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FLORIDA, June 3, 2013 — Whether the station in question is a network affiliate or a cable channel, most people would probably expect some sort of bias to be present. Is this actually the case?
Today, anyone can favor a news outlet on the basis of his or her political stances. In the long run, won't this allow media bias to run even more rampant? On both sides of the political spectrum, new media outlets have emerged to seriously challenge established sources. Does this have anything to do with bias or might other factors be at work?
Speaking of media bias, what is its most detrimental aspect? Over the last several decades, conglomerates have purchased many formerly independent news outlets. What impact has this had on our country's mass media?
Craig Aaron is the president and CEO of Free Press, which is perhaps our nation's foremost organization devoted to media accountability and journalistic integrity. In this first part of our discussion, he answers the questions listed above.
Joseph F. Cotto: Whether the station in question is a network affiliate or a cable channel, most people would probably expect some sort of bias to be present. Do you believe that this is actually the case?
Craig Aaron: I don't really believe there is such a thing as objective journalism. Everyone brings some kind of bias to the job. But there is fact-based journalism; there is truth-seeking journalism; there is in-depth and investigative journalism. And what we need is more of that kind of journalism as opposed to he-said, she-said journalism or televised shouting matches pretending to constitute journalism.
It's also why we benefit from many competing sources of journalism: Citizens need a range of information and opinions about what's happening in their communities if we're going to have a functioning democracy.
Cotto: Today, anyone can favor a news outlet on the basis of his or her political stances. In the long run, won't this allow media bias to run even more rampant?
Aaron: Well, certainly if you only read outlets you agree with 100 percent of the time you are probably not getting the full picture. But I don't really worry about right-wing or left-wing media if they are honest about what they are. What I worry about is media pushing an agenda while pretending they're doing something else. And usually that agenda is one that advances the interests of the biggest corporations and those in power. And what I really worry about is replacing reporters with pundits.
We need more people doing interviews and digging through records and trying to hold the powerful accountable — especially at the local level.
Cotto: On both sides of the political spectrum, new media outlets have emerged to seriously challenge established sources. From your perspective, does this have anything to do with bias, or might other factors be at work?
Aaron: I think there are many factors at work. The Internet has enabled anyone with something important or interesting to say to find an audience without going through the traditional gatekeepers — that's a great thing generally, though not always. The best established sources sometimes do more fact-checking or are more skeptical of spin. The Internet can encourage transparency and a two-way conversation as opposed to the more traditional, top-down broadcast model.
I think another factor is that the established media gutted its newsrooms and pushed out veteran reporters — that sent their audiences elsewhere.
Cotto: What would you say is the most detrimental aspect of media bias?
Aaron: Denial. We should stop pretending that media bias doesn't exist. We should start pursuing content-neutral policies that will diversify ownership of the media and create opportunities for new voices to get out there. Forget the Fairness Doctrine. I think we need to talk about incentives for local ownership, a major reinvestment in public and noncommercial media and — maybe most importantly — Net Neutrality so that anybody on the Internet with a better idea or a new business model can compete with the establishment on an even playing field.
Do those things and media bias won't matter as much.
Cotto: Over the last several decades, conglomerates have purchased many formerly independent news outlets. What impact has this had on our country's mass media?
Aaron: The impact has been disastrous. Runaway media consolidation has been bad for journalism. It has been bad for local communities. It has been bad for business, too. Tens of thousands of journalists have lost their jobs. Foreign and statehouse bureaus have been shuttered. So many important local stories have gone uncovered.
This crisis in journalism can be tied to the disruption of the traditional advertising market and the larger problems with the economy. But the biggest factor was runaway media consolidation — which concentrated so much media power is so few hands.
And these companies got so big, took on so much debt, that they started to topple under the weight. Look at Tribune Co.: Bad management of a newspaper in Chicago wasn't just a problem for Chicago. Because of consolidation, it also damaged operations in Los Angeles, Baltimore, Hartford, Orlando, etc. And in TV, everyone thinks their local newscast is the worst in the country.
But the problem is that they're all the same — in some markets literally so, because one company is doing the news for two or three stations. And then there's radio, which doesn't even do news anymore with a few exceptions; and whether it's music or talk, unique local voices have been replaced by the same cookie-cutter content from coast-to-coast.
This article is the copyrighted property of the writer and Communities @ WashingtonTimes.com. Written permission must be obtained before reprint in online or print media. REPRINTING TWTC CONTENT WITHOUT PERMISSION AND/OR PAYMENT IS THEFT AND PUNISHABLE BY LAW.


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Medgenics Initiates U.S. Biopump Processing Site
Medgenics, Inc. (NYSE MKT: MDGN and AIM: MEDU, MEDG), the developer of the novel Biopump™ technology for the sustained production and delivery of therapeutic proteins in patients using their own tissue, announced today it has initiated its first U.S. Biopump processing facility in Davis, California.
EPODURE™ Biopumps for the treatment of anemia are now being processed by the Company's contract manufacturing organization ("CMO") in a good manufacturing practice ("GMP") certified facility. This marks the first Biopump processing site outside of Israel, and provides Medgenics with a significant ability to scale-up its clinical and commercial capabilities to address global therapeutic areas such as anemia and hemophilia.
In a key "dry run" test of the production system, tissue micro-organs were obtained and loaded into individual closed processing chambers in Israel, and then shipped to the U.S. CMO Biopump processing center in California. There, the micro-organs were processed in their closed systems into fully functioning EPODURE Biopumps, meeting the release criteria for use in human clinical trials in the U.S. This demonstrates Medgenics' capability to support the treatment of patients at remote clinical sites, transporting their Biopumps to and from strategically located processing facilities, thereby allowing for multicenter clinical trials and practical commercial implementation.
Medgenics recently announced that it had received clearance from the U.S. Food and Drug Administration ("FDA") for its Investigational New Drug ("IND") application to conduct a Phase IIb study of EPODURE for the treatment of anemia in dialysis patients in the U.S."The launch of this U.S. processing facility is another important step for advancing our U.S. clinical trials and product commercialization. The initial processing of Biopumps in the GMP facility of our U.S. CMO resulted in product that meets all quality requirements for use in human clinical trials. We plan to continue with processing additional lots of product to ensure consistency and reliability before the U.S. clinical trial commences," stated Andrew L. Pearlman, Ph.D., President and Chief Executive Officer of Medgenics. "Importantly, this U.S. GMP processing center has been launched through an existing facility, which is much less capital intensive and simpler to establish than typical protein production facilities. As Medgenics grows and expands, we believe that similar Biopump processing facilities can be easily set up in other sites around the world."
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|This article needs additional citations for verification. (June 2007)
A tray of Laddus
|Dessert, snack
|Place of origin
|Pakistan, India
|Thaggu ke laddu, Netraam k Laddu
|Main ingredients
|Flour, milk, sugar
|Gram flour, rava
|Other information
|Served on festive or religious occasions
|Cookbook:Laddu Laddu
Laddu or Laddoo is a ball-shaped sweet popular in the Indian Subcontinent. Thaggu ke Laddu (Kanpur) and motichoor ke laddu of Neetram(Allahabad) is famous and exported to different area across globe.[1][2] Laddu is made of flour, minced dough and sugar with other ingredients that vary by recipe. It is often served at festive or religious occasions.[3][4]
Common flours used for laddu include besan (chickpea flour), rava (wheat semolina) and ground coconut. These are combined with sugar and other flavorings, cooked in ghee and molded into a ball shape. Some laddu recipes are prepared using Ayurvedic medicinal ingredients, including methi laddu, multigrain and resin laddu.
Laddu flour (alternate spelling: ladoo flour, ladu flour) is a coarsely ground whole wheat flour sold particularly in the USA as an ingredient for certain Indian dishes (in particular for laddu). The ostensible explanation for the purpose of the term is to differentiate it from the many other kinds of wheat flours.
Laddu is often prepared for festivals or family events such as weddings and births, or given as a prasad at Hindu temples, especially Tirupati Venkateswara temple, Andhra Pradesh. Laddu is considered a traditional Eid dessert in some Muslim communities.
In Maharashtrian cuisine, there are traditional recipes for laddu intended as travel provisions.
Cultural references[edit]
In the Sesame Street episode "Rakhi Road", laddus are featured prominently as a favoured Indian dessert. Elmo is shown making laddus and enjoying eating them as part of the celebrations around the Indian festival of Rakhi.[5]
A laddu weighing 6,300 kg was made for a Ganesh festival in Andhra Pradesh, India in September 2012. This was claimed to be the largest known laddu.[6]
In the movie English Vinglish, the protagonist Shashi Godbole (Sridevi) is a housewife who makes and sells laddoos as a home-run business.
Motichoor laddu[edit]
Motichoor laddu is made from fine boondi where the balls are tiny and is cooked with ghee or oil. It is often served in good occasions like marriages, raksha bandhan, deepavali, etc.
Besan Laddu[edit]
Besan Laddu (Hindi: बेसन के लड्डू) is a popular Indian sweet dish made of Besan (chickpea flour or gram flour), sugar and ghee.
Besan is roasted in ghee till golden brown appearance with nutty fragrance. Then sugar is added to it. Pistachio pieces are also mixed in this mixture optionally. Sweet balls are then made from this mixture. It has a long shelf life.
It is often served at festivals, family events and religious occasions in India.
See also[edit]
- ^ [1]
- ^ Razan Baker (5 October 2006). "A Sweet Traditional Hejazi Treats". Arab News. Retrieved 22 August 2012.
- ^ http://newindianexpress.com/cities/chennai/Sweet-shops-make-hay-in-Diwali-shine/2013/10/31/article1864851.ece
- ^ http://www.thehindu.com/features/metroplus/Food/as-good-as-home/article5288375.ece
- ^ "Show Guide Landing". Sesame Street. Retrieved 2011-10-13.
- ^ "6,300 kg Tapeswaram laddu creates record". The New Indian Expres. Express Network Private Limited. Retrieved 27 September 2012.
|Wikimedia Commons has media related to Laddu.


