Skin lesions, differential diagnosis and practical approach to potential survivors of torture.

As the international refugee crisis has reached new proportions (BMJ, 355, 2016 and i5412), survivors of torture increasingly present in treating physicians with an array of acute or chronic skin lesions. Physicians should be aware of common presentations and likely differential diagnoses in order to avoid mislabelling or under-recognizing torture. Survivors of torture also frequently suffer from psychological sequelae, such as post-traumatic stress disorder, and appropriate referrals are essential in order to improve recovery trajectory. Skin sequelae are the most common physical findings of torture. Not all skin lesions seen in tortured survivors are due to perpetrator inflicted injuries, and many dermatological conditions can mimic lesions typical of torture, as can scars as a result of folk remedies or cultural practices specific to geographical regions. Medical documentation of torture includes injury and lesion description. While forensic dermatology and other forensic specialties use an injury description taxonomy, and the standard dermatologic taxonomy uses an anatomic description, they are complementary sciences for lesions inflicted by torture. This results in an opportunity for learning across disciplines in order to improve evidence documentation for survivors of torture. This article describes features of common skin lesions consistent with torture, including their clinical appearances, differential diagnoses, patterns of injury and appropriate clinical descriptions.

The natural history of neonatal jaundice.

The relationship between infant feeding type and the occurrence and natural history of neonatal jaundice in term newborn infants has been studied. A retrospective chart review of 124 records confirmed earlier reports indicating that jaundice is recognized more often in breast-fed than in formula-fed infants. A prospective cohort study of 140 term newborn infants was conducted using the Minolta Air-Shields transcutaneous jaundice meter. For 3 weeks, 115 white infants and 25 black infants were followed at predetermined intervals. The peak jaundice meter readings were higher and the elevated levels lasted longer in breast-fed than in formula-fed infants. Formula-fed infants' readings returned to base-line levels in eight days whereas the readings were still elevated in breast-fed infants when the study ended on the 21st day. Black infants had higher transcutaneous readings than white infants due to their deeper skin pigmentation, but otherwise they followed a course identical with that of the white babies. The distribution of jaundice in the white infants was bimodal; in approximately one fourth of the breast-fed infants, the jaundice meter readings reached levels corresponding to bilirubin values greater than 13 mg/dL whereas the remaining three fourths followed a pattern similar to that of the formula-fed infants. It can be concluded that human milk feeding is associated with more prolonged hyperbilirubinemia than formula-feeding in normal term infants.

The Missouri child fatality study: underreporting of maltreatment fatalities among children younger than five years of age, 1983 through 1986.

Estimates of the incidence of child maltreatment fatalities vary widely; most experts believe they are underreported. To investigate the suspicion that fatal maltreatment was underreported in Missouri preschool children, a statewide, population-based study was conducted using nine data sources. The study cases included the 384 children younger than age 5 who died from 1983 through 1986 and whose death certificates were coded with an external cause (injury) or whose deaths were substantiated as abuse or neglect fatalities by the Missouri Division of Family Services. Each fatality was categorized as one of the following: definite maltreatment, probable maltreatment, possible maltreatment, non-maltreatment, or inadequate information. Of the 121 cases classified as definite maltreatment, only 47.9% had codes consistent with maltreatment on their death certificates. The Division of Family Services had substantiated 79.3% of definite maltreatment cases as abuse or neglect fatalities. The Federal Bureau of Investigation Uniform Crime Reports database reported only 38.8% of these cases as homicides. In 37.2% of the cases, there was at least one criminal conviction. Child maltreatment fatalities are drastically underreported as such in Missouri because of inadequate investigations, lack of information-sharing between investigators and agencies, and reporting systems that fail to capture the contribution of maltreatment as a cause of death. Missouri has created a statewide system of child fatality review panels and a child fatality surveillance system to address the problems documented in this study.

Building public health goals into the purchasing process: the Missouri Medicaid agency as purchaser.

INTRODUCTION: As managed care radically changes the medical care environment, public health leaders are under increasing pressure to focus more on core public health functions and less on personal health services. As public health re-evaluates its key strategies, it can take advantage of its strategic role in purchasing medical care to forge new partnerships that benefit its constituents. METHODS: Specific roles for public health in medical care purchasing are discussed. The state of Missouri is used as an example of successful strategies for positioning public health as a leader in the managed care environment. Key strategies include increasing influence in contracting; selecting and reporting of key health status indicators; promoting use of population-based data files; taking leadership roles in government-sponsored insurance programs; and assuring stability of critical health conditions during managed care transitions. CONCLUSION: Public health has unprecedented opportunities to develop new methods for improving health status. Public health's well-developed scientific principles and methods, combined with strategic leadership, will position the discipline in the forefront of the dialogue about our nation's health system into the next century.

Efficacy of an intervention to promote use of hearing protection devices by firefighters.

Numerous cases of hearing loss consistent with noise-induced damage were noted among firefighters in the city of Columbia, MO. A survey of firefighting vehicles in operation showed that the firefighters were exposed to excessive noise levels and put at risk for noise-induced hearing loss (NIHL). Audiologic evaluation showed that 36 percent of the firefighters had moderate or severe hearing loss (a threshold of 40 decibels (dB) or more at 3,000, 4,000, or 6,000 hertz (Hz) in either ear). An educational program on NIHL was then carried out to increase the use of hearing protection devices (HPDs) by firefighters, followed by an evaluation of the intervention. The educational intervention successfully increased knowledge of NIHL, positive attitudes toward HPDs, and resulted in more frequent use of HPDs. After the intervention, 85 percent of firefighters regularly used HPDs compared with 20 percent before the intervention. Recommendations are made for fire departments to reduce the risk of NIHL.

