Using Computed Tomography skeletal surveys to evaluate for occult bony injury in suspected non-accidental injury cases - A preliminary experience.

INTRODUCTION: This case series summarises our institution's preliminary experience of using computed tomography skeletal surveys (CT-SS) for the assessment of infants with suspected non-accidental injury (NAI) who were unable to undergo radiographic skeletal surveys (SS). This paper describes our experience using CT-SS in terms of radiation doses achieved, occult bony injury detection and forensic utility. METHODS: Ten infants aged between two weeks and ten months underwent a CT-SS. The results of the CT-SS were compared with concurrent imaging results where available. Radiation doses from imaging procedures were calculated for each patient. RESULTS: Six infants had abnormalities identified on CT-SS. Two patients had both an ante-mortem CT-SS and post-mortem imaging. All fractures identified on alternate imaging modalities were visible on at least one CT-SS reconstruction. The radiation dose associated with CT-SS imaging ranged from 0.73 to 1.46mSv. CONCLUSION: The radiation dose received by the ten infants in this study was greater than the two skeletal survey approach but was less than the dose received during a bone scintigraphy examination, sometimes used to assess for occult bony injury in this setting. While CT-SS imaging results could not be compared with those obtained with current contemporaneous gold standard imaging techniques, CT-SS identified all fractures observed on the radiographic images where performed. CT-SS also identified additional rib fractures in two patients. Our preliminary findings indicate the need for future prospective studies to clarify the ability of CT-SS to detect metaphyseal fractures reliably.

Technology-facilitated sexual assault in children and adolescents; is there a cause for concern? Fourteen years of experience at a metropolitan forensic paediatric medical service.

AIM: To quantify and characterise sexual assaults occurring after 12-17-year-old children connect with an alleged offender online (technology-facilitated sexual assault: TFSA) examined at a paediatric forensic medical service in Melbourne, Australia between 2014 and 2020. To compare these findings to a previous 7-year audit (2007-2013) to determine if there has been an increase in TFSA over the last 14 years. METHODS: A retrospective audit was undertaken of medical records of children aged 12-17 who underwent forensic medical examinations at the Victorian Forensic Paediatric Medical Service following an allegation of sexual assault, between 1 January 2014 and 31 December 2020. Cases identified as being technology facilitated were further analysed. Results from 2014 to 2020 7-year cohort were then compared to an existing audit over the preceding 7-year period (2007-2013). RESULTS: Of 515 sexual assault cases between 2014 and 2020, 70 (14%) victims reported connecting with the offender on a technological platform, compared to 4% of cases between 2007 and 2013. In 2019 and 2020, TFSA comprised almost one-fifth of caseload. Of the 70 TFSA cases, the majority occurred at the first face-to-face meeting following a variable period of online communication. Approximately one-third of TFSA's occurred at the offender's residence, and another third in a public place (park, public toilets). Technological platforms used evolved over the 14-year study period. CONCLUSIONS: The proportion of TFSA caseload seen at an Australian paediatric forensic medical service increased over the last 14 years, with common characteristics to these sexual assaults suggested.

A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury.

Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.

Fabricated or induced illness in children: A guide for Australian health-care practitioners.

Many paediatricians have, or will have at some time in their career, a child under their care who has, or is suspected to have, Fabricated or Induced Illness in a Child (FIIC). Often a pattern of investigation, treatment and referral develops, with things 'just not quite adding up' and the diagnosis of FIIC is not considered. How can Australian health-care practitioners better recognise and respond to concerns around fabricated or induced illness? When should concerns be reported to protective services? How should we talk to families when we suspect fabrication or induction of illness in their child, and what is the role of specialised forensic paediatric services in Australia in relation to such cases? FIIC is almost certainly not as rare as commonly perceived and it can be identified early. Although challenging, FIIC can be managed effectively with a thoughtful multidisciplinary team approach. This article aims to provide paediatricians with a strategy that will hopefully serve to raise awareness, facilitate earlier intervention and simplify the approach to management, encouraging the view that taking action need be no different to addressing any other complex paediatric problem.

Hepatitis B prophylaxis in adolescents who present for examination after alleged sexual assault.

