Approach to evaluation of sexual assault in children. Experience of a secondary-level regional pediatric sexual assault clinic.

OBJECTIVE: To determine whether a 3-year-old girl, brought to an after-hours clinic because her mother was concerned, had been assaulted by her father during a weekend visit. SOURCES OF INFORMATION MEDLINE: was searched using the key words child, sexual assault/abuse, and expectations. Recent textbooks on childhood sexual assault and abuse were consulted. The secondary-level regional pediatric sexual assault clinic's experience over 1 year was reviewed. Articles in the literature generally provide level II evidence. MAIN MESSAGE: The literature review and the clinic's experience both indicated that specialty centres for child sexual assault and abuse rarely produce positive physical findings that conclusively confirm or rule out sexual assault, especially when children are asymptomatic and not in an acute state. Primary care practitioners can use a brief history and physical examination to decide on the next level of care and determine the urgency of referral. Urgent assessment of children thought to have been abused or assaulted is required when children disclose assault (especially with genital-genital contact or ejaculation); when children have acute pain, bleeding, or discharge; when results of a physician's examination are abnormal; or when parents are extremely distressed. CONCLUSION: Family physicians have a pivotal role in evaluation of childhood sexual assault or abuse. Knowledge of the outcomes of evaluation is crucial to understanding when and how to refer.

Keutel syndrome: clinical report and literature review.

In 1972 Keutel et al described a brother and sister with brachytelephalangism, hearing loss, peripheral pulmonary stenosis and abnormal cartilage calcification. Since then, three additional cases have been reported. We report a sixth case and discuss the clinical findings and cause.

Endocrine complications of topical and intralesional corticosteroid therapy.

Four previously healthy children acquired skin problems that were treated with topical or intralesional fluorinated corticosteroids. Three developed signs that suggested Cushing's syndrome 1-4 months after initial treatment. Investigation showed low plasma cortisol levels and inadequate response to corticotrophin stimulation. After 7 months of treatment with topical steroids the fourth child presented with failure to thrive; during a febrile illness he had a convulsion followed by acute hypotension which responded to parenteral corticosteroid administration. Adrenal function was not studied in this patient. Although fluorinated corticosteroids seldom lead to overt adrenal suppression in children, they may impair pituitary-adrenal responses in some. Such patients should be given oral or parenteral steroid cover in the event of illness or trauma.

Further studies on plasma proteins, lipids, and dye- and drug-binding in a child with analbuminemia.

A previously reported patient with analbuminemia was re-investigated after 4 1/2 years, at age 6. The serum albumin concentration was 150 mg/L by radioimmunoassay. Most of the observed increase in total plasma protein over the 4 1/2 years was attributable to gamma-globulin. Concentrations of total and high-density lipoprotein cholesterol were increased; the esterified:free ratio and the lecithin-cholesterol acyltransferase activity were both normal. Albumin is apparently not essential for binding of lysolecithin generated by the acyltransferase-catalyzed reaction. The binding of bromphenol blue suggested that analbuminemic serum has about 25% of normal binding capacity for bilirubin (more than expected in a patient with analbuminemia), which may explain why newborns with this disorder do not develop kernicterus. Binding by the patient's plasma of diazepam (1020 mg/L) and warfarin (1040 mg/L), which bind primarily to albumin, as well as of propranolol (1.05 g/L), which binds primarily to alpha 1-acid glycoprotein, was also studied. The proportions of free diazepam (14.4%) and warfarin (4.8%) were about 10-fold normal. In contrast, the proportion of propranolol in the free form was decreased (4.5%). Evidently, other plasma proteins are partly compensating for the deficiency of albumin.

Analbuminemia in a neonate.

A small-for-gestational-age infant, found to have analbuminemia in the neonatal period, is reported and the twelve cases recorded in the world literature are reviewed. Patients lacking this serum protein are essentially asymptomatic, apart from minimal ankle edema and ease of fatigue. Apparent compensatory mechanisms which come into play when serum albumin is low include prolonged half-life of albumin and transferrin, an increase in serum globulins, beta lipoprotein, and glycoproteins, arterial hypotension with reduced capillary hydrostatic pressure, and the ability to respond with rapid sodium and chloride diuresis in response to small volume changes. Examination of plasma amino acids, an investigation not previously reported, revealed an extremely low plasma tryptophan level, a finding which may be important in view of the role of tryptophan in albumin synthesis.