Evaluation of physician preferences for guideline implementation.

Although current literature supports the use of evidence-based clinical practice guidelines (CPGs) by physicians, there is limited research concerning operational issues that may be inhibiting effective CPG implementation. The objective of our research was to increase understanding of clinical practice patterns by identifying physician preferences for CPG accessibility, format, content and learning strategies. Semistructured interviews were conducted with resident and faculty physicians in an academic medical center after they were presented with a CPG during treatment of a patient with acute pancreatitis. The results of our study revealed that physicians prefer CPGs in the form of evidence-based algorithms with treatment-specific information that is placed on the front of the patient chart during treatment. In addition, they felt that discussion of the guideline with colleagues, reminder notes/stickers on front of the patient chart, and verbal reminders from a nurse were the most effective means of encouraging utilization.

A medical project in an African village.

The authors led a group of 15 students on a medical project to a remote traditional village in Sierra Leone, West Africa. The team lived in the village for one month. They staffed an outpatient clinic, performed a community health survey, and organized an immunization project and a health education program. This project offered a unique opportunity to teach many aspects of primary care, including clinical skills, use of health education, practice of preventive medicine, methods of community epidemiology, and the relationship of health to sociocultural factors. By living in the community, seeing the overwhelming health problems in the clinic, and working in the community to improve health, the students had a provocative and educational primary health care experience. Family medicine teachers are well suited for leading international medical projects.

Papanicolaou smears without endocervical cells. Are they inadequate?

The retrieval of columnar endocervical cells from the squamocolumnar junction has generally been considered to be a measure of the adequacy of a Papanicolaou smear; this implies that, if endocervical cells are absent from the smear, the examination for cervical cancer is less than optimal and should be repeated. A study was undertaken to determine if women with serial Papanicolaou smears without endocervical cells showed an increased rate of development of cervical atypia in subsequent smears. The smears of 18,914 women were evaluated for the presence or absence of endocervical cells and for the subsequent development of an abnormal smear over a four-year study period. No differences were found in the rates of atypia between women with and those without endocervical cells on serial Papanicolaou smears. Women with prior Papanicolaou smears without endocervical cells were much more likely to have a subsequent Papanicolaou smear without endocervical cells. Although no difference was found in the incidence of cervical atypia in the two groups during this short study period, these results should be considered to be preliminary.

Improved yield of endocervical cells on Papanicolaou smears in a residency setting.

Techniques employed in the collection of cervical cytology show a wide range of detection rates of endocervical cells. The presence of endocervical cells is currently considered to be an important factor in assessing the adequacy of a Papanicolaou smear. In a clinical trial in a university-based family practice center, the yield of endocervical cells was compared during several interventions. These interventions included wetting the cotton swab, changing the number of slides collected, and introducing an extended tip spatula. Clinic physicians were divided into experimental and control groups. Significant improvement in the yield of endocervical cells was found in the group using the extended tip spatula. There was no consistent effect of level of residency training on endocervical cell yield during any intervention.

Public health in the next century.

The over-reliance of our health care system on treatment of disease rather than prevention of disease has brought it to the point of near financial collapse. Although improvements in longevity and in key health status indicators have occurred, to some extent from advances in medical care, many of the gains in healthy living have come from basic population-based interventions known as public health. This article describes the role and function of public health, describes the public health system in Missouri, and recommends the reinventing of public health for the next century.

Sexual assault examinations in children. The role of a statewide network of health care providers.

OBJECTIVE: To describe the formation of a statewide network of health care providers to care for child victims of sexual assault and to describe the patients seen by network providers. DESIGN: Clinical description, patient series. SETTING: Private practices, hospital clinics, and emergency departments. PARTICIPANTS: One thousand five hundred fifty-five child victims of suspected sexual assault. SELECTION: Children were referred to the Sexual Assault Findings Examination Network by the state's child protection agency, law enforcement agency, or the child's parent or guardian. No sampling system was used; the children compose the entire population of network patients. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Detailed physical examinations were performed on all patients, along with extensive collection of pertinent behavioral and historical information. Substantiation of child abuse-neglect by the state's child protection agency was higher in incidents in which SAFE Network providers evaluated the child as compared with all other providers, even where there was no physical evidence. CONCLUSIONS: The network concept, including mandatory training, standard data form and protocol utilization, uniform reimbursement, and continuing education, provides a more reliable level of care for child victims of sexual assault than is available with a variety of providers working independently.

Judgments regarding appropriate child supervision to prevent injury: the role of environmental risk and child age.

Parents, social service workers, and medical personnel failed to differ in the amount of time they estimated that children of 11 differing ages should be left without adult supervision within 5 different supervision domains. More hazardous circumstances dramatically reduced the amount of time respondents said children should be left unsupervised. Amount of unsupervised time increased with age, with clear developmental cutoffs that varied by level and type of risk. When the moderate center of the distribution was examined, 3 clear areas of consensus emerged. For most domains, constant supervision was recommended for preschool children. For early elementary school children, nearly constant (0-5 min without supervision) or close (0-15 min without supervision) supervision was recommended in safer locations, with constant supervision still recommended in high-risk situations. Only with older children was there an absence of consensus regarding supervision. The implications of these results for future injury prevention research are discussed.