AIM: In Australia, the risk of hepatitis B virus (HBV) transmission from single sexual contact is low. This, combined with assumed widespread immunity from vaccination, has resulted in a lack of clarity surrounding the necessity for hepatitis B post-exposure prophylaxis following recent sexual assault. METHODS: This retrospective audit was conducted through the Victorian Forensic Paediatric Medical Service (VFPMS) at the Royal Children's Hospital, Melbourne, Australia. Subjects were patients aged 13-17 years who presented to VFPMS between 1 January 2007 and 31 December 2016 for forensic medical examination following an alleged penetrative sexual assault. Data collected included subject demographics, immunisation status, route of potential HBV exposure, time between alleged sexual assault and presentation, whether HBsAb levels were tested and the results and whether HBV prophylaxis was administered to the subject and its timing. RESULTS: A total of 2121 records were reviewed, and 420 subjects were found to be eligible for inclusion; 26.2% (n = 110) had HBsAb levels measured at initial presentation. Of these 110 subjects, 45.5% (n = 50) had titre levels less than 10 (deemed to be non-protective) and were therefore vulnerable to HBV infection. Of the 420 subjects, 4.5% (n = 19) received HBV prophylaxis as a result of their assessment. CONCLUSIONS: Results suggest that a high proportion of Australian adolescents presenting following recent sexual assault may be at risk of hepatitis B infection. Very few received timely prophylaxis. Follow-up attendance rates were poor. Administration of the hepatitis B booster vaccine at the point of contact may reduce the risk of HBV infection in this group of adolescents.

Risk and protective factors for meningococcal disease in adolescents: matched cohort study.

OBJECTIVE: To examine biological and social risk factors for meningococcal disease in adolescents. DESIGN: Prospective, population based, matched cohort study with controls matched for age and sex in 1:1 matching. Controls were sought from the general practitioner. SETTING: Six contiguous regions of England, which represent some 65% of the country's population. PARTICIPANTS: 15-19 year olds with meningococcal disease recruited at hospital admission in six regions (representing 65% of the population of England) from January 1999 to June 2000, and their matched controls. METHODS: Blood samples and pernasal and throat swabs were taken from case patients at admission to hospital and from cases and matched controls at interview. Data on potential risk factors were gathered by confidential interview. Data were analysed by using univariate and multivariate conditional logistic regression. RESULTS: 144 case control pairs were recruited (74 male (51%); median age 17.6). 114 cases (79%) were confirmed microbiologically. Significant independent risk factors for meningococcal disease were history of preceding illness (matched odds ratio 2.9, 95% confidence interval 1.4 to 5.9), intimate kissing with multiple partners (3.7, 1.7 to 8.1), being a university student (3.4, 1.2 to 10) and preterm birth (3.7, 1.0 to 13.5). Religious observance (0.09, 0.02 to 0.6) and meningococcal vaccination (0.12, 0.04 to 0.4) were associated with protection. CONCLUSIONS: Activities and events increasing risk for meningococcal disease in adolescence are different from in childhood. Students are at higher risk. Altering personal behaviours could moderate the risk. However, the development of further effective meningococcal vaccines remains a key public health priority.

Is it exposure to cigarette smoke or to smokers which increases the risk of meningococcal disease in teenagers?

BACKGROUND: Passive smoking appears to increase the risk of meningococcal disease (MD) in adolescents. Whether this effect is attributable to exposure to cigarette smoke or contact with smokers is unknown. METHODS: We conducted a prospective population-based case-control study with age, sex matched-controls in 1:1 matching. Participants were 15-19 year old with MD recruited at hospital admission in six regions (65% of the population of England) from January 1999 through June 2000, and their matched controls. Data on potential risk factors were gathered by confidential interview, including seven passive smoking variables. Factor analysis was performed to assess the dimensionality of the passive smoking exposure variables. The data were analysed with univariate and multivariate conditional logistic regression. RESULTS: 144 case-control pairs were recruited (51% male; median age 17.6). Factor analysis identified two independent factors representing passive smoking (P < 0.01), one associated with 'exposure to smoke', the other with 'smoker contact'. Only smoker contact was a significant risk factor for MD (OR = 1.8; 95% CI 1.0-3.3; P = 0.05). In multivariate analysis this factor was still associated with MD independently of potential confounders such as active smoker status and household crowding. CONCLUSION: Contact with smokers is associated with increased risk of MD in adolescents. This is more likely to be due to higher carriage rates in smokers than to exposure to smoke and emphasizes the importance of public health measures to stop smoking. In epidemiological studies that assess risk from passive smoking, exposure to smoke should be differentiated where possible from contact with smokers.

Effectiveness of meningococcal C conjugate vaccine in teenagers in England.

Meningococcal C conjugate vaccine was introduced into clinical practice in the UK before phase 3 trials had been undertaken. We therefore did a case-control study in teenagers to assess vaccine effectiveness. All cases (n=31) enrolled had laboratory confirmed meningococcal C disease. We also enrolled between one and three controls (n=65) per case, matched by age, sex, and general practitioner. Three patients and 23 controls had been vaccinated. The protective effectiveness of the vaccine, estimated by conditional logistic regression, was 93% (95% CI 39-99), which is similar to screening method estimates. The estimated protective effectiveness varied little when potential confounding risk factors were taken into account. Our findings indicate that the vaccine is highly protective against invasive meningococcal C disease.