Standards and practices for bite mark photography.

In most crimes where bite marks are discovered, photographic accuracy is crucial to the investigative process since in many instances the bite mark(s) may be the only evidence linking a particular suspect to the crime. Therefore, the rationale for employing superior photographic principles is mandatory for the investigation team. This paper will discuss current standards, best practice, and armamentaria for digital photography of bite mark injuries on skin. Full spectrum protocols will be described including Alternate Light Imaging, Reflective Ultra-violet, and Infrared techniques for photo-documentation of images of bite marks and other bruise patterns that have been inflicted on human skin.

Review of the score-reporting policy for the United States Medical Licensing Examination.

In 1998, the authors, acting on behalf of the National Board of Medical Examiners (NBME), undertook a review of the scoring policy for the United States Medical Licensing Examination (USMLE). The main goal was to determine the likely effect of changing from numeric score reporting to reporting pass-fail status. Several groups were surveyed across the nation to learn how they felt they would be affected by such a change, and why: all 54 medical boards; 1,600 randomly selected examinees (including 250 foreign medical graduates) who had recently taken either Step 1, Step 2, or Step 3 of the USMLE; 2,000 residency directors; the deans, education deans, and student affairs deans at all 125 U.S. medical schools accredited by the Liaison Committee on Medical Education; and all 17 members of the Council of Medical Specialty Societies. Responses from the different groups surveyed varied from 80% to a little less than half. The authors describe in detail the various views of the respondents and their reasons. Some members in each group favored each of the reporting formats, but the trend was to favor numeric score reporting. The majority of the responding examinees desired that their USMLE scores be sent to them in numeric form but sent to their schools and to residency directors in pass-fail form. Based on the responses and a thorough discussion of their implications, the Composite Committee (which determines USMLE score-reporting policy) decided that there is no basis at this time for changing the current policy, but that it would review the policy in the future when necessary.

Forensic photography: an expanding technology.

Forensic dental photography involves different goals and, therefore, different techniques than traditional dental photography. One of these techniques involves using different parts of the light spectrum to uncover and document evidence that is difficult or impossible to see under normal lighting conditions. This article describes some of the techniques and equipment used in forensic photography.

Use of alternative light source illumination in bite mark photography.

Recent investigation regarding the optical properties of human skin has lead to studies measuring autofluorescence, absorption, and reflectance of monochromatic light during exposure both in vitro and in vivo environments. The Stokes Shift deviation in absorbed and reflected light energy that occurs when skin is illuminated by 450 nanometer visible blue light can produce an augmentation in the appearance of pattern injuries when viewed through colored blocking filters. This paper demonstrates a comparison between photographic appearances of several bitemarks inflicted on living and deceased persons to determine the corroborability and usefulness of fluorescent versus full spectrum visibility of bitemark pattern injuries.

Nonepileptic paroxysmal events in childhood.

Seizures are the most commonly occurring paroxysmal events of childhood. There are a large number of other disorders, however, that present with discrete attacks separated by symptom-free intervals. The differentiation of these conditions from seizures depends on a willingness to consider alternate diagnoses and a thorough review of the history of the events. Laboratory tests, and especially the electroencephalogram, are aids to diagnosis, but reliance on laboratory data has many pitfalls. The clinical features of the important nonepileptic paroxysmal disorders of childhood are reviewed.

Pharmacologic treatment of childhood migraine.

This review of pharmacologic treatment of childhood migraine shows that no agent for abortive treatment has been proved effective in controlled studies and that most commonly used prophylactic agents (e.g., propranolol and cyproheptadine) lack proof of their effectiveness. Flunarizine seems to be the only agent with positive results in controlled studies. This drug, although well tolerated, is slow to act. For the treatment of an acute attack, aspirin or acetaminophen may be chosen. Two of us currently use propranolol as the first-choice prophylactic agent because of its tolerance and cost, and on the assumption of its effectiveness reported by the adult studies. For children with a history of asthma, metoprolol may be chosen because of its selective blocking of the beta 1-adrenoreceptor. One of us (W.N.M.) prefers cyproheptadine as the drug of choice. Behavioral therapy may be a good alternative to pharmacotherapy in the management of childhood migraine.

Role of attention deficit hyperactivity disorder in learning disabilities.

ADHD refers to a combination of symptoms in the general areas of inattention, impulsivity, and hyperactivity. This condition becomes evident in the preschool years and affects males predominantly. The behavior is seen as being disruptive and unacceptable by parents and teachers, and the child is socially handicapped as a result. Treatment relies on behavioral techniques and medication, predominantly psychostimulants. ADHD is strongly associated with learning disabilities; the treatment of the learning disorder should be based on educational intervention, not drug therapy. Symptoms of ADHD may continue into adulthood, and recommendations for treatment of adults are being made with increasing frequency. The prognosis is best for children who do not have symptoms of a conduct disorder and who lose the symptoms of ADHD before adolescence. A superimposed conduct disorder and maintenance of the symptoms of ADHD put the patient at high risk for antisocial behavior and substance abuse in adolescence and adulthood.

Multivariate analysis of family risk factors in predicting appointment attendance in a pediatric otology and communication clinic.