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Charlie Brooker hosts a comedy panel show that celebrates failure. Guests try to out-wrong each other with their ideas and stories
5/5 Charlie Brooker celebrates failure with guests Sarah Millican, Lee Mack and Iain Morris.
First broadcast: 08 Jun 2010
4/5 Liza Tarbuck, Richard Herring and Jack Whitehall confess their worst ever excuses.
First broadcast: 01 Jun 2010
3/5 Comedy panel show of glorious failures with Richard Herring, Holly Walsh and Iain Morris.
First broadcast: 25 May 2010
2/5 Charlie Brooker seeks the best in wrong answers, with Lee Mack, Josie Long and Tom Basden.
First broadcast: 18 May 2010
1/5 Charlie Brooker's comedy panel show celebrates failure with David Mitchell and guests.
First broadcast: 11 May 2010
5/5 Charlie Brooker celebrates failure with guests Sarah Millican, Lee Mack and Iain Morris.
Tue 29 Apr 2014 22:30 BBC Radio 4 Extra
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My arrangement of Fly Me To The Moon is being used in a bit by Martin Short for The Academy of Canadian Cinema & Television's new Canadian Screen Awards. Since I am in the United States, I cannot watch it live. I could not find a live stream of it at this writing. It airs 5pm EST or 8pm PST.
Bill Fulton arrangement of Fly Me To The Moon featured in Canadian Screen Awards with Martin Short
March 3, 2013 by


