The relationship between the transverse hymenal orifice diameter by the separation technique and other possible markers of sexual abuse.

OBJECTIVE: To evaluate the relationship between the transverse hymenal orifice diameter as measured by separation technique (THODST), using a method that maximized the diameter of the hymenal orifice, and other possible markers of sexual abuse in girls from 3 through 12 years old. METHODS: Over a 10-year period, clinical information was recorded on girls referred to the WakeMed Child Sexual Abuse Team in Raleigh, NC at the time of examination. The study population comprised 1975 girls of the 2058 evaluated for sexual abuse. The girls were interviewed, examined, and tested for sexually transmitted diseases. Information from referral sources, accompanying guardians, and previous recent physical examinations was recorded. The girls were assigned to three groups based upon their risk of being sexually abused. Linear regression was performed to evaluate how well the THODST distinguished between the risk groups, as well as how it was correlated with individual established markers of sexual abuse. RESULTS: The size of the THODST did not distinguish between the three risk groups, nor did it correlate with any potential or established markers of sexual abuse other than three potential markers of hymenal trauma: narrowing of the posterior hymenal rim, hymenal tears and lacerations, and hymenal clefts between 5 and 7 o'clock in the supine position. CONCLUSION: Thus, we found the THODST as we measured it to have no value for answering the question, "Was this child sexually abused?"

Risk assessment for gonococcal and chlamydial infections in young children undergoing evaluation for sexual abuse.

OBJECTIVE: Testing for gonorrhea (GC) and chlamydial (Ct) infection in children who are being evaluated for sexual abuse is invasive and costly. We developed selective criteria to limit unnecessary testing for these infections. METHODS: Over a 10-year period (May 1988 to May 1998), clinical information was collected in a prospectively designed database for all children ages 0 to 12 years by the WakeMed Child Sexual Abuse Team in Raleigh, North Carolina. The study population comprised 3040 (2414 girls and 626 boys) of the 3064 children evaluated for sexual abuse. Children were interviewed, examined, and tested by culture for GC and Ct orally, rectally, and genitally. Information from referral sources, accompanying guardians, and previous recent physical examinations was recorded. Bivariate analyses and logistic regression were used to develop 2 sets of screening criteria to predict children at greatest risk of infection with: 1) GC and/or Ct (GC/Ct) and 2) GC alone. RESULTS: Fifty-eight children were identified with GC/Ct infections (37 with GC, 25 with Ct; 4 children were coinfected). The proposed algorithm for GC/Ct infections would have identified all children with these infections, while avoiding testing 56% of children without infection. Using genital cultures only, the proposed risk score for GC/Ct infections would have identified 100% of GC/Ct cases with 85% fewer cultures compared with testing all children with oral, rectal, and genital cultures. CONCLUSION: The use of a risk assessment algorithm for GC and Ct infections may reduce the cost and trauma of testing young children who are being evaluated for sexual abuse. sexual abuse, gonorrhea, Neisseria gonorrhoeae, chlamydia, Chlamydia trachomatis, sexually transmitted diseases, children.

A high degree of natural immunologic priming to the capsular polysaccharide may not prevent Haemophilus influenzae type b meningitis.

BACKGROUND: A current debate is whether the immunologic priming of infants with Haemophilus influenzae type b (Hib) conjugate vaccines would be protective in the absence of circulating antibody to the capsular polysaccharide (PS). Data from the prevaccine era on the PS antibody responses of older children to Hib meningitis may be informative on this issue. METHODS: PS antibody was assayed by radioantigen binding in sera taken in the first month postadmission in 47 children ages 2 to 136 months with culture-proved Hib meningitis. RESULTS: Sera obtained on admission had very low antibody concentrations, and the subsequent response during convalescence was age-dependent. The major finding is that some patients, including 10 of 11 children older than 2 years, had substantial antibody elevations within a few days of admission, increases resembling the response to PS vaccine in infants primed with PS-protein conjugate vaccines. CONCLUSIONS: In this group of patients with Hib meningitis, natural priming did not prevent infection. Hib may have the ability to invade despite the capacity for a vigorous antibody response.

