When Oral Therapy Can Replace Intravenous Antibiotics-Changing Practice as New Data Emerge.

This essay describes a physician-patient's experience with unchanged practice patterns despite the publication of new data challenging those patterns.

Sexual assault documentation program.

Since 2001, the Los Angeles County Department of Coroner has collaborated with Los Angeles County-University of Southern California Medical Center Violence Intervention Program and their Sexual Assault Center. The partnership was established at the suggestion of the district attorney's office to enhance the clinical recognition of sexual assault in the medical examiner's office using the extensive experience of experts in the field of sexual assault. As of December 2008, over 5 dozen victims of sexual assault have been evaluated with this collaboration. The partnership relied on the expertise of 2 pediatricians who are established clinical experts in the field of sexual abuse and assault, in collaboration with the staff of the medical examiner's office. In cases of suspected sexual assault, a joint evaluation by the clinical experts and the medical examiner was made. The goal of the project was for the medical examiners to become more confident in their observations and documentation of crimes of sexual abuse. Even though they are still available upon request, consultations with the sexual assault experts have decreased as the skills of the medical examiner to evaluate sexual assault cases have increased.

Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child.

OBJECTIVE: To study healing patterns of anogenital trauma in prepubescent children. METHODS: A prospective 10-year study was conducted of 94 children who had anogenital trauma and were followed to healing and documented using a colposcope with 35-mm camera attachment. RESULTS: The 13 boys and 81 girls were referred with injuries as a result of sexual assault or anogenital trauma. Hymenal injuries occurred in 37 cases; 2 transections healed after surgery, and 15 persisted unchanged. Partial tears, hymenal abrasions, or hematomas healed completely or with minor nonspecific changes. Of the 47 injuries to the posterior fourchette, 22 abrasions, hematomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacerations required surgery; and 6 scarred and 4 healed with vascular changes. Only 2 of 39 cases of perihymenal trauma healed with vascular changes. All 17 cases of labial trauma healed completely. Anal trauma healed completely in 29 of 31 with scarring occurring in only 2 cases that required surgery. CONCLUSIONS: Anogenital trauma heals quickly, often without residua. Of the 94 cases, there were diagnostic anatomic changes in the 15 cases of hymenal transections (2 other cases healed completely with surgical reconstruction), 6 cases after surgical repair of posterior fourchette, and 2 cases of anal scarring after surgery.

Children referred for possible sexual abuse: medical findings in 2384 children.

OBJECTIVE: The goal of this study was to compare rates of positive medical findings in a 5-year prospective study of 2384 children, referred for evaluation of possible sexual abuse, with two decades of research. The prospective study summarizes demographic information, clinical history, relationship of perpetrators, nature of abuse, and clinical findings. The study reports on the results by patterns of referral and the medical examination. RESULTS: There were 2384 children evaluated in a tertiary referral center between 1985 and 1990 for possible sexual abuse. Children were referred after they disclosed sexual abuse, because of behavioral changes or exposure to an abusive environment, and because of possible medical conditions. A total of 96.3% of all children referred for evaluation had a normal medical examination; 95.6% of children reporting abuse were normal, 99.8% who were referred for behavioral changes or exposure to abuse were also normal. Of the 182 children referred for evaluation of medical conditions, 92% were found to be normal at the time of examination by the Child Advocacy Center. The remaining 15/182 (8%) that were found to be abnormal were diagnosed with sexually transmitted diseases, acute or healed genital injuries, and were 17% (15/88) of the total cases found to have medical findings diagnostic of abuse. Interviews of the children indicated that 68% of the girls and 70% of the boys reported severe abuse, defined as penetration of vagina or anus. Penetration was associated with a higher percentage of abnormal findings in girls (6%) compared to 1% of the boys. The relationship of the abuser impacted on the severity of the abuse. CONCLUSION: Research indicates that medical, social, and legal professionals have relied too heavily on the medical examination in diagnosing child sexual abuse. History from the child remains the single most important diagnostic feature in coming to the conclusion that a child has been sexually abused. Only 4% of all children referred for medical evaluation of sexual abuse have abnormal examinations at the time of evaluation. Even with a history of severe abuse such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%. Biological parents are less likely to engage in severe abuse than parental substitutes, extended family members, or strangers.

Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings.

STUDY OBJECTIVE: To review all existing studies of genital anatomy in girls selected for nonabuse, clarify terminology used to describe hymenal morphology and nonspecific findings, and test consensus terminology in the reevaluation of hymenal morphology and nonspecific findings in 147 premenarchal girls selected for nonabuse. METHODS: Over six months, the authors identified and evaluated 147 premenarchal girls without history of sexual abuse who were referred for gynecological examination. Parents and patients were screened for possible abuse or significant past medical or behavioral history, and each girl was interviewed and then received a complete examination including a genital examination documented by colposcopy with both 35 mm camera and video capabilities. Using established terminology(1) each case was then independently reviewed and hymenal morphology and nonspecific findings documented. RESULTS: The study population consisted of 147 premenarchal girls; 76.9% were Hispanic, 12.3% African-American, and 10.3% Caucasian. Subjects had a mean age of 63 months (+/minus sign 38). Hymenal configurations included: annular (concentric) 53%, crescentic (posterior rim) 29.2%, sleeve-like (redundant) 14.9%, septate 2%, and other (imperforate, cribriform) < 1%. Nonspecific findings included peri-hymenal bands, 91.8%; longitudinal intravaginal ridges, 93.8%; hymenal tags, 3.4%; hymenal bumps/mounds, 34%; linea vestibularis, 19%; ventral hymenal cleft/notch at 12 o'clock in 79% of annular or redundant hymens; ventral cleft/notch not at 12 o'clock, 19%; failure of midline fusion, 0.6%; hymenal opening size > 4 mm, 30.6%; erythema, 48.9%; change in vascularity, 37.4%; labial adhesions, 15.6%; posterior hymenal notch/cleft (partial), 18.3%; posterior notch/cleft (complete), 0%; posterior hymenal concavity or angularity, 29.5%. In addition, each case was assessed for the presence of a thickened (45.5%) or irregular (51.7%) and narrowed (22.4%) hymenal edge. Each case was also reviewed for exposed intravaginal anatomy (93%). CONCLUSIONS: The authors concluded that improved techniques and photo documentation have provided examiners with a better understanding of hymenal morphology and that nonspecific genital findings are commonly found in a population of girls selected for nonabuse. A thorough understanding of normal studies and a consistent application of established terminology can prevent the misinterpretation of nonspecific or congenital findings as posttraumatic changes.