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Disclosures: Sara Schutzman, MD Nothing to disclose. Richard G Bachur, MD Nothing to disclose. Douglas R Nordli, Jr, MD Nothing to disclose. James F Wiley, II, MD, MPH Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Head trauma occurs commonly in childhood. Most head trauma in children is minor and not associated with brain injury or long-term sequelae. However, a small number of children who appear to be at low risk after minor head trauma may have a clinically important traumatic brain (ciTBI) injury. (See 'Clinically important traumatic brain injury' below.)
The clinical challenge for evaluating minor head trauma in pediatric patients is to identify those infants and children with ciTBI while limiting unnecessary radiographic imaging and radiation exposure. Neuroimaging, usually with computed tomography (CT), is highly sensitive for identifying brain injury requiring acute intervention. However, individual clinical predictors for ciTBI are often nonspecific, particularly in young children. Thus, evaluation for high-risk findings and the use of a clinical decision rule can provide a balanced approach that identifies almost all infants and children with ciTBI after minor head trauma without overuse of CT.
This topic will discuss the epidemiology of head trauma in infants and children, the incidence of traumatic brain injury (TBI), clinical features of head-injured children with and without ciTBI, and the evaluation of infants and children with mild head trauma.
The management of minor head trauma in children, severe TBI in children and adolescents, concussion and mild head trauma in adolescents, and inflicted head trauma in children are reviewed separately. (See "Initial approach to severe traumatic brain injury in children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children" and "Sport-related concussion in children and adolescents: Clinical manifestations and diagnosis" and "Sport-related concussion in children and adolescents: Management".)
Minor head trauma — Because of the difference in mechanisms and presentations, it is best to define minor head trauma differently by age as follows (see 'Mechanism' below and 'Incidence of brain injury' below):
●Children younger than two years of age – Experts define minor head trauma in these patients as a history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or awakens to voice or light touch [1].
Minor head trauma is generally defined separately in children younger than two years of age for the following reasons [1,2]:
•Clinical assessment is more difficult
•Infants with intracranial injuries are frequently asymptomatic
•Skull fractures or clinically important traumatic brain injury (ciTBI) may occur despite minor trauma
•Inflicted injury occurs more frequently
●Children two years of age and older – The definition of minor head trauma for children two years of age and older has often been based upon the Glasgow Coma Scale (GCS). Some have defined minor head trauma as a GCS score of 15, whereas others have included children with scores ≥13 (table 1) [3,4]. However, the rate of traumatic brain injury in children with a GCS of 13 is as high as 20 percent, which makes computed tomography (CT) of the head indicated for most children with this degree of altered mental status.
Thus, for the purposes of this discussion, we define minor head trauma in previously healthy children two years of age and older as follows:
•GCS of 14 or 15 at the initial examination
•No abnormal or focal findings on neurologic examination
•No physical evidence of skull fracture (eg, no palpable skull defect and no signs of basilar skull fracture such as hemotympanum, CSF oto- or rhinorrhea, or periocular or posterior auricular hematomas)
However, the clinician should regard these patients as having apparently minor head trauma because approximately 5 percent have TBI on neuroimaging, and 1 percent have ciTBI. (See 'Incidence of brain injury' below.)
Mild traumatic brain injury — Mild traumatic brain injury (TBI) is generally associated with symptoms, such as a brief loss of consciousness, disorientation, or vomiting. Like minor head trauma, patients with mild TBI usually have GCS scores of 13 to 15, measured approximately 30 minutes after the injury. In comparison, patients with moderate TBI generally have initial GCS scores between 9 and 12, whereas those with severe injury have GCS scores ≤8 (table 1) [5]. (See 'Clinical features' below.)
Concussion — From a clinical standpoint, concussion can be defined as trauma-induced brain dysfunction without demonstrable structural injury on standard neuroimaging. As such, concussion is a type of mild traumatic brain injury. (See "Sport-related concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Definition' and "Concussion and mild traumatic brain injury", section on 'Definitions'.)
The clinical manifestations, diagnosis, and management of concussion in children and adolescents are discussed in greater detail separately. (See "Sport-related concussion in children and adolescents: Clinical manifestations and diagnosis" and "Sport-related concussion in children and adolescents: Management" and "Concussion and mild traumatic brain injury".)
Clinically important traumatic brain injury — Several observational studies have been performed to identify infants and children who are at higher risk of intracranial injury (ICI) after minor head trauma [6]. For this topic, we will define clinically important traumatic brain injury (ciTBI) using criteria similar to that established for the largest cohorts studied as follows [7-10]:
●Presence of an ICI (eg, epidural hematoma, subdural hematoma, or cerebral contusion) on CT associated with one or more of the following:
•Neurosurgical intervention (either surgery or invasive intracranial pressure monitoring)
•Endotracheal intubation for the management of head injury
•Hospitalization directly related to the head injury for at least 48 hours
●Depressed skull fracture warranting operative elevation (ie, depressed past the inner table of the skull)
●Clinical findings of a basilar skull fracture (periorbital ecchymosis, Battle's sign (picture 1), hemotympanum (picture 2), cerebrospinal fluid [CSF] otorrhea, or CSF rhinorrhea)
PATHOPHYSIOLOGY — Brain injury can occur following a minor head trauma because rotational acceleration-deceleration of the head generates shearing forces that cause mechanical disruption of nerve fibers, resulting in diffuse axonal injury. This process has been described in association with severe brain injury and occurs in mild traumatic brain injury (TBI) as well. Whether or not this pattern of injury differs in the developing brain is uncertain [11].
Mild TBI usually occurs with head trauma due to contact and/or acceleration (including translational and rotational acceleration) or deceleration forces. The type of mechanical forces applied to the brain may determine, to some extent, the nature of the resultant injury as follows [12,13]:
●Acceleration occurs when a moving object strikes a stationary head. Linear acceleration is considered the least injurious force and typically is associated with superficial contusions or in rare cases, intracranial hematomas.
●Deceleration results when a moving head strikes a stationary surface. Sudden deceleration is thought to be responsible for most severe brainstem injuries.
●Rotation of the brain occurs when the head is struck in an asymmetric manner or an infant is vigorously shaken. Rotational acceleration-deceleration can induce widespread injury including large subdural hematomas. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology", section on 'Pathophysiology'.)
●Epidural hematomas typically arise from a direct blow resulting in a linear fracture that cross middle meningeal arterial branches or dural venous sinuses, but may also occur without an associated fracture in a significant number of children. (See "Intracranial epidural hematoma in children: Epidemiology, anatomy and pathophysiology", section on 'Associated abnormalities'.)
EPIDEMIOLOGY — Head trauma occurs commonly in children. In the United States, among children younger than 14 years of age, traumatic brain injury (TBI) accounts for approximately 500,000 emergency department (ED) visits, 37,000 hospitalizations and over 2000 deaths annually [14]. In developed countries, TBI is the most common cause of death and disability in childhood [15].
Most children with head trauma are young, male, and have a mild injury. This was demonstrated in a large prospective series that described minor head trauma in 10,965 children in the United Kingdom [16]. Fifty-five percent of children were younger than five years of age, with 28 percent younger than two years of age. Boys accounted for 65 percent of patients, and 98 percent of children had Glasgow Coma Scale (GCS) scores of 15. Other series of children with head trauma have reported lower GCS scores but many of these describe selected populations, such as children with head injury who had neuroimaging performed [17,18].
Mechanism — Falls are the most common mechanism of injury for children sustaining minor head trauma, followed by motor vehicle crashes, pedestrian and bicycle accidents, projectiles, assaults, sports-related trauma, and abuse [7,16]. These mechanisms cause isolated head trauma in the majority of patients [7].
Infants sustain more falls and are at increased risk for inflicted injury. It is of utmost importance to identify children who have sustained an inflicted head injury, even if the injury is minor. Children who remain in the care of the perpetrator are at significant risk for being injured again. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
Incidence of brain injury — The true incidence of clinically important traumatic brain injury (ciTBI) following minor head trauma is unknown. Most studies providing incidence data are from selected populations in which children with moderate to severe injury are overrepresented (eg, including only children who have had computed tomography [CT] or primarily children with nontrivial trauma) [17-20]. Consequently, the risk of ciTBI in these series may be overestimated.
Estimates of the incidence of TBI following head trauma from selected populations are summarized as follows:
●Among children two years of age and older with minor head trauma and a normal neurologic examination, 3 to 7 percent may have a TBI noted on CT scan [7,17-21]. Approximately 1 percent have ciTBI, and 0.1 to 0.6 percent require surgical intervention [8,19,22,23].
●For children younger than two years with minor head trauma and a normal neurologic examination, approximately 3 to 10 percent have a TBI on CT, 1 percent have ciTBI, and 0.2 percent require surgical intervention [7,8,17-19,24]. Many of these younger children have no clinical symptoms of brain injury (19 to 48 percent), although most of these patients have scalp hematomas [7,25,26]. In a prospective series of infants under two years of age, 1 of 14 asymptomatic infants with ciTBI required surgery [26].
Data from two European populations suggest that the incidence of ciTBI after minor head trauma is much lower (0.6 to 1.2 percent). However, only 2 to 3 percent of patients in these studies underwent neuroimaging [9,27].
Patients with shunts or bleeding disorders — Although the threshold for obtaining neuroimaging after minor head trauma in patients with ventricular shunts or bleeding disorders is lower for many clinicians, it is not clear that clinically important traumatic brain injury (ciTBI) after minor head trauma actually occurs more frequently than in normal children. As an example, in planned secondary analyses of a large multicenter observational study of children with minor head injury, approximately 1 percent of children with either ventricular shunts (98 children) or bleeding disorders (230 children) had a ciTBI (eg, head injury resulting in death, neurosurgery, intubation >24 hours, or hospital admission >2 nights) compared with 0.9 percent of the approximately 40,000 normal children [28-30]. However, with the low numbers of patients in these studies, the true frequency of ciTBI following minor head trauma in children with bleeding disorders or ventricular shunts could be as high as 4 to 5 percent, respectively. Furthermore, the rate of ciTBI seen in children with bleeding disorders occurred despite significantly fewer severe mechanisms of injury when compared with normal children [29,30].
CLINICAL FEATURES — Similar to reports of the incidence of clinically important traumatic brain injury (ciTBI), some studies that describe clinical features following minor head trauma only included children who underwent head computed tomography (CT). Consequently, these data also likely represent children whose injuries were more severe.
Common findings — Observational studies have identified loss of consciousness, scalp hematoma, vomiting, and headache as common features associated with minor head trauma in children evaluated in emergency departments [31].
Loss of consciousness — Loss of consciousness (LOC) following minor head trauma occurs in approximately 5 percent of children <2 years of age and up to 13 percent of children ≥2 years of age and is frequently used to make decisions regarding neuroimaging [7,32]. It may be associated with ciTBI depending upon the duration of LOC and the presence of other clinical predictors [7,9,32].
However, the risk of TBI in the setting of brief, isolated LOC without any other clinical predictors of TBI, is low [32]. As an example, in one large multicenter, prospective cohort study of 5850 children with LOC after mild head trauma, 0.5 percent of 2780 children with isolated LOC, defined as LOC without any of the age-related PECARN clinical predictors for ciTBI (table 2), had ciTBI compared with 4 percent of 3070 children with LOC and other PECARN clinical predictors [32]. In this study, longer duration of LOC was also associated with ciTBI occurring in 1 percent of 907 children with LOC for <5 seconds and up to 4 percent of 200 children with LOC >5 minutes. (See 'Approach' below.)
Scalp hematoma — Most children with isolated scalp hematomas and no other clinical symptoms do not have ciTBI (eg, injuries resulting in death or requiring hospitalization for >2 days, endotracheal intubation for >24 hours, or neurosurgery). However, hematomas can be an important indicator of potential TBI when they appear in younger infants, are larger (eg, >3 cm), and are located in nonfrontal regions. As an example, in a multicenter observational study of 2998 children younger than 24 months of age with an isolated scalp hematoma, 50 of 570 children (8.8 percent) that underwent CT had TBI (eg, subdural or epidural hematomas, cerebral or subarachnoid hemorrhages, or cerebral contusion). Of 111 patients younger than three months with any hematoma who underwent CT, 21 percent (23 out of 111) had TBI on CT confirming that an isolated scalp hematoma is an important indicator of potential brain injury in neonates and young infants. However, ciTBI occurred in only 12 patients (0.4 percent of all 2998 patients), none of whom died or required neurosurgery [33]. On multivariate analysis, characteristics independently associated with TBI on CT included younger age, larger hematoma size, nonfrontal hematoma location, and more severe mechanisms of injury. A previously validated clinical score incorporates age and hematoma characteristics and may help stratify the risk of TBI in young infants (table 3) [34]. The mechanism of injury is also an important consideration not addressed in this score. (See 'Younger than two years' below.)
