The prevalence of genital injuries in post-pubertal females presenting for forensic examination after reported sexual violence: a systematic review.

BACKGROUND: Sexual violence is a prevalent issue in contemporary society requiring a robust forensic healthcare response. It is critically important that forensic examiners put clinical examination findings into an appropriate evidence-based context. The presence of genital injuries has been shown to increase the likelihood of successful criminal prosecution and report the crime. However, the reported rates of genital injury vary widely in published studies. AIMS AND OBJECTIVES: We aim to critically evaluate and synthesize existing literature on the prevalence of genital injuries in post-pubertal females, examined following sexual violence, with a view to describing the prevalence and characteristics of genital injuries as well as the range of forensic practices employed. METHODS: Three online databases (PubMed, Embase, and Scopus) were systematically searched with key terms. RESULTS: Of the 1224 studies screened, 141 full-text publications met the inclusion criteria. Reported injury prevalence rates varied widely. Details pertaining to forensic examinations included in each study, such as grade of the examiner, type of examination, location of examination, and time interval from assault to examination also varied widely. Injury prevalence was highest in studies where enhanced visualization techniques were utilized. CONCLUSIONS: This systematic review demonstrates that there is no universally agreed standard for documenting genital injuries in cases of sexual violence and highlights the need for standardized approaches and guidelines for assessing, documenting, and reporting these injuries. The review provides robust evidence to support a call for establishing consistent context, terminology, classification systems, and data collection methods to improve the comparability and reliability of future research findings.

Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice and Education among Obstetricians and Gynaecologists in Ireland

This paper summarises results of a survey of obstetricians in Ireland regarding their technique, management, and education on episiotomy and Obstetric Anal Sphincter Injury (OASIS). An anonymous survey was emailed to all obstetricians and gynaecologists in Ireland, including trainees between January and September 2017. The response rate was 45% (155/343) with 111 out of 144 (77%) reported clinical experience as part of their training and 92 (64%) attended an OASIS workshop or classroom teaching. The majority prescribe antibiotics and laxatives post-op, request physiotherapy review and follow-up patients in outpatient settings. We identified that most specialists and trainees practice within guidelines, but some recognise a need for further teaching and exposure to these types of injuries. These results will direct future curriculum and optimise ongoing training for trainees, unify service provision and contribute to patient safety.

A Dedicated Perineal Clinic ­ An Audit in Support

Aims To assess the quality of care in both the initial management of obstetric anal sphincter injury (OASI) and subsequent follow up postnatally in a tertiary maternity hospital without direct access to a perineal clinic. Methods Medical records were reviewed over a one-year period in University Maternity Hospital Limerick (UMHL) to determine the characteristics of patients sustaining OASI, how and where the repair was undertaken, the complications recorded and their follow up in the postpartum period. This pathway of care was compared with care currently available in three dedicated perineal clinics nationally. Results There were 44 patients with OASI recorded over a one-year period in UMHL. The majority were diagnosed in primiparous women having an operative vaginal delivery (OVD). Only 23 of 44 women had a documented review postnatally. Conclusion Audit of OASI is paramount to providing the best standard of care for affected women. It also aids clinician training and will be important in the establishment of a dedicated perineal clinic in UMHL.

Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes.

Lamivudine treatment and outcome in pregnant women with high hepatitis B viral loads.

Perinatal transmission is the most common mode of hepatitis B virus (HBV) transmission and is a leading cause of chronic infection worldwide. Maternal treatment with lamivudine (LAM) can result in a rapid and significant reduction in HBV viral load (VL) and, thus, mitigate the risk of mother-to-child transmission (MTCT). The aim of this study was to retrospectively evaluate the safety of LAM treatment administered in the third trimester of pregnancy and determine the influence, if any, on infant outcome. The medical charts of all HBV surface antigen (HBsAg)-positive women eligible for treatment with LAM and who registered for antenatal care between 2007 and 2012 were retrospectively reviewed. During the 6-year period, 45 women met the criteria for LAM treatment. Thirty-six women (80 %) accepted treatment; the remaining women declined treatment (5), defaulted from care (3) or transferred to another maternity unit (1). The median duration of treatment was 11.4 weeks (range 5.3-17.4) and the median baseline VL was 1.4 × 10(8) IU/mL (range 1.8 × 10(7)-1.7 × 10(8)). The median VL at delivery was 2.3 × 10(5) IU/mL and 60 % of women achieved a VL reduction >2 log10 IU/mL before delivery. No cases of perinatal transmission occurred in the infants born to mothers who received treatment; however, one infant, born to a mother who defaulted from care, was HBV-infected at 8 months. The results suggest that LAM therapy in highly viraemic HBV-infected pregnant women could lower the rate of vertical transmission.

