P B

Reviewer: Amanda Croxton

Article:  Lindberg et al, Pediatrics 2013

Objective: Validate that AST/ALT >80 IU/L improves identification of occult abdominal injury in children of abuse.

Why this article: Earlier this year I completed an elective with the child protection team and was first introduced to using transaminases in screening for children with concern for abuse. I was told about a case in which the child had significantly elevated AST/ALT at an OSH and subsequently did not receive imaging and was diagnosed with acute hepatitis, he was sent home and ultimately died of a liver laceration.
I had a case in the PICU this year of a child with an acute stroke without apparent etiology and child abuse was a concern, she had elevated transaminases upon admission but multiple providers including PICU attendings, surgery attendings and even child protection team were in disagreement about further working up occult abdominal trauma so I wanted to investigate the validity of using transaminases as a screen in workup of these children.

I did a pubmed search for “hepatic transaminases and child abuse” and came upon this study which I felt was recent and comprehensive to explore this topic.

Methods: The author’s did a retrospective secondary analysis of a multicenter observational study, Examining Siblings To Recognize Abuse research network, that was previously completed. The study was completed at20 different centers with established child abuse teams.

2890 children were enrolled in the study between January 2010 and April 2011. Inclusion criteria were children <10 years old and had undergone subspecialty evaluation for concerns for abuse. As this was an observational study, no protocol for screening was endorsed and there were no interventions to increase screening.

Physicians recorded the results of the LFTs and whether or not the child had undergone definitive testing (including abdominal CT, MRI, surgical exploration or autopsy). Any injury to abdominal organs were considered positive, bony injuries and isolated elevation of lab tests were excluded.

Categorical variables of tested vs. non tested were compared with chi-square tests, Mann-Whitney U test was used to evaluate continuous variables and odds ratio was used for dichotomous variables of testing and definitive imaging. Likelihood ratios for detecting abdominal injuries were calculated using the highest of the ALT vs. AST of the first value obtained.

Results: There were 2892 patients enrolled in the study. Of these 82 had 1+ intrabdominal injury identified. In the subjects that had abdominal injuries, they were perceived to have a HIGH likelihood of having been abused prior to work-up using the 7 point scale of abuse likelihood. These subjects that had abdominal injuries had a highter mortality 11% of injured patients and onlt 2.5% overall. Also of note, the subjects with injuries has a median age of 20.5 months compared to 11 months as the median age of participants in the study.

In regards to transaminases, 1538 of the 2892 children had LFT testing. These children tended to be higher risk and had a higher perceived likelihood of abuse as well as more non-abdominal injuries identified. Of the 1538 that had transaminases, 298 (19.4%) had definitive testing and 4.8% had intrabdominal injury. Of those that did not have transaminases 2.1% had definitive testing and 0.6% had injuries identified. The ROC curve for highest transaminase level had an AUC of 0.87 for identification of intraabdominal injury. Transaminases >80 had a sensitivity of 83.8% and specificity of 83.1% of predicting injury. Physical exam looking at bruising, tenderness, distention or abnormal bowel sounds occurred in 47 children for a sensitivity of 57.3.

Reviewer Comments: This article was extremely valuable to me validated the use of hepatic transaminases in screening of patients with concern for abuse. It was impressive to me that there was a sensitivity and specificity of ~83% of just one elevated transaminase vs. the sensitivity of the physical exam alone being on 57%. While there is certainly an expense to running LFT’s on every patient with concern for abuse, this expense seems worth it given the expense of the morbidity and mortality of abuse not verified.

 

As a student growing up in France, I was always looking for ways to improve my English, often with a heavy French-to-English dictionary in tow. Since then, technology has opened up a wide world of new educational opportunities, from simple searches to Google Translate (and our backpacks have gotten a lot lighter). But it can be hard to find time and the means to practice a new language. So when the Web Speech API made it possible to speak to our phones, tablets and computers, I got curious about whether this technology could help people learn a language more easily.

That’s the idea behind Spell Up, a new word game and Chrome Experiment that helps you improve your English using your voice—and a modern browser, of course. It’s like a virtual spelling bee, with a twist.
We worked with game designers and teachers to make Spell Up both fun and educational. The goal of the game is to correctly spell the words you hear and stack them to build the highest word tower you can—letter by letter, word by word. The higher the tower gets, the more difficult the word challenges: You’ll be asked to pronounce words correctly, solve word jumbles and guess mystery words. You can earn bonuses and coins to level up faster.

We worked with game designers and teachers to make Spell Up both fun and educational, and we encourage teachers to try it in the classroom.

Spell Up works best in Chrome on your computer and on Android phones and tablets. (It also works on iPhones and iPads, but you’ll need to type rather than talk.) Whether you’re just learning English or you’re already a pro, check it out! And if you’re a teacher, we encourage you to try it out in your classroom.

Posted by Xavier Barrade, Creative Lead and Polyglot, Creative Lab London

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North Side drivers who use 73rd Street have undoubtedly seen these new pavement markings and wondered, “What are they and what am I suppose to do?” These new striping patterns are Indianapolis’ first Bike Boxes. What are bike boxes? According to the DPW’s Bike Boxes website (they actually created a dedicated site to talk about these),

“…by definition, a designated area at the head of a traffic lane at a signalized intersection that provides bicyclist with a safe and visible way to get turning bicyclist ahead of queuing traffic during the red signal phase. Bike boxes serve as an advanced stop bar and do not affect moving traffic.”

So, now that we know what they are and what they do, what can cyclists and motorists expect out there in the real world? First, the familiar sight of a bicycle should clue drivers off that the new striping is to aid cyclists. What they won’t be familiar with is the additional space at the head of the line where the bike is located.

The pictures I snapped, at the intersection of 73rd & Spring Mill Road, indicate just how the boxes work. The existing bike lane feeds into the box at the head of traffic, allowing cyclists to bypass stopped auto traffic at the signal and obtain a safe area to turn left or right onto Spring Mill. Spring Mill Road has also been outfitted with a number of sharrows (sorry, no bike lanes), so from a network perspective, the bike boxes serve a real function in giving cyclists some visibility on what is, for lack of better description, a high speed suburban style through-way.

Indeed, as I was taking these pictures during morning rush hour, cars zoomed by at uncomfortable speeds by pedestrian standards. This is compounded by the lack of sidewalks. I have to admit, when I first read about the locations I wondered, “Why here?” and after visiting to take the photos I can vouch, the need for safe facilities for cyclists seems real here. I only stopped at 73rd & Spring Mill for these photos, but similar layouts are also employed at 71st & Cross Key Drive and 71st & Lakeview, on the west side.

Will these new safety improvements boost cycling share in these areas? Time will tell. As I pointed out in yesterday’s post about the coming 71st Street Bike Ways, this corridor is highly suburban so there is a clear need for making the roads safer for cyclists.