Vomiting — At least one episode of vomiting is reported in approximately 13 percent of patients following minor head trauma [7,35]. Most of these children do not have ciTBI [7,8,35]. However, ciTBI is more likely in children who have vomiting and other findings associated with ciTBI (eg, severe mechanism of injury, loss of consciousness, or altered mental status). As an example, of 5557 children evaluated for vomiting after minor head trauma at multiple centers, ciTBI occurred in 0.2 percent (95% CI 0-0.9 percent) of 815 children with isolated vomiting (ie, vomiting alone without other findings of ciTBI) and in 2.5 percent (95% CI 2.1-3.0 percent) of 4577 children with vomiting and other findings of ciTBI [35]. Although the incidence of ciTBI among those with isolated vomiting was low, it was higher than patients without vomiting or other high risk symptoms (0.2 versus 0.04 percent). In a case control study comparing 162 children with mild head injury (as defined by discharge to home from the emergency department [ED]) and vomiting with matched controls, predictors of vomiting included a personal history of vomiting, motion sickness, and headache associated with the injury [36].
Whether the number of vomiting episodes and the timing of these episodes can help identify patients with ciTBI is unclear. Vomiting two or more times after head trauma was associated with an approximately 37 percent increase in traumatic brain injury in one multicenter observational study [8]. However, increased frequency or later onset of vomiting after head injury did not identify children with ciTBI in another multicenter cohort [35].
Headache — Headache is a frequent complaint, occurring in up to 45 percent of children. In preverbal children, irritability may be an indication of discomfort, such as headache [7,9].
Seizures — Among unselected populations of children with head trauma, immediate posttraumatic seizures occurred in ≤0.6 percent [9,27]. In smaller series, seizures have been reported in approximately 3 to 8 percent of patients [4,19,37]. In one large cohort, the frequency of seizures after minor head trauma was 4 percent with approximately half occurring at the time of impact [8].
Skull fractures — Skull fractures occur in up to 10 percent of children younger than two years of age following minor head trauma [3,38]. Most skull fractures in this population are linear. Among children with linear skull fractures, 15 to 30 percent have associated intracranial injuries [2,19,20,26,39,40].
Most children with skull fractures will also have overlying scalp hematomas. However, most children with scalp hematomas, outside of infancy, do not have a skull fracture. In infants younger than one year of age, large scalp hematoma size, younger age, and/or nonfrontal location (highest risk with temporal or parietal), suggest a higher incidence of skull fracture. However, in one prospective series of 422 children, no infant with a frontal hematoma had an intracranial injury [38].
Other findings of skull fracture include a palpable skull defect, cerebrospinal fluid rhinorrhea or otorrhea, posterior auricular hematoma (Battle's sign) (picture 1), hemotympanum (picture 2), and periorbital hematomas ("raccoon eyes") (picture 3).
The evaluation and management of skull fractures in children are discussed in greater detail separately. (See "Skull fractures in children".)
Other findings — Transient cortical defects, such as cortical blindness and acute confusional states, have been reported rarely in association with minor head trauma [41-43]. These deficits are thought to be secondary to vascular hyperreactivity and may be trauma-induced, migraine-equivalent phenomena. Although rare, there are also case reports of ischemic or thrombotic stroke following mild head trauma in children [44,45].
EVALUATION — The priority for the evaluation of children with apparently minor head trauma is to identify those patients with traumatic brain injury (TBI) who may require immediate intervention (eg, an expanding epidural hematoma), admission for monitoring (eg, small stable epidural hematomas or cerebral contusions) or close follow-up (eg, skull fracture without intracranial injury), while limiting unnecessary neuroimaging.
In addition, children who may have sustained an inflicted injury must be identified. The evaluation of abusive head trauma is discussed in detail elsewhere. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
Features of the history and physical examination, along with selective neuroimaging, generally identify children who have sustained a brain injury with acute management implications.
History — Historical features that may suggest an increased risk of clinically important traumatic brain include the following:
●Caregiver concern that a child younger than two years of age is not acting normally
●Seizure, confusion, or loss of consciousness
●Severe or worsening headache
●High-risk mechanism, such as a fall from greater than 3 to 5 feet (depending on age), significant motor vehicle collision, penetrating injury, inflicted injury, or unknown mechanism (which may represent inflicted injury)
●Preexisting conditions that place the child at risk for intracranial hemorrhage, such as arteriovenous malformation or a bleeding disorder (see 'Patients with shunts or bleeding disorders' above)
Physical examination — The clinician should perform a thorough head and neurological examination (including mental status). Vital signs and evidence of associated extracranial injury, such as neck or abdominal tenderness, also warrant careful evaluation.
The presence of the following specific findings is significant:
●Scalp abnormalities, such as hematoma, tenderness, or depression
●In infants, bulging anterior fontanelle
●Abnormal mental status
●Focal neurologic abnormality
●Signs of basilar skull fracture (periorbital ecchymosis, Battle's sign (picture 1), hemotympanum (picture 2), cerebral spinal fluid [CSF] otorrhea, or CSF rhinorrhea)
Predictors of traumatic brain injury — The approach to neuroimaging in children with suspected abusive head trauma is discussed separately; however, any child with concerns for abusive head trauma should undergo neuroimaging. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Imaging'.)
In children with minor head trauma, no combination of clinical findings is both highly sensitive and specific for clinically important traumatic brain injuries (ciTBI). However, clinical findings can help stratify a patient's risk of ciTBI as high, intermediate, or low as follows:
●High risk – Observational reports from selected populations have consistently described the following findings as significant predictors of ciTBI in children [9,21,27,46-48]:
•Focal neurologic examination
•Altered mental status (persistent Glasgow score ≤14)
•Findings indicating a skull fracture, such as a palpable skull defect, cerebrospinal fluid rhinorrhea or otorrhea, posterior auricular hematoma (Battle's sign) (picture 1), hemotympanum (picture 2), and periorbital hematomas ("raccoon eyes") (picture 3)
●Intermediate risk – Variable significance has been reported for each of the following findings [7,21,27,46-50]:
•Loss of consciousness
•Age less than two years
•Nonfrontal scalp hematoma in children younger than one year of age
•Persistent or worsening headache
•Significant trauma mechanism (eg, bicycle-related injury, falls from >0.9 to 1.5 m [3 to 5 feet], serious motor vehicle collision)
●Low risk – Patients with none of the above findings (low mechanism of injury, normal exam except frontal hematoma, no symptoms) are considered low risk and should typically not undergo neuroimaging.
Clinical decision rules have been developed to guide neuroimaging decisions. (See 'Clinical decision rules' below and 'Approach' below.)
Neuroimaging — An approach to neuroimaging of children with minor head trauma that is based upon risk of ciTBI is provided below. (See 'Approach' below.)
Most children with minor head trauma do not need computed tomography (CT) of the head CT to exclude ciTBI. The decision to obtain a head CT should be made using clinical predictors to determine risk of ciTBI. (See 'Approach' below.)
The approach to neuroimaging in children with suspected abusive head trauma is discussed separately. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Imaging'.)
Children who have minor head trauma and who are at an increased risk for ciTBI that may require neurosurgical intervention or intensive care or monitoring should be initially imaged with unenhanced CT. Head CT identifies essentially all ciTBI [3]. It can be rapidly obtained in most hospitals. Skull radiography is of little or no added value if a head CT is performed. (See "Approach to neuroimaging in children", section on 'CT applications' and "Approach to neuroimaging in children", section on 'Plain radiographs'.)
The decision to obtain a head CT for children with minor head trauma must balance the importance of identifying a significant, but rare ciTBI with the estimated risks of late onset malignancy associated with radiation exposure from CT. The risk of death or major disability if a ciTBI is missed is considerable and immediate. Furthermore, evidence suggests that a clinician's ability to predict the presence of such an injury in patient without high-risk findings (eg, altered mental status, focal neurologic examination, or signs of basilar skull fracture) is poor [50].
On the other hand, the estimated lifetime risk of cancer mortality from a head CT is substantially higher for children than for adults because of a longer subsequent lifetime and the greater sensitivity of some developing organs (eg, brain or bone marrow) to radiation. Estimates suggest that the lifetime risk of death due to cancer caused by radiation from one head CT is 1 in 1500 in a one year old infant and 1 in 5000 in a 10 year old child [51]. However, the latency period for development of cancer may be decades. (See "Approach to neuroimaging in children", section on 'Radiation'.)
Thus, the probability of ciTBI as determined by clinical findings is a key factor for identifying the optimal approach in individual patients. As an example, in a clinical decision analysis of the optimal neuroimaging strategy that weighed the risk of ciTBI with the risk of radiation exposure from head CT and subsequent malignancy for children younger than two years of age with minor head trauma, no imaging was the best strategy when the probability of ciTBI was about 0.9 percent and head CT was the preferred strategy only for patients at higher risk [52].
Clinical decision rules — Clinical decision rules are not intended to replace clinical judgment. Based upon existing evidence, they assist rather than completely direct the clinician's approach to neuroimaging of children with minor head trauma.
For infants and children with minor head trauma, absence of high-risk signs or symptoms of ciTBI, we suggest that management decisions, especially the performance of neuroimaging and observation, be guided by the use of the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules (table 2) rather than other rules because it was derived in the largest cohort and is the only rule to be validated. (See 'Neuroimaging' above and 'Approach' below.)
This recommendation is based upon the following evidence:
●The PECARN rule was derived and validated in large pediatric cohorts (33,785 and 8627 patients, respectively) at multiple centers including pediatric and general emergency departments and consists of six low-risk predictors in two age groups (table 2) [7]. The goal of this decision rule is to identify children who are at low risk for ciTBI and do not need neuroimaging.
In prospective validation, high sensitivities for the detection of ciTBI (100 percent for children <2 years [95% CI 86-100 percent] and 97 percent for children ≥2 years [95% CI 89-100 percent]) and high negative predictive values (100 percent for children <2 years [95% CI 99.7-100 percent] and 99.95 percent [95% CI 99.81-100 percent] or children ≥2 years) were achieved. The prevalence of ciTBI was approximately 1 percent in both the derivation and validation cohorts.
Not all children who do not meet these low-risk criteria require neuroimaging (as this would likely increase imaging rates) so the authors defined high and intermediate-risk groups. Those with altered mental status and signs of fracture were considered high risk which corresponded to a 4 percent incidence of ciTBI. The investigators felt that all such patients warranted neuroimaging.
Patients who did not meet low-risk criteria, other than altered mental status or signs of fracture (table 2), were considered at intermediate risk which corresponded to a 0.9 percent incidence of ciTBI. These children accounted for approximately 30 percent of all patients. Imaging or observation was suggested, based upon other factors, such as clinician experience, with a lower threshold to image children with multiple, more severe, or worsening signs or symptoms. (See 'Approach' below.)
●Implementation of the PECARN rule in the management of 356 children (46 percent under two years of age) in a separate setting from its original derivation or validation was associated with the following findings [53]:
•High clinician satisfaction with the rule (96 percent)
•High adherence to the rule (94 percent)
•Identification of all three children with a ciTBI at the first visit
•A marginal increase in the rate of head CT after implementation from 7 to 8 percent that was not statistically significant
●Several other clinical decision rules for children with minor head trauma have been derived [6,31]. Of these, CHALICE (table 4) and CATCH (table 5) were derived in the largest and most heterogeneous cohorts. However, no other clinical decision rule, including CHALICE or CATCH, has either been validated or achieved similar results during implementation [6].
Unlike PECARN, which sought to identify children at low risk who would not require imaging, the CHALICE rule, derived from a prospective study of 22,772 patients, has identified 14 high-risk criteria for ciTBI (table 4) that serve as indicators for head CT. During derivation, the rule had a sensitivity of 98 percent (95% CI 96-100 percent) and a specificity of 87 percent [9]. However, evidence suggests that the CHALICE rule may increase the rate of head CT without improved detection of ciTBI as follows:
•In a retrospective analysis of the application of the CHALICE rule in 1065 children, use of this rule would have increased the rate of head CT from 6.5 to 10 percent with only seven additional skull fractures or intracranial injuries identified during initial evaluation [54]. Furthermore, had the CHALICE rule been applied to these patients and head CT obtained at the initial evaluation, the outcomes probably would not have been different.
•In a retrospective observational study of 1091 head injured patients evaluated in one pediatric emergency department (ED), application of the CHALICE rule would have been associated with an increase in the rate of head CT from 19 to 46 percent [54]. In addition, six patients with intracranial injuries would have been missed, including one requiring neurosurgery.
CATCH is also a high-risk decision rule for ciTBI consisting of four high-risk factors and three additional medium-risk factors (table 5) [8]. During derivation in almost 4000 children, including those with a Glasgow Coma Scale (GCS) score of 13, it achieved high sensitivity (98 percent for intermediate-risk factors and 100 percent for high-risk factors). However, it would require that 52 percent of patients undergo CT. In addition, CATCH has not been prospectively validated.
●In a prospective, single center observational study of physician judgment and clinical decision rules in which PECARN, CHALICE, and CATCH decision rules were all applied to 1009 children with minor head injury (2 percent with ciTBI and 19 percent undergoing CT), only physician practice (sensitivity 100 percent, 95% CI 84-100 percent) and the PECARN rule (sensitivity 100 percent, 95% CI 84-100 percent) identified all ciTBI, including four patients requiring neurosurgical intervention [55]. Both CATCH and CHALICE misclassified a small number of patients with ciTBI as low risk. Both rules also missed one injury that warranted neurosurgical intervention.