Sexual assault of the older person: Attendances to the Republic of Ireland's sexual assault treatment unit network.

BACKGROUND: Sexual assault (SA) poses a threat to all areas of contemporary society. Although older individuals represent a vulnerable demographic, a considerable gap exists in the literature regarding the context in which older individuals experience SA. This study aims to provide a comprehensive description of older individuals' attendances at the Sexual Assault Treatment Unit (SATU) network in the Republic of Ireland. METHODS: A 7-year national cross-sectional study was performed to analyse the attendances of older people (≥65 years old) to the SATU network, and to compare them with younger attendances (<65 years old), with a more in-depth subset analysis of Dublin SATU attendances. RESULTS: During the study period, there were 6478 attendances to the SATU network, of which 0.93 % (n = 60) were older people. These included 59 females and 1 male, with the average age of 76.05 years ± 8.16. Forensic examinations were performed in 81.7 %, with the majority seeking assistance within 7 days (80 %). Comparison of older (≥65 years) and younger (<65 years) attendees revealed older individuals were more uncertain whether a sexual assault had occurred (35.5 % vs. 14.4 %, p < 0.001) but more likely to report the incident to the police (78.3 % vs. 64.3 %, p = 0.02). Assault by a person in authority was significantly more common in older age groups (11.7 % vs. 1.8 %, p < 0.001). Older individuals were significantly more likely to be assaulted in their own home (33.3 % vs. 21.5 p < 0.03) or in 'other-indoors' settings (e.g. nursing home/hospital) (43.3 % vs. 23.4 % p < 0.001). They were less likely to be assaulted in the assailant's home (5.0 % vs. 22.9 %, p < 0.001) or outdoors (5.0 % vs. 19.7 %, p = 0.004). In our subset analysis of 19 cases, 73.7 % occurred in healthcare facilities, 63.2 % had dementia, and 42.1 % were care dependent. Genital injuries were present in 44.4 % of patients and extra-genital injuries in 22.2 %. CONCLUSION: Unique patterns are evident in sexual assault experienced by older people, underscoring the necessity for tailored interventions and effective support systems for reporting and addressing this vulnerable demographic. This is especially crucial in healthcare environments, where a notable proportion of cases occur, frequently involving individuals with dementia and requiring care assistance.

Women attending the sexual assault treatment unit services in the Republic of Ireland: A 7-year review.

OBJECTIVE: Sexual assault is pervasive in today's society, with the numbers of those reporting it increasing. In Ireland, 50% of women will experience some form of sexual violence in their lifetime. We sought to describe the incident details of females presenting to the Sexual Assault Treatment Unit (SATU) network in the Republic of Ireland and to determine associations between incident characteristics and: (1) victim age, (2) presence of injury, (3) victim-perpetrator relationship, and (4) number of assailants. METHODS: This was a retrospective cross-sectional study of all females who attended between 2017 and 2023. Descriptive bivariate analysis was performed. RESULTS: There were 5942 female attendances, with an average age of 26 years. The largest age group was women between 18 and 25 years (38.1%, n = 2263). Forensic examinations were performed in 76.6% (n = 4549). Assailants were male in 92% (n = 5469) of incidents, with multiple assailants disclosed in 7.3% (n = 435). Strangers or recent acquaintances were the assailant in 38.5% (n = 2290) of incidents, and close associates in 22.9% (n = 1359). Incidents occurred at the survivor's home in 22% (n = 1306) of incidents, and in the assailant's home in 22.6% (n = 1342). Drug use within 24 h was reported in 15.1% (n = 897) of cases, and alcohol use in 72% (n = 4276). Drug-facilitated assault was suspected by 16.1% (n = 955). Injuries (genital and extra-genital) occurred in 30.3% (n = 1800) of attendances and were more likely to be seen in those who disclosed ingesting alcohol (Relative risk [RR] 1.325, P < 0.001) or drugs (RR 1.111, P = 0.04) in the 24 h preceding the incident, in those who presented within 24 h (RR 1.646, P < 0.001), those aged 18 years or older (RR 1.07, P = 0.003), and those where the incident occurred outdoors (RR 1.24, P < 0.001). CONCLUSION: This study, one of the largest on female attendances to a national SATU network, offers detailed insights into demographics, incident details, and circumstances. Most were young women, mainly 18 years and older, many of whom were full-time students. Forensic examinations were the primary reason for attendance, underscoring the network's key role in evidence collection. The study also identified factors linked to a higher risk of injury detection, such as immediate post-incident attendance, being over 18, outdoor incidents, perpetration by a stranger, and prior alcohol or drug use.