Ehrlichiosis: findings on chest radiographs in three pediatric patients.

OBJECTIVES: Ehrlichiosis is a newly recognized tick-borne infection affecting both children and adults. The disease is usually mild, with flulike symptoms, but can be fatal. We present the chest radiographs and, in one case, the chest CT scan of all recognized pediatric cases of ehrlichiosis to date from our institution. CONCLUSION: Ehrlichiosis should be included in the differential diagnosis of acutely ill pediatric patients with a history of possible tick exposure and radiographic patterns of interstitial prominence, alveolar opacities, or consolidation that may be associated with pleural effusion.

Vaginal gonococcal cultures in sexual abuse evaluations: evaluation of selective criteria for preteenaged girls.

OBJECTIVE: Accurate selective criteria could limit the number of vaginal cultures for Neisseria gonorrhoeae performed on preteenaged girls as part of their sexual abuse evaluations. This study was performed to determine whether the published selective criteria by the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and by Siegel et al would have accurately detected all cases of vaginal gonococcal infections in our large study population. METHODS: We prospectively studied girls, ages 1 to 12 years, who were referred to our Child Sexual Abuse Team (CSAT) at Wake Medical Center in Raleigh, NC, between July 1, 1976 to July 1, 1996, for sexual abuse evaluations which were performed using a protocol that included collecting historical information, a sexual abuse interview, and a detailed genital examination which included a vaginal culture for N gonorrhoeae. RESULTS: Our study population consisted of 2898 girls of whom 2731 (94%) had vaginal cultures successfully performed for N gonorrhoeae. There were 84 girls with vaginal gonococcal infections, 80 of whom had a vaginal discharge. The four girls without a vaginal discharge included two with a history of having vaginal intercourse with an alleged perpetrator with gonorrhea, one with N gonorrhoeae isolated from a urine culture, and one whose preteenaged sister had gonorrhea. All of the 84 girls would have been identified using the selective culturing criteria of the AAP Committee on Child Abuse and Neglect: culturing when epidemiologically indicated (interpreted as the girl having another sexually transmitted disease [STD], a child sibling, child household member, a close child associate or a perpetrator with a known STD) or when the history and/or physical findings suggest the possibility of oral, genital, or rectal contact, or Siegel et al's more selective criteria: only culturing prepubertal girls for N gonorrhoeae if there is a vaginal discharge at the time of presentation or if there is a high risk for STD acquisition, defined as having a STD diagnosed, a sibling with a STD, contact with a perpetrator known to have a STD, contact with multiple perpetrators, or Tanner stage III or above. CONCLUSION: Both the selective criteria of the AAP Committee on Child Abuse and Neglect and the more selective criteria of Siegel et al as we interpreted them were accurate when applied to identifying girls with vaginal gonococcal infections in our study population.

Cervical-vaginal and intraanal human papillomavirus infection of young girls with external genital warts.

To expand information regarding the epidemiology of genital human papillomavirus (HPV) infection in young girls, girls with external genital warts were examined for the prevalence of cervical-vaginal or intraanal HPV infection. Cervical-vaginal wash specimens and biopsies of external lesions were examined for HPV genotypes 1, 2, 4, 6, 11, and 16 using Southern transfer hybridization with restriction endonuclease fragment length analysis. Exfoliated cells from cervical-vaginal and intraanal canals were processed for cytologic study. Of 18 girls, 8 (44%) had cytologic or genomic evidence (or both) of cervical-vaginal or intraanal HPV infection. Five had cervical-vaginal wash specimens that were positive for HPV genome and showed mild dysplasia. As is true for adults, young girls with external anal-genital warts are also frequently infected with HPV at internal mucosal sites. Determining the immediate and long-term prognosis of infected children and those with intraepithelial neoplasia will require appropriate prospective studies.