Taken together, the evidence suggests that the PECARN rule provides a sensitive means of identifying children with ciTBI at an acceptable cost when applied to patients who have sustained more than trivial head trauma but who do not have obvious indications for neuroimaging.
Although not prospectively validated, the CHALICE rule has been implemented in the United Kingdom, and other investigators have suggested use of the CHALICE rule instead of the PECARN rule for the following reasons:
●In two separate analyses, investigators determined, based upon theoretical estimates, that implementation of the PECARN rule would increase the amount of neuroimaging to a greater extent than the CHALICE rule [6,31]. However, as noted above, actual implementation of the PECARN rule in one emergency department (ED) with a low rate of head CT only marginally increased the number of head CTs while identifying all children with ciTBI [53]. Given the low pre-implementation imaging rate, however, the lack of increase may have been due to the preponderance of low-risk patients at this center.
●In a decision analysis that compared the CHALICE and PECARN rules and assigned costs based upon the United Kingdom National Health Service experience, CHALICE was the optimal strategy for evaluating children with minor head trauma [56]. However, all decision rules evaluated in this study had similar costs and outcomes. Specifically, the PECARN rule achieved quality of life estimates similar to the CHALICE rule while costing about ₤75 (approximately USD $125) more per patient. This difference in cost is likely within the margin of error for the model.
Approach — Although there is not uniformity regarding risk factors derived from the large, multicenter observational studies, there are many consistencies particularly for the high and low-risk groups that permit a suggested approach to neuroimaging in children with minor head trauma [7-10,48]. This approach is largely consistent with guidelines for evaluation and management of minor head trauma in children previously proposed by expert consensus [1].
Younger than two years — Because children younger than two years of age are more difficult to assess, may be asymptomatic despite having a ciTBI, are at risk for abusive head trauma, and are more prone to skull fractures than older children, we suggest the following criteria for neuroimaging (see 'Minor head trauma' above and "Minor head trauma in infants and children: Management", section on 'Minor head trauma'):
●Perform neuroimaging – Infants and children younger than two years of age with high risk for intracranial injury or with suspected skull fracture should have a head CT [1,7,57].
High-risk patients have one or more of the following signs or symptoms:
•Suspicion of child abuse
•Focal neurologic findings
•Acute skull fracture, including depressed or basilar fracture
•Altered mental status change (eg, lethargy or irritability)
•Bulging fontanelle
•Persistent vomiting (see 'Vomiting' above)
•Seizure following injury
•Definite loss of consciousness if longer than a few seconds and especially if associated with other clinical predictors of ciTBI (table 2) (see 'Loss of consciousness' above)
●Observe or perform neuroimaging – Intermediate-risk patients may be managed with close observation for four to six hours after the injury (with imaging obtained for any worsening condition during this period), or they may be evaluated immediately by head CT.
Patient at intermediate-risk have any one or more of the following signs or symptoms:
•Vomiting that is self-limited
•Loss of consciousness that is uncertain, or isolated and very brief (less than a few seconds) (see 'Loss of consciousness' above)
•History of lethargy or irritability, now resolved
•Behavioral change reported by caregiver
•Injury caused by high-risk mechanism of injury (eg, fall more than three feet, patient ejection, death of a passenger, rollover, high-impact head injury)
•Scalp hematoma (particularly nonfrontal)
•Skull fracture more than 24 hours old (nonacute)
•Unwitnessed trauma of concern (eg, fall heard in adjacent room with possible loss of consciousness)
•Age younger than three months with nontrivial trauma
The clinician should have a lower threshold for imaging if symptoms are multiple, worsening or severe, if vomiting is persistent, and for the youngest patients with nontrivial trauma [7,11,21].
The risk for fracture and TBI with scalp hematomas can be stratified using a validated scalp score (table 3) [34]. Younger patients, larger hematomas, and nonfrontal hematomas (temporal-parietal more concerning than occipital) have the highest risk. As an example, in a large multicenter, cohort study, 8 out of 16 patients younger than three months of age with large temporal/parietal hematomas who underwent imaging had TBI on CT [33]. If a scalp hematoma is the only finding, evidence from this study indicates that there is approximately a 0.4 percent risk of ciTBI, and a 1.7 percent risk of TBI on CT.
For patients for whom the sole criterion is a high-risk mechanism for injury, the risk of ciTBI is 0.3 percent [7,58].
If immediate CT is deferred for intermediate-risk patients, we suggest observation for at least four to six hours after injury to ensure no progression of clinical findings that warrant CT.
Preliminary evidence suggests that observation of selected children younger than two years of age at intermediate risk reduces the number of head CTs without missing a ciTBI. As an example, in an observational study of 1318 children evaluated for minor head trauma at a single pediatric ED, including 509 children younger than two years of age, the rate of head CT among children who were chosen for observation was 5 percent [59,60]. The adjusted time dependent decrease in CT rate for children at intermediate risk according to the PECARN decision rule was 72 percent and their median time of observation was three hours. None of the intermediate-risk children were subsequently found to have a ciTBI.
Skull radiographs may occasionally be useful to screen for fracture and avoid the risk of radiation and sedation from CT in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas [57]. However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children [61]. If a screening skull radiograph shows a fracture, then a head CT should be performed. (See 'Skull radiographs' below.)
●Do not perform neuroimaging – Imaging studies should be avoided in children <2 years of age at very low risk for brain injury. These patients should have a normal neurologic examination (including a normal fontanelle), no history of seizure, and no persistent vomiting. The clinician should also have no suspicion for abuse.
Low-risk patients should meet all of the following criteria (table 2) [7]:
•Normal mental status
•No parietal, occipital or temporal scalp hematoma
•No loss of consciousness >5 seconds (see 'Loss of consciousness' above)
•No evidence of skull fracture
•Normal behavior according to the routine caregiver
•No high-risk mechanism of injury (severe mechanisms: fall >0.9 m (3 feet); head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle)
The risk for clinically important traumatic brain injury is less than 0.02 percent in these patients [7].
Two years and older — Criteria to guide decisions about neuroimaging in children two years of age and older are derived from several large multicenter observational studies [7,9,21] and a metaanalysis of observational studies [46].
We suggest the following approach:
●Perform neuroimaging – Children ≥2 years of age with one or more of the following signs and symptoms appear to be at the highest risk for ciTBI and should have CT of the head performed [7,9,21,46]:
•Focal neurologic findings
•Skull fracture, especially findings of basilar skull fracture
•Persistent altered mental status (eg, agitation, lethargy, repetitive questioning, or slow response to verbal questioning)
•Prolonged loss of consciousness (LOC) (see 'Loss of consciousness' above)
Multiple observational studies have found these individual findings to be highly associated with ciTBI in children [31].
●Observe or perform neuroimaging – For children with signs and symptoms that have been variably associated with intracranial injury, close observation for four to six hours after the injury (with imaging obtained for any worsening symptoms or concerns during this period) is an alternative to immediate CT of the head. The clinician should have a lower threshold for imaging for severe, persistent, worsening, or multiple clinical findings. These signs and symptoms include:
•Vomiting (see 'Vomiting' above)
•Questionable or brief loss of consciousness (LOC)
•Injury caused by high-risk mechanism of injury
The risk of ciTBI is approximately 1 percent in patients with at least one of these criteria and 0.6 percent if the sole criterion is a high-risk mechanism for injury [7,58]. Patients with isolated LOC that is brief have a low risk of ciTBI. Most of these patients do not require neuroimaging [32]. Multiple or worsening symptoms or signs likely puts the child at greater risk than an isolated finding [7,11,21].
Evidence suggests that observation of patients with these signs and symptoms may decrease the utilization of head CT without missing clinically important traumatic brain injury as follows:
•In a multicenter, prospective observational study, children (median age five years) who were observed had a lower rate of head CT use than those who were not (31 versus 35 percent, respectively, difference -4 percent [95% CI -5 to -3 percent]) [62]. The observed patients had a similar rate of clinically important traumatic brain injury (0.8 versus 0.9 percent). In this study, most observed children were older than two years of age.
•In a single center prospective observational study previously discussed, the rate of head CT in children who were chosen to be observed was 5 percent and the median time for observation was 2.5 hours [59]. Overall, 20 percent of children received a head CT. The adjusted time dependent decrease in CT rate overall was 69 percent (odds ratio [OR] 0.31, 95% CI 0.25-0.37). Most observed patients were intermediate risk by the PECARN decision rule and two years of age or older. All eight children with ciTBI had an immediate head CT although clinical follow-up was confined to electronic medical record review.
Thus, observation appears to be a safe and effective approach for selected children two years of age and older who are at an intermediate risk of ciTBI based upon the PECARN decision rule.
●Do not perform neuroimaging – Imaging studies should be avoided in children ≥2 years of age at very low risk for ciTBI. These patients should have a normal neurologic examination, no physical evidence suggesting a skull fracture, and no preexisting condition that might increase the risk of intracranial hemorrhage (eg, bleeding disorder) [63].
Low-risk patients should meet all of the following criteria (table 2) [7]:
•Normal mental status
•No LOC (see 'Loss of consciousness' above)
•No vomiting (see 'Vomiting' above)
•No signs of basilar skull fracture
•No severe headache
•No high-risk mechanism of injury (severe mechanisms: fall >1.5 m (5 feet); head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without a helmet struck by a motorized vehicle)
The risk for clinically important traumatic brain injury is less than 0.05 percent if none of these findings are present [7].
Skull radiographs — Because plain skull radiographs give no direct information about intracranial injury, they are rarely performed as the initial imaging study. Instances in which skull radiographs may assist the clinician in deciding whether or not to perform CT of the head include the following:
●When the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse)
●To rapidly evaluate for the location of a radiopaque foreign body (eg, whether a projectile is intracranial or not)
●In rare instances, to screen for fractures in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas
However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children [61].
If a screening skull radiograph shows a fracture, then a head CT should be performed. If a screening skull radiograph shows no fracture, the risk of a ciTBI may be lower, but the clinician should understand that it may still be present. (See "Skull fractures in children", section on 'Radiologic evaluation' and 'Incidence of brain injury' above.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient information: Head injury in children and adolescents (The Basics)")
●Beyond the Basics topic (see "Patient information: Head injury in children and adolescents (Beyond the Basics)")
●In infants, minor head trauma refers to patients who are alert or awaken to voice or light touch but have a history or physical signs of blunt trauma to the scalp, skull, or brain. In children two years of age or older, this topic defines minor head trauma as children who have sustained head trauma but have a Glasgow Coma Scale (GCS) score of 14 to 15, normal physical examination, and no physical evidence of a skull fracture. (See 'Definitions' above and 'Epidemiology' above and "Minor head trauma in infants and children: Management", section on 'Definitions'.)
●Although associated clinically important traumatic brain injury (ciTBI), (ie, intracranial injury requiring neurosurgical intervention, intensive monitoring and supportive care, prolonged hospitalization; a depressed skull fracture requiring elevation; or a basilar skull fractures) occurs in a small percentage of children and infants who have a normal neurologic examination at presentation, it must be recognized in order to prevent deterioration and subsequent morbidity or mortality. In addition, abusive head trauma must also be identified because it often results in serious intracranial injury and carries a significant risk of recurrence. (See 'Clinically important traumatic brain injury' above and 'Incidence of brain injury' above and "Minor head trauma in infants and children: Management", section on 'Definitions'.)
●Features of the history and physical examination along with careful observation in children with equivocal findings usually identify children who have sustained a ciTBI and warrant neuroimaging. (See 'History' above and 'Physical examination' above and 'Predictors of traumatic brain injury' above.)
●Those who are at an increased risk for ciTBI that may require neurosurgical intervention or intensive care or monitoring should be initially imaged with unenhanced computed tomography (CT). Skull radiography is of little or no added value if a head CT is performed. (See 'Neuroimaging' above and 'Skull radiographs' above.)
●The probability of ciTBI as determined by clinical findings is a key factor for identifying the optimal approach in individual patients. Patients at high risk for ciTBI should undergo prompt neuroimaging. Those at intermediate risk may undergo neuroimaging or observation with performance of imaging if persistent, worsening or new symptoms occur during observation. Infants and children at low risk for ciTBI should not undergo neuroimaging. Clinical decision rules can assist the clinician in determining the level of risk and need for neuroimaging but should not replace clinical judgment. (See 'Clinical decision rules' above.)
●For infants and children with minor head trauma and absence of high-risk physical findings of ciTBI, we suggest that management decisions, especially the performance of neuroimaging or emergency department (ED) observation, be guided by the use of the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules (table 2) rather than other rules. (See 'Clinical decision rules' above.)
●An approach to neuroimaging of infants and children with minor head trauma that differs by age and is based upon the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules and known additional findings that predict a higher risk for ciTBI is provided. (See 'Younger than two years' above and 'Two years and older' above.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.