Storage of evidence and delayed reporting after sexual assault: Rates and impact factors on subsequent reporting.

BACKGROUND: Sexual assault (SA) is alarmingly prevalent, yet reporting rates remain disproportionately low. Forensic examinations (FE) play a crucial role in both immediate medical care and evidence collection, yet many victims/survivors may not report the crime initially, leading to the loss of vital forensic evidence. The storage of evidence "Option 3″ care alternative provides post-SA care including FE without initial police involvement. METHODS: This is a cross-sectional study analysing the attendances of people who chose to store evidence at the Dublin Sexual assault Treatment Unit (SATU) between January 1, 2017 and December 31, 2023. RESULTS: There were 238 storage of evidence FEs ('Option 3') performed during the study period, which represented 12.8 % of all FEs. The majority identified as female (89.1 %), with an average age of 26.6 years. 31.9 % attended within 24 h of the incident, and 51.3 % self-referred. Most assaults occurred over weekends (64.7 %), with alcohol consumption reported in 82.2 % of cases and drug-facilitated SA concerns in 20.2 %. Genital injuries were present in 17.9 % of females and 19 % of males. Those that availed of storage of evidence (compared with those who initially reported to the police) were significantly more likely to have consumed alcohol (p < 0.001) and the assault was more likely to have occurred indoors (p = 0.002). There was no significant difference in care option choice for those 'unsure' of the assault occurrence (p = 0.353). Among storage of evidence cases, 20.2 % subsequently reported to the police, with females more likely to report (p = 0.02), while people who were uncertain whether an assault had occurred were less likely to report (p = 0.04). Genital injury (p = 0.822), victim-assailant relationship (p = 0.465), assault location (p = 0.487), and substance consumption (p = 0.332) did not significantly affect subsequent reporting rates. CONCLUSIONS: The availability of storage of evidence has afforded people the opportunity to access prompt, responsive SATU care including collection of forensic evidence which may have significant evidential value. This approach provides further opportunity for comprehensive detection of a crime, even if reporting to the police is delayed.

Retrospective analysis of leukemoid reactions in extremely preterm infants in a tertiary NICU from 2018-2021.

BACKGROUND: Neonatal leukemoid reaction is associated with higher risk of mortality, chronic lung disease and has been associated with chorioamnionitis. Literature on extremely low birth weight infants with leukemoid reaction is limited. OBJECTIVES: The aim of our study was to characterize the maternal and placental factors associated with neonatal leukemoid reaction and to describe outcomes of these ELBW infants. Our objective was to assess if there were maternal factors that would assist the decision-making process regarding the delivery of preterm infants at risk of chorioamnionitis and the sequelae of this inflammatory process. METHODS: This was a retrospective case-control study performed in a single, tertiary Maternity Hospital in Dublin. Two matched controls were identified for each case based on gestation and year of birth and data was collected on both the infants and their mothers. RESULTS: 7 extremely preterm neonates were identified as having a leukemoid reaction, defined as a total white cell count of >50,000 or in the first seven days of life. Baseline characteristics between the groups were similar. The median gestational age in the cases group was 24 + 4 weeks and in the control group was 24 + 1. The mean birthweight was 650 g in the cases group vs. 655 g in the control group. There was a higher percentage of males in the control group, 42.9% vs 28.6% in the cases. The preterm infants with leukemoid reaction had a longer duration of ventilation with a median of 18 days (7.5-23.5 days) compared to 6.5 days (2.8-24.5 days) in the control group. More infants in the leukemoid reaction group required inotropes for hypotension in the first 72 h after delivery (42.9% vs 7.1% in the controls, p value .169). Death or Bronchopulmonary dysplasia (BPD) occurred in 85.7% of the cases identified with a leukemoid reaction vs 71.4% of the controls matched. Median maternal CRP was higher in cases prior to delivery vs the controls (66 vs 18.1 mg/L, p-value = .2151). There was histological evidence of maternal inflammatory response in all cases with fetal inflammatory response in 71% of cases. CONCLUSIONS: Leukemoid reaction in ELBW infants with evidence of maternal and fetal inflammatory response syndrome on placental histology is associated with a longer duration of initial ventilation, increased need for inotropes in the first 72 h after birth, higher rates of death, and BPD. Prospective studies are required to identify potential biomarkers such as proinflammatory cytokines, IL-6, which might aid the decision-making process in delivery.

Medicine, media and the law: The effect on training in obstetrics and gynaecology.

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury.

