 American Medical Association. All rights reserved.
JAMA, July 7, 1999—Vol 281, No. 1 29


Acta no

El Progreso, Yoro, 18 de junio, dos mil diez, sesión Ordinaria celebrada por la Honorable Corporación Municipal, presidida por el Alcalde Municipal Alexander López Orellana, con la presencia del Vice Alcalde Juan Pompilio Tejeda Duarte, con la asistencia de los Regidores: Guillermo Antonio Gáleas.- Otto René Sorto Morales.- Rolando Rafael Handal Hasbum.- María Carlota Rodríguez Andrade.- Oscar Armando Rubí Guzmán.- Mariano Arias Castro.- Rafael Arturo Morales Soto.- María Famelicia Rivera Rivera, con excusa los Regidores los Francisco Gallo Canales y José Elías Nazar Ordóñez.- con la presencia del Asesor Legal Abogado Maynor López y el Gerente General Ing. Roberto Zelaya, por ante la secretaria Municipal que da fe Abog. Yasmín Francelia Quiroz Mejía, se procedió de la siguiente manera:


Autumn UPDATE 2006 BdMax's Finishing Spray ZeroInHuman Essence Now is the time to consider the On ready-to-pick gold kiwifruit, after two benefits of using ZeroIn. applications of ZeroIn a week apart, followed by 10 days of rain, dry matter ZeroIn is used in the last few levels were .7% higher in the treated weeks, prior to harvest, to