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St. Clement Vineyards
Sterling Vineyards
Storybook Winery
Turnbull Wine Cellars
V. Sattui Winery
Vine Cliff Winery
Cakebread Cellars Wine Tasting Tours, Hours & Prices:
By Prior Appointment Only: 10:00 a.m. to 4:00 daily. Select Tasting: $15
Library Tasting: 1pm & 2:30pm by appointment
Red Wine Tasting: $30 per person; $20 per person for wine club members
Group Tasting
By Prior Appointment Only
90 minute Educational Tour and Tasting
By Prior Appointment Only
Wine & Food Pairing Experience
By Prior Appointment Only
Cakebread Cellars Wine Tasting Notes
Small, dark, intimate tasting room with intelligent pourers. We went before they made it "appointment only", but I imagine the high quality of service is the same. They offer a great 90 minute wine education tour and tasting, among other interesting classes, which we highly recommend. What you get here is quality wine with quality service, (if you can fight the Highway 29 weekend traffic to get there).
Great producer of whites.
Cakebread Cellars Wines
Ratings and tasting notes coming soon!


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The DSW Chair
Simplicity is invariably the key when it comes to furniture design and this is a principal that the American designer, Charles Eames, knew only too well. The embodiment of his endeavours to create highly functional and striking, yet devilishly simplistic, pieces of designer furniture can surely be found with the understated but luxurious Charles Eames DSW chair. This wonderfully simple but brilliantly conceived piece of designer furniture was Eames' entry for a low-cost... Read More