OBJECTIVE: To compare two postpartum laxative regimens in women who have undergone primary repair of obstetric anal sphincter injury. DESIGN: Randomised controlled trial. SETTING: National Maternity Hospital, Dublin. POPULATION: A total of 147 postpartum women who had sustained anal sphincter injury at vaginal birth. METHODS: Women were randomised to receive either lactulose alone thrice daily for the first three postpartum days followed by sufficient lactulose to maintain a soft stool over the following 10 days (lactulose group, n = 77) or the lactulose regimen combined with a sachet of ispaghula husk daily for the first 10 postpartum days (Fybogel group, n = 70). All patients kept a diary of bowel habit for the first 10 postpartum days and were invited to return for review at 3 months postpartum. MAIN OUTCOME MEASURES: Patient discomfort with first postpartum bowel motion, incidence of postnatal constipation and incontinence and incontinence score in postnatal period. RESULTS: Pain scores were similar in the two treatment groups; but incontinence in the immediate postnatal period was more frequent with the two preparations compared with lactulose alone (32.86% versus 18.18%, P = 0.03). CONCLUSIONS: This study does not support routine prescribing of a stool-bulking agent in addition to a laxative in the immediate postnatal period for women who have sustained anal sphincter injury at vaginal delivery.

Screening for asymptomatic urogenital Chlamydia trachomatis infection at a large Dublin maternity hospital: results of a pilot study.

BACKGROUND: There are currently no Irish guidelines on screening for Chlamydia trachomatis infection in pregnancy. Prevalence rates in the antenatal population are not known which has prevented the development of screening recommendations for this group. AIMS: The objective of this study was to determine the prevalence of asymptomatic urogenital C. trachomatis infection in young women attending for care at a large maternity hospital. METHODS: All patients aged 25 years and under attending the Hospital between December 2011 and December 2013 were offered screening for urogenital C. trachomatis infection. Nucleic acid amplification testing of the C. trachomatis cryptic plasmid was performed on either endocervical swabs or first void urine samples. RESULTS: There were 2687 women tested for C. trachomatis infection, 83.4 % (2241/2687) through the antenatal clinics, 7.1 % (193/2687) through the gynaecology clinic, and 9.4 % (253/2687) through the emergency department. The rate of a positive test result was 5.6 % (151/2687) overall. The rates in women ages 16-18, 19-21 and 22-25 years were 9.1 % (31/340), 6.5 % (50/774) and 4.4 % (69/1561), respectively. A positive test result was more likely in those who were unemployed (p = 0.04), those who were Irish (p = 0.03) and those who were unmarried (p < 0.01). There were no cases of neonatal C. trachomatis infection in babies born to mothers who were screened in early pregnancy. CONCLUSIONS: The prevalence rate of detected C. trachomatis infection was 5.6 % in the study population. Screening of antenatal patients may have a role in preventing vertical transmission of infection to the neonate.

Impact of Xpert MRSA/SA blood culture PCR assay on management of positive blood cultures in obstetric patients: a retrospective audit.

BACKGROUND: The Xpert MRSA/SA blood culture assay (Cepheid, USA) is a rapid PCR test which can be used for positive blood cultures where Gram-positive cocci in clusters are seen. It can detect Staphylococcus aureus and also the mecA gene, which encodes for ß-lactam resistance. The assay was introduced into the Rotunda Hospital for positive blood cultures to allow earlier detection of MRSA and methicillin susceptible S. aureus. AIM: To assess the impact of the Xpert MRSA/SA blood culture assay on the management of obstetric patients with a positive blood culture where Gram-positive cocci in clusters were seen. The main outcome measures were duration of intravenous antimicrobials and length of admission. METHODS: Pre-intervention and post-intervention groups were identified relating to whether or not the test was in use at the time. A standardised form was used to retrospectively review the medical notes and laboratory results. RESULTS: There were 35 obstetric patients with positive blood cultures with Gram-positive cocci in clusters in the pre-intervention group and 22 cases in the post-intervention group. All 22 positive blood cultures in the post-intervention period were correctly identified. The antimicrobial duration was reduced from a median of 55.5-43.5 h and length of admission reduced from a median of 66.5-56 h (Mann-Whitney U value = 161, p = 0.46 and U value = 256, p = 0.15, respectively). CONCLUSION: This study has shown a reduction in the median duration of intravenous antimicrobials and admission; however, larger multi-centre studies are needed to evaluate this potential benefit further.

Differential sensitivity of p53(-) and p53(+) cells to caffeine-induced radiosensitization and override of G2 delay.

Most drug discovery efforts have focused on finding new DNA-damaging agents to kill tumor cells preferentially. An alternative approach is to find ways to increase tumor-specific killing by modifying tumor-specific responses to that damage. In this report, we ask whether cells lacking the G1-S arrest in response to X-rays are more sensitive to X-ray damage when treated with agents that override G2-M arrest. Mouse embryonic fibroblasts genetically matched to be (+) or (-) p53 and rat embryonic fibroblasts (+) or (-) for wild-type p53 function were irradiated with and without caffeine, a known checkpoint inhibitor. At low doses (500 microM), caffeine caused selective radiosensitization in the p53(-) cells. At this low dose (where no effect was seen in p53(+) cells), the p53(-) cells showed a 50% reduction in the size of the G2-M arrest. At higher doses (2 mM caffeine), where sensitization was seen in both p53(+) and p53(-) cells, the radiosensitization and the G2-M override were more pronounced in the p53(-) cells. The greater caffeine-induced radiosensitization in p53(-) cells suggests that p53, already shown to control the G1-S checkpoint, may also influence aspects of G2-M arrest. These data indicate an opportunity for therapeutic gain by combining DNA-damaging agents with compounds that disrupt G2-M arrest in tumors lacking functional p53.

Conservative management of a traumatic uterovesical fistula ('Youssef's syndrome').

'Youssef's syndrome' is characterised by cyclical haematuria, the absence of vaginal bleeding and complete urinary continence. It is a rare complication of caesarean section when bladder injury occurs and a fistula develops. While operative repair may be required, we describe a case that was managed conservatively and resolved without surgical intervention.

Solvent-detergent plasma as replacement therapy in a pregnant patient with factor V deficiency.

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.

Median and ulnar nerve conduction in pregnancy.

OBJECTIVE: A prospective, observational study assessed median and ulnar nerve conduction during pregnancy, to identify the optimum test for differentiating physiological effects of pregnancy from pathological carpal tunnel syndrome (CTS). METHODS: Pregnant women (n=18) and age- and parity-matched non-pregnant controls (n=13) were recruited. Symptomatic and neurophysiological evaluations were performed. Median and ulnar nerve latencies and intrapalmar latency (difference between median and ulnar nerve latencies) were computed. RESULTS: Median nerve distal latency is more prolonged in pregnant women compared with non-pregnant controls. Median nerve latency is more prolonged in pregnant women with symptoms of CTS than in asymptomatic women. The difference between median and ulnar nerve conduction (normal <0.2 ms) discriminates well between symptomatic and asymptomatic pregnant women. CONCLUSIONS: Intrapalmar latency is proposed as a useful diagnostic test for classification of carpal tunnel syndrome during pregnancy.

Endometriosis in caesarean section scars.

We report two cases of endometriosis in caesarean section scars. This is a condition, which, in our experience, follows approximately one caesarean section in every thousand. With increasing rates of caesarean section this potentially troublesome condition may be seen more frequently, and we propose a modification in practise to reduce its incidence.

The emergency room at the Rotunda Hospital: evidence of an improving service over the past 3 years.

INTRODUCTION: This is a retrospective review of the Rotunda Hospital Emergency Room (ER) documentation with respect to attendances for a 4-month period (August-November) in both 2009 and 2012. The aim was to quantify the workload and assess the quality of care offered to patients attending the ER over the two time periods and to highlight any improvements in care after changes were implemented following the initial 2009 review. MATERIALS AND METHODS: This study was done comparing the ER patient attendances over two time periods (1st August 2009 to 30th November 2009 and same period in 2012). SPSS version 20 was used to make statistical analysis along with simple percentage calculation. Comparing the two time frames, a decrease in the number of antenatal patients attending ER was seen (p < 0.001) [7,128 (91.0 %) in 2009 and 6,890 (89.4 %) in 2012], waiting times fell (p < 0.001) [4,351 (55.5 %) in 2009 seen within 2 h and 5,855 (76.2 %) in 2012], less women left ER without being seen (p < 0.001) [151 (1.9 %) in 2009 and 119 (1.5 %) in 2012] and record keeping regarding outcome of attendances improved (p < 0.001) [465 cases (5.9 %) in 2009 not recorded and 259 (3.3 %) in 2012]. CONCLUSION: The improvements noted may be due to establishment of an early pregnancy assessment unit facility and changes in ER staffing. Two registrars being on-call rather than one registrar. Increased numbers of gynaecology patients (p < 0.001) [334 (4.3 %) in 2009 and 463 (6 %) in 2012] were seen, most likely due to changes in benign gynaecology services in north Dublin. All the comparisons were statistically significant.