Parents of pediatric patients attending regional otologic medical clinics were given a questionnaire to document family risk factors predictive of poor appointment attendance, and to determine barriers which caused non-attendance of medical appointments. Family risk factors which affected clinic attendance were studied using univariate and multivariate analyses. Univariate analyses revealed all factors except patients' sex and family size to be correlated with attendance. However, multivariate analysis revealed that parental age (p less than 0.0153), ownership of car (p less than 0.0012), parental education (p less than 0.0048), and age of patient (p less than 0.0023) were major predictors of clinic attendance. Although ownership of a car was a major independent factor, it was highly correlated with parental age and parental education and only shown to be significant in the subset of patients not having access to public transportation. The identified parental factors which affect pediatric health care delivery underscores the importance of family centered case management in promoting the health care of children and casts doubt on the effectiveness of interventions which are solely centered on the patient or are designed to mitigate only one of these factors.

Tourette syndrome: recent advances.

Clinical and genetic studies have allowed the limits of Tourette syndrome to be broadened. There is now strong evidence that chronic motor tics and Tourette syndrome are different manifestations of an autosomal dominant gene with high penetrance. A genetic link with obsessive-compulsive disorder also appears to have been established. Up to 10% of cases of Tourette syndrome may be nongenetic phenocopies, however. There is also an association between Tourette syndrome and attention deficit hyperactivity disorder. This complicates therapy, as psychostimulant drugs may precipitate or exacerbate tics in some individuals. A high proportion of patients with Tourette syndrome also has neuropsychological deficits and learning disabilities. The pathophysiology is incompletely understood. The best supported hypothesis is that there is dopamine receptor supersensitivity, although there are strong suggestions of abnormalities in serotonin metabolism. The possibility of abnormalities in neuropeptide systems is being explored. Treatment of tics relies primarily on neuroleptics with dopamine receptor blocking activity. Clonidine may be useful in some patients, especially those with behavior problems. Obsessive-compulsive symptoms can be treated using appropriate pharmacologic agents. The treatment of attention deficit disorder in patients with tics should begin with behavioral strategies. Clonidine can be tried as the first-line drug, and psychostimulants should be used only if necessary and with great caution. In rare instances it may be necessary to combine a psychostimulant and a neuroleptic.

Pertussis vaccine and injury to the brain.

A syndrome of pertussis vaccine encephalopathy was first reported 56 years ago. Analysis of the recent literature, however, does not support the existence of such a syndrome and suggests that neurologic events after immunization are chance temporal associations of neurologic conditions that occur in the target age group, even in the absence of immunization. Population-based studies do not prove a causal relationship with acute encephalopathy. There are no consistent neuropathologic findings suggesting a specific pathophysiologic process, and hypotheses concerning possible mechanisms of damage are not supported by reproducible studies in children. No acceptable animal model exists. There clearly is an increased risk of a convulsion after diphtheria-tetanus-pertussis immunization but no evidence that this produces brain injury or is a forerunner of epilepsy. Studies have also not linked immunization with either sudden infant death syndrome or infantile spasms.

Promotion of patient appointment compliance in indigent pediatric medical care by use of a microcomputer.

A computerized system for appointment scheduling, medical record keeping, medical billing, patient tracking, and epidemiologic data generation was developed and applied in an indigent pediatric otologic clinic. Functions used to augment appointment compliance are 1) notifying the referring physicians, agencies, and health department coordinators of failed appointments and sending medical information on the attended appointments, 2) listing patients who failed appointments, 3) production of mailings for failed appointments, 4) automatic rescheduling of failed appointments, and 5) automatic calculation of patient attendance ratios. The attendance ratio can be used to help identify patients for referral to social service workers and to implement rewards designed to promote medical compliance. The automatic rescheduling of failed appointments resulted in 21% of new patients and 30% of return patients above controls returning for a medical visit. The recalled had much lower economic status than our average clinic patient, ie, the system was effective in reaching the target population.

The relationship between stimulant medication and tics.

Clinical evidence supports the observation that stimulant drugs increase the severity of tics in 25% to 50% of patients with TS, and occasionally can precipitate TS in a patient who did not previously manifest symptoms of this disorder. As ADD is frequently associated with TS, the clinician is often faced with a dilemma. A conservative approach to the use of stimulant medication, stringent criteria for its use, adequate counseling of the child and parents, and a thorough cost-benefit analysis before initiating treatment are required. Behavior management and environmental manipulation can be useful techniques with the child with ADD, and should be tried before medication is considered.

Management of headaches in children.

Headaches are a common cause of disability in childhood. Although the symptom of headache raises concerns about serious neurologic disease, the cause is most commonly vascular or due to muscle contraction. The differentiation between muscle-contraction and vascular headaches is clinical, and laboratory studies rarely are required. Treatment of muscle-contraction headaches is symptomatic. Migraine headaches sometimes require periods of prophylactic therapy. The chronic nature of headaches mandates a comprehensive approach to management of the child and family. This approach is best carried out in the primary care setting.

The role of nuclear magnetic resonance imaging in the diagnosis of MS in childhood.

MS in the pediatric age group is a rare condition, often diagnosed after a considerable delay. Nuclear magnetic resonance imaging (NMR) has proven to be the single most useful diagnostic modality in adult MS patients. We present three patients with childhood MS. NMR demonstrated multiple white matter lesions in the supratentorial and posterior fossa regions consistent with those lesions described by NMR in adults. This report suggests that NMR is a valuable diagnostic procedure in children as well as adults.