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Secular Independent Celebrants for All your life / love / loss events - Bespoke Wedding, Funeral & Naming Ceremonies & Toastmaster. Blog: http://t.co/mI3Ee9nz


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Mixed Metals Tassel Necklace
A shimmery tassel inspired by precious metals and glittering beads bring out the splendor of neutrals. Glass/acrylic beads in champagne, bronze, gray and gold; delicate nickel-free metal chain finished in goldtone, silvertone and chocolate plating. Lobster claw clasp; extender. Length: 25"-27".
We're so sorry: this item sold out sooner than expected. For an equally stylish substitute, please call our Style Experts at 1.877.948.2525. Or click on Live Help below for immediate assistance.


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A brand new rear wing for China. The main profile and flap sport a curved profile at the centre, with the exit edge of the flap remaining completely flat. The endplates feature a drag-reducing cut at the rear of the top edge, similar to that on the Williams. They also have a long, vertical slit just...»
In Turkey, Toro Rosso are the latest team to adopt the double-decker wing, first introduced by Renault last year and since adopted by others in various forms. The upper profile extends from the inside edge of the endplate, exactly as on the Renault. The benefits of this solution are better handling...»
As seen earlier in the year on the Toyota and Ferrari, in Hungary Toro Rosso introduced rim shields for their rear wheels. A carbon lip is applied to the outer face of the wheel with the aim of improving brake cooling, whilst at the same time providing a minor aerodynamic gain by cutting turbulence...»


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Aiseesoft FLV to DVD Converter
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Price: $35.00 USD Category: Video Added: Apr 22nd 2012 Publisher: Aiseesoft Studio Homepage: http://www.aiseesoft.net


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Reach tens of thousands of people instantly by advertising with Ekklesia. Find out more
A report on fracking for shale gas commissioned by the DECC, recommending that the drilling method be allowed to continue, has been criticised.
Two of the leading candidates for Mayor of London have pledged to use their powers to prevent the London arms fair taking place again if they are elected.
Green MP Caroline Lucas has slammed yesterday's budget as the "nail in the coffin" of the Coalition's commitment to be "the greenest government ever".
Critics have accused the coalition government's NewBuy scheme of being an irresponsible attempt to entrench unaffordable house prices.
The Green Party of England and Wales, meeting in Liverpool, has voted to recommend progressive new food legislation to tackle childhood obesity.
The authorities at St Paul's Cathedral have failed to respond to calls for clear answers about their role in the eviction of Occupy London Stock Exchange.
Two Labour council leaders are supporting calls from the Green Party for the government to "come clean" on their future proposals for local government finance.
The competitive nature of the top-down, corporate capitalist system means we can never truly be 'all in this together', says Jonathan Bartley. All we do is sacrifice the most vulnerable for the sake of maintaining an unjust order. Economic alternatives are essential, and go well beyond statism.
The Green Party has backed campaigners who say changes to Disability Living Allowance and other welfare benefits will push more people into poverty and distress.
Shadow chancellor Ed Balls has effectively "given up any attempt to set out an alternative economic agenda", Green Party leader Caroline Lucas says.


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A collection of relevant and timely media clips and resources.
Posted on June 5, 2012
Thanks to your votes and efforts, Scott Walker has won the recall election for Governor in Wisconsin defeating rabidly anti-gun Milwaukee Mayor Tom Barrett.
Scott Walker has proven his dedication to the Second Amendment by signing into law right-to-carry legislation, castle doctrine legislation, and the Hunting Heritage Act during his short tenure as Wisconsin's chief executive. Scott Walker also supported statewide preemption of firearm laws and an amendment to the Wisconsin Constitution guaranteeing the individual right to keep and bear arms. In contrast, Tom Barrett has a career-long "F" rating from NRA-PVF and has supported bans on commonly owned firearms, supported exposing hunters to prosecution, and has consistently opposed common sense self-defense legislation.
Your NRA was fully vested in this race with a comprehensive campaign that included tens of millions of online ads and hundreds of thousands of television, radio and print ads before today's recall election. The media campaign was also supplemented by a concentrated advocacy and get-out-the-vote phone and mail program. All-in-all, almost two million pieces of advocacy mail were sent and phone calls made in this remarkable victory for freedom.
The NRA's media campaign was complemented with a strong grassroots effort, utilizing field coordinators to conduct literature drops, canvassing and volunteer efforts across the state in the months before the election.
Together we made a difference in this race. But, as always, what mattered most in this race was your vote. Thanks to gun owners in Wisconsin, one of the strongest pro-gun Governors in the country will continue working to support our fundamental, individual Right to Keep and Bear Arms.
Established in 1975, the Institute for Legislative Action (ILA) is the "lobbying" arm of the National Rifle Association of America. ILA is responsible for preserving the right of all law-abiding individuals in the legislative, political, and legal arenas, to purchase, possess and use firearms for legitimate purposes as guaranteed by the Second Amendment to the U.S. Constitution.READ MORE
© 2014 National Rifle Association of America. Institute for Legislative Action. This may be reproduced. It may not be reproduced for commercial purposes.11250 Waples Mill Rd. Fairfax, VA 22030 1800-392-8683(VOTE)


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Wifi or 3G, which should you use, and what's the difference between them? In very simple terms, your laptop can have the capability of using either wifi (Wireless Fidelity) or 3G (3rd Generation) technology to connect to the internet without using cables or modems. Wifi will use "hotspots" to give you a coverage area, and 3G will use the mobile network. To connect to wifi, your laptop needs to be wireless capable (most modern ones will be). To use a 3G USB device, you just need a USB port.
Is one better than the other? Not really, whichever is most convenient. There might be some advantages with coverage using 3G as the mobile network covers a large area of not just the main islands, but also most of the popular offshore Mamanuca and Yasawa island chains. To use wifi, you need to be in a hotspot area, and those are generally found at your resort or internet cafes. With 3G, if you can get a cellphone signal, you can be connected to the 'net.
Not so long ago, your internet options in Fiji were limited to using an old slow computer in the resort lobby, or finding an internet cafe in one of the main centers. But things have changed in Fiji over the past few years, and 3G has become more widely available.
No longer do you have to pay ridiculous prices, or wait in line for a free computer. You can browse the 'net, check emails, send files, all from the comfort and privacy of your bure or hotel room, using your own laptop or other 3G device. It's easy to get connected, and surprisingly cheap.
The Vodafone shop in the arrivals area of Nadi airport sells Vodafone 3G dongles for fj$39, this comes with 1GB of free data. It is actually easier to buy this than to put credit onto your NZ or Australian dongle. Just uninstall youu current dongle if you have one, then run the setup for your new Fijian one... it saves computer conflicts if you uninstall first before you plug in the new one.
Tip! If you don't think that 1GB will be enough for you, then buy extra data when you get the new dongle. Don't wait until you are running out to try and find a Vodafone shop and go through the hassle of trying to get topped up (speaking from experience).
While coverage can be a bit patchy in some of the remote places, it makes sense to use this in preference to purchasing a wifi card at your resort. Many places sell a connect scratch card for wifi, which can cost up to fj$30 for 24hrs. Of course, if the resort offers free wifi, that's great, but most of the budget places will charge you.
Prices start at fj$6 for 400mb. If you want a reasonable amount of data, then 2gb will cost fj$25 (this is about 1/3 the price you pay for the same thing in NZ!). You can either purchase a USB Flashnet device (known as a "dongle" in Australia, and a "Mobile Broadband USB Stick" in NZ) at any of the Vodafone shops in Fiji, or bring your own and get it recharged in Fiji. There is a Vodafone shop in Nadi airport, so you could get yourself set up almost as soon as you arrive in the country.
This stretches from Nadi, along the Coral Coast to Suva and surrounds. Also the Mamanuca and Yasawa islands, as well as most of the main offshore islands such as Ovalau and Kadavu. For areas that don't pick up 3G, then there is the slower 2G. Vodafone has 320 3G base stations, and cover the majority of the "tourist belt" so chances are, you will be in an area that has good service.
It's quick and simple to convert your mobile for use in Fiji. A new sim card will cost you $25 at the airport, which comes with 1hr local calls and 1hr international... very cheap compared to NZ mobile prices.
If you don't have a cellphone, then you can buy a cheap throwaway Nokia at the Vodafone shop for fj$59. Nothing fancy, but it works well, and it's at the right price.
Top up phone cards are available at almost any supermarket, service station or general store in Fiji. We chose to use Vodafone, although there are other companies such as Digicel. Top up cards come in only two denominations, fj$6 and fj$11. All the mobile companies offer regular specials too, such as a "double up Friday" where you get your minutes doubled.
Getting connected in Fiji really is easy these days!
Copyright © 2014 All rights reserved www.Fiji-Budget-Vacations.com.


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The credits for this production have not yet been completed or verified.
The Cherry Orchard
This production played in repertory with The Cradle Song, Hedda Gabler, The Would-Be Gentleman, Peter Pan
Civic Repertory Theatre , (10/15/1928 - circa. 12/1928)
Category: Play, Comedy, Revival, Broadway
Description: A play in four acts
Setting: Ranevskaya's estate


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Charles Henry Davis, born 16 January 1807 in Boston, Mass., was appointed Midshipman 12 August 1823 and made many valuable scientific contributions to the Navy before the Civil War during which he served with distinction. As Flag Officer of the Mississippi Flotilla he directed the capture and destruction of seven Confederate gunboats and rams near Memphis, Tenn., and received the surrender of the city 6 June 1862; joined Farragut's fleet for operations against Vicksburg; and cooperated with the Army expedition up the Yazoo River from 16 to 27 August 1862. From 1862 to 1865 Admiral Davis served as Chief of the Bureau of Navigation, then served as Superintendent of the Naval Observatory; Commander in Chief, South Atlantic Squadron; Commandant of Norfolk Navy Yard; and member of the Lighthouse Board. Admiral Davis died in Washington, D.C., 18 February 1877. TB-12, DD-65, and DD-395 were named to honor him.
George Fleming Davis born 23 March 1911 in Manila, Philippine Islands, graduated from the Naval Academy 31 May 1934. He was on board Oklahoma (BB-37) when the Japanese attacked Pearl Harbor, and served in Honolulu (CL-48) from 1942 to 1944, earning the Legion of Merit for his services as Damage Control Officer. He was given command of Walke (DD-723) and died on board her 6 January 1945 as a result of a Japanese suicide plane attack. For his fearlessness in directing the destruction of four attacking kamikazes and his refusal to leave the bridge despite serious injuries until the safety of his ship was assured, Commander Davis was posthumously awarded the Medal of Honor. DD-937 is named in his honor.
(DD-395: dp. 1,850; l. 390'11"; b. 36'11"; dr. 11'4"; s. 38 k.; cpl. 235; a. 8 5", 9 21" tt.; cl. Sampson)
The third Davis (DD-395) was launched 30 July 1938 by Bath Iron Works, Bath, Maine; sponsored by Miss E. Davis, granddaughter of Rear Admiral Davis; and commissioned 9 November 1938, Commander T. D. Carr in command.
Davis was assigned to Neutrality Patrol in the North Atlantic after war broke out in Europe 1 September 1939. On 13 November she sailed from Boston for Galveston, Tex., from which she patrolled in the Gulf of Mexico and conducted training exercises until clearing for patrol duty on the west coast between 11 March 1940 and 26 April 1941. She returned to the Caribbean for patrol and escort duty.
Continuing to serve in the Caribbean, after the United States entered the war, Davis also sailed on escort and patrol off Recife, Brazil, occasionally voyaging to the southern ports of the United States to pick up men and cargo, or to join convoys. On 19 July 1942 she rescued 10 men from the torpedoed British sailing ship Glacier. She sailed from Recife 19 December 1943 for a blockade runner Burgenland (7 January 1944) whom she transferred to the authorities at Recife upon arrival 9 January.
Davis arrived in New York 15 April 1944 escorting Franklin (CV-13), and sailed for England 14 May as a convoy escort, arriving at Plymouth 25 May. On 5 June she was underway from Milford Haven, Wales, to join a convoy en route to Baie de la Seine for the invasion of Normandy. Davis arrived 7 June and five days later, while on patrol, repulsed an enemy torpedo boat attack. Returning to the Baie from Devonport, England, 21 June, with a support convoy, she was heavily damaged from an explosion on the port quarter, probably a mine, and after emergency repairs departed 2 days later for Portland England. She continued to Charleston, S.C., arriving 11 August for permanent repairs.
Davis returned to convoy escort duty 26 December 1944 and until 21 June 1945 made four voyages between New York and English ports. Arriving at Norfolk 10 July, she remained there until decommissioned 19 October 1945. She was sold 24 November 1947.
Davis received one battle star for World War II service.


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Family Yoga - Ongoing/Yoga Events Series
|Shanti Yoga - Yoga Event ***Ongoing Yoga Events/Series
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|Join us for fun Family Yoga! Not only will you learn new poses and breathing techniques but you will be delighted with games, partner poses and be part of a community of like minded individuals who are committed to the total wellness of the kids in their lives. Treat yourself to an increased sense of well being while gaining effective tools to better serve the children in your life. Be ready to laugh and spend some quality time with your loved ones. This class is designed for the whole family (whether its parent, grandparent, aunt or uncle) and kids ages 5-12.
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text: History Department Part-Time Instructor, Secondary Education Coordinator On Faculty since 2002 Office: Blanchard Hall 204 Phone: (630)752-5130 Email: firstname.lastname@example.com Education M.A. Educational Administration, Northern Illinois University, 1977 B.A. History, Wheaton College, 1961 About John (Jack) Scott During 38 years of teaching in the public schools and at Wheaton College, Mr. Scott has been interested in encouraging young people to enter the field of secondary education. He has a lifelong interest in improving public education, particularly the teaching of social studies at the secondary level. While in the public schools Mr. Scott helped innovate courses in the humanities and American history. In addition to teaching two courses and supervising student teachers, Mr. Scott maintains records that support Wheaton's NCATE accreditation. In this capacity he is responsible for creating and filing reports to the National Council for the Social Studies and to the Illinois State Board of Education. He is a member of Wheaton's Secondary Education committee and acts as liaison between the History and Education departments. It is his responsibility to help maintain a high level of excellence in Wheaton's teacher preparation program. Mr. Scott brings a wealth of personal experience to his position. Jack's personal life centers around his wife, Carol, three children (Jennifer, Jonathan, and Allan), and eight grandchildren. Two of his children are teachers in the public schools. He is an avid reader (history, mysteries and other novels, Christian literature, politics) as well as an amateur photographer and gardener. He has run a successful painting and decorating business since 1965. Courses Taught Methods of Teaching History/Social Science Student Teaching (supervision) Introduction to the Social Sciences Membership in Professional Societies National Council for the Social Studies Association for Supervision and Curriculum Development


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Hijazi, Miskin Ali (1982) (Urdu) Punjab Main Urdu Akhbar Nawisi. PhD thesis, University of the Punjab, Lahore.
Full text not available from this repository.
|Item Type:
|Thesis (PhD)
|Arts & Humanities (b) > Mass communication(b7)
|ID Code:
|Deposited By:
|Mr. Javed Memon
|Deposited On:
|22 Oct 2010 13:58
|Last Modified:
|22 Oct 2010 13:58
Repository Staff Only: item control page


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It is the primary reason that the EARTH supports LIFE!
The many pollutants, poisons, contaminants, toxins, bacteria, yeast, fungus, mold, carbon dioxide, and on and on, are controlled and counter balanced with more oxygen!******
Unplug a pump on a fish tank and watch how long it takes for the fish to die.
When Chlorine biodegrades as it mixes with water, it produces Dioxin. Dioxin is one of the "Dirty Dozen" of toxins. It is one of the most carcinogenic chemicals known to man. CHLORINE is ALSO a HALOGEN!
Many years ago, in Washington and Oregon, the forest industry and paper mills were using CHLORINE BLEACH to bleach the paper for stationery, newspapers and cigarettes, among many other things. Because of this, most of the fish, ducks, birds, frogs and other wildlife died. The entire area became nearly desolate of natural WILDLIFE. The chlorine created Dioxin which was killing the ability of the lakes, streams, and rivers to support life. The run-off from the "Chlorine saturated water" used in the milling process was destroying these states' wildlife community and ultimately entering into the water supply of the people as well.
The EPA stepped in and told them ENOUGH! Then people began to smoke brown cigarettes, and use tan stationery. That was just the beginning of weaning people off of pure white paper products. The industry still had to make more changes!
The millers found out that they could use Oxygen products, similar to ours that DID NOT CONTAIN CHLORINE, and still get the "bleaching" effect without the chlorine or the toxins like dioxin. So to this day, that's what they use.
I believe that Oxygen is EXACTLY what people today need more of. The body is complex and WANTS to heal itself. It knows how to use Oxygen, just like every living thing on earth knows how to use Oxygen. It is our life source in physical terms. From our first breath, to our last, every moment ON THIS EARTH is dependent on OXYGEN. If people who are suffering from exposure to toxicity, dealing with physical trauma, stress, high altitude issues, illnesses, and are then denied getting supplemental oxygen to assist their bodies to cope with these deficiencies or toxins, they will continue to deplete their body's resources until they no longer can continue. Oxygen is extremely beneficial for sports and athletic events that put a greater demand on the human body as well.
When a person is treated in the hospital or put into an ambulance, the first thing the attendants give them is oxygen! When coming out of surgery, during surgery, or dealing with life-threatening traumas, getting them on Oxygen is considered life-saving!
"Opaline® Dry Oxy" and "Opaline® Wound Care & Detox Bath" Products DO NOT CONTAIN ANY CHLORINE OR SISTER TOXINS. THEY DO NOT CONTAIN ANY HALOGENS.
Personal Opinion of Sandra Lemire
General Manager
Opaline® Solutions, LLC