Crowded letter and crowded picture logMAR acuity in children with amblyopia: a quantitative comparison.

AIMS: Clinically, picture acuity tests are thought to overestimate visual acuity (VA) compared with letter tests, but this has not been systematically investigated in children with amblyopia. This study compared VA measurements with the LogMAR Crowded Kay Picture test to the LogMAR Crowded Keeler Letter acuity test in a group of young children with amblyopia. METHODS: 58 children (34 male) with amblyopia (22 anisometropic, 18 strabismic and 18 with both strabismic/anisometropic amblyopia) aged 4-6 years (mean=68.7, range=48-83 months) underwent VA measurements. VA chart testing order was randomised, but the amblyopic eye was tested before the fellow eye. All participants wore up-to-date refractive correction. RESULTS: The Kay