Neisseria gonorrhoeae in children.

By culturing for N gonorrhoeae in cases of neonates and children with conjunctivitis, vaginitis, urethritis, proctitis, sepsis, and arthritis, gonococcal infections can be identified easily. They are then treated with ceftriaxone. In neonates, the mother and her sexual contacts also should be treated. In children, a full evaluation for sexual contacts, with the assistance of other professionals, if necessary, will almost always identify a sexual contact. Appropriate action then can be taken to protect the child from further sexual contact. .

Epidemiology of adult sexually transmitted disease agents in children being evaluated for sexual abuse.

This prospective study describes the epidemiology of adult sexually transmitted disease agents in 1538 children ages 1 to 12 years being evaluated for possible sexual abuse. Infections with these agents were related to the presence or absence of a history of sexual contact. Neisseria gonorrhoeae (GC) was found in 2.8% (41 of 1469); human papillomavirus presenting as condyloma acuminata, 1.8%; Chlamydia trachomatis, 1.2% (17 of 1473); Treponema pallidum (syphilis), 0.1% (1 of 1263); and herpes simplex virus, 0.1%. Overall a history of sexual contact was present in 83% of children with N. gonorrhoeae; condyloma acuminata, 43%; Chlamydia trachomatis, 94%; syphilis, 0%; and herpes simplex virus, 50%. Selected vaginal discharges were examined for Trichomonas vaginalis and bacterial vaginosis. In children comprehending questions regarding sexual contact (i.e. were "verbal"), 89% with N. gonorrhoeae, 100% with Chlamydia trachomatis and 63% with condyloma acuminata had a history of sexual contact, indicating that in "verbal" children any infection with N. gonorrhoeae or C. trachomatis was highly associated with sexual contact.

Gardnerella vaginalis infection and sexual contact in female children.

Gardnerella vaginalis (GV) infection has been reported as being acquired via sexual contact in adults and as an indicator of sexual contact in female children (DeJong, 1985). The purpose of this study was to determine if GV infection was more commonly found in 191 female children who gave a history of sexual contact and/or were infected with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) (Group 1), compared with 144 female children evaluated for possible sexual abuse and found to have no such history or infection with GC or CT (Group 2), or 31 female children (friends of the authors) without such a history or GC or CT infection (Group 3). Vaginal GV was found in 5.3% of Group 1, 4.9% of Group 2 and 6.4% of Group 3 (p > .05). Also, vaginal GV infection was not related to the type of sexual contact or race, but did increase with age in white female children. Because vaginal GV infection is not more commonly found in children with a history of sexual contact than those without such a history, the finding of GV in a vaginal culture in an individual case would not be a reliable marker of sexual contact. Routine culturing for GV is not recommended as part of a sexual abuse workup.

Ureaplasma urealyticum and large colony mycoplasma colonization in female children and its relationship to sexual contact, age, and race.

In order to determine if Ureaplasma urealyticum (Uu) or large colony mycoplasma (LCM) colonization was related to a history of sexual abuse, the type of sexual contact, an enlarged vaginal introitus transverse diameter (greater than 4 mm), age or race, 452 female children, ages 1-12 years, were evaluated by the Child Sexual Abuse Team at Wake Medical Center in Raleigh, NC. Thirty-six girls were deleted because of inadequate cultures. When controlled for race and age, Uu throat (T), vaginal (V), and rectal (R) colonization and LCM vaginal and rectal colonization were not related to any of the other variables listed above. The enlarged vaginal introital diameter was related to a history of sexual abuse (p less than .001). Uu and LCM vaginal colonization rates were increased in black girls as compared to white girls (p less than .05). Uu V, Uu R, LCM V, and LCM R colonization increased with age. In our study population, Uu and LCM colonization was not a useful marker of sexual contact.

Hand washing in pediatric ambulatory settings. An inconsistent practice.

The first phase of this study was performed to determine the rate of breaks in hand washing technique by physicians in two pediatric ambulatory settings and to determine whether this technique was influenced by the physician's level of training. The second phase was performed to determine if reminding physicians to wash their hands would decrease the rate of breaks. A hand washing break in technique was defined as not washing hands before patient contact. The observations were made by medical students accompanying the providers. In the 496 encounters during the first phase, 254 breaks (51.2%) occurred. In the 293 encounters during the second phase, 150 (51.2%) breaks occurred. During both phases, the rates of hand washing breaks among the four groups of providers (residents in postgraduate years 1 through 3 and faculty) were similar. Breaks in hand washing technique occur at an unacceptably high rate in outpatient settings.

Variations in somatomedin-C/insulin-like growth factor-I associated with environmental temperature and nutrition.

The influences of environmental temperature and energy intake on plasma concentrations of somatomedin-C/insulin-like growth factor-I (IGF-I) have been investigated in young growing pigs. After 10 weeks acclimation, IGF-I was significantly greater at 35 than 10 degrees C (P less than 0.001) and on a high than a low energy intake (P less than 0.001). During the period 16-26 h after the last meal, there was a significant decline in IGF-I with time (P less than 0.01). These results can be explained partly in relation to differences in energy exchange in warm and cold environments and may also be related to changes in growth and thyroid hormones.

Vaginal introital diameter in the evaluation of sexual abuse.

Physical objective markers to aid in the diagnosis of sexual abuse are few. We therefore studied 242 females, ages 1 through 12 years, to determine if the vaginal introital diameter is useful in evaluating a child for sexual abuse. The children were divided into three groups: Group I, history of sexual contact and/or Neisseria gonorrhoeae; Group II, no history of sexual contact but at risk; and Group III, nonabused. A vaginal introital transverse diameter of greater than 4 mm was more prevalent among children in Group I (94%) than in Group II, (5%); or in Group III (0%) (chi 2, p less than .001). Eighty-eight percent of children who complained of penile-vaginal penetration had a vaginal introital diameter greater than 4 mm as compared to 18% of children with no penetration (chi 2, p less than .001). Forty-six percent of children who complained of fondling with penetration had a vaginal introital diameter of greater than 4 mm as compared to 14% in those without a history of penetration (chi 2, p less than .008). Fifty-eight percent of children with more than one encounter had a vaginal introital diameter greater than 4 mm as compared to 29% in those with one encounter (chi 2, p less than .006). In a logarithmic regression analysis, the greatest proportion of children with a vaginal introital diameter greater than 4 mm was observed in the penile-vaginal contact group (chi 2, p less than .00003). The test is not very sensitive but highly specific. The sensitivity drops precipitously at greater than 5 mm without losing the specificity. A vaginal introital diameter of greater than 4 mm is highly associated with sexual contact in children less than 13 years of age.

Time course of the change in nuclear 3,5,3'-triiodothyronine receptors of skeletal muscle in relation to energy intake.

Nuclear triiodothyronine receptors have been investigated in skeletal muscle from young pigs living at thermal neutrality (26 degrees C). Animals were fed at a high (H) or low (L) level of energy intake for 3 or 21 days and killed at 6 or 24 h after the last meal. Receptor numbers were significantly greater on the H than the L intake, even after only 3 days of treatment. The difference in receptors between animals on H and L diets was somewhat less at 6 compared with 24 h after feeding. It is postulated that these changes could be mediated through the action of glucagon.

Thyroid hormone nuclear receptors in skeletal muscle as influenced by environmental temperature and energy intake.

Young litter-mate pigs were kept at either 10 or 35 degrees C and fed either a high (H) or a low (L) food intake producing four groups: 10 H, 10 L, 35 H and 35 L. The numbers of receptors for thyroid hormone in the nuclei of skeletal muscle were estimated and found to be greatest in the 35 H group and least in the 10 L group. The numbers of receptors in the 10 H and 35 L groups were similar and took intermediate values. It is suggested that the differences in receptor numbers represent an adaptation which regulates the tissue response to thyroid hormone. Some possible consequences of this adaptation are discussed.

Influence of environmental temperature and energy intake on skeletal muscle respiratory enzymes and morphology.

Influence of a cold (10 degrees C) or warm (35 degrees C) environment and a high or low level of energy intake on respiratory enzyme activities has been investigated in porcine skeletal muscle. Scanning microdensitometry was used to measure the reaction products from mitochondrial enzymes in individual slow- and fast-twitch muscle fibres. A cold environment was found to increase the activity of succinate dehydrogenase in both types of muscle fibre (P less than 0.001 for dark fibres, P less than 0.01 for light fibres) from young growing animals. Enzyme activity was also increased in animals on a low compared with a high energy intake (P less than 0.01) when living at 10 degrees C but not at 35 degrees C. Similar findings were obtained for NADH diaphorase and cytochrome oxidase aa3. The numbers of slow-twitch muscle fibres also increased after exposure to cold (P less than 0.01) and as a result of a low energy intake (P less than 0.01). These results are similar to those obtained in other species after exercise or as a result of peripheral arterial insufficiency. The extent to which they could be related to local tissue hypoxia or to changes in metabolic hormones is discussed.

Effect of propranolol on the metabolism of thyroid hormones.

The effect of propranolol on thyroxine (T4) and 3,5',3'-triiodothyronine (T3) plasma concentrations, fractional disappearance rates (k), metabolic clearance rates (MCR) and catabolic rates has been investigated in young pigs. The animals were examined in the period 18-24 h after feeding. Plasma concentrations of T3 were lower after treatment with propranolol, but T4 was not significantly affected. The k value of T4 was decreased by propranolol but that for T3 was unaffected. The MCR of T4 and the catabolic rates of both hormones were reduced by propranolol. The reduction in metabolic rate after propranolol is thus probably related to its action on thyroid hormone metabolism.

Effect of localized changes in scrotal and trunk skin temperature on the demand for radiant heat by pigs.

Localized warming of the scrotal skin to 42 degrees C decreased the number of operant responses for reinforcements of radiant heat when young pigs were exposed to cold (15 degrees C); warming a similar area of the skin on the trunk had no effect on behaviour. The decrease in responding for heat was more pronounced immediately after a meal than when animals were observed 22 hr after their last meal. Cooling the scrotal or trunk skin to 20 degrees C did not modify operant behaviour. It is concluded that the thermal signal from the scrotum is in disproportion to the surface area of the scrotum indicating either increased concentration of thermal receptors per surface unit of the skin, or processing and amplifying the thermal information along the scrotal-brain neural pathway. The significance of the elicited changes in the demand for radiant heat is discussed in relation to the control of testes temperature.

Heat production and respiratory enzymes in normal and runt newborn piglets.

The heat productions of newborn runt and normal piglets were estimated over a range of ambient temperatures. Most runts increased their heat production in the cold, but when expressed as J X kg-0.67 X min-1 it was significantly lower than in normal piglets (201.3 +/- 16.0 and 144.7 +/- 16.2 J X kg-0.67 X min-1 for controls and runts, respectively, at 32 degrees C). Runts consequently had lower deep body temperatures (37.8 +/- 0.2 and 36.8 +/- 0.3 degrees C for controls and runts, respectively, at 32 degrees C). Some runts failed to increase their metabolic rate in the cold and these had the lowest deep body temperature. Activities of respiratory enzymes in heart and diaphragm muscle were similar in all animals, whereas the longissimus dorsi of runts had significantly lower enzyme activities (76.3 +/- 4.2 and 55.5 +/- 6.6 in absorbance units for controls and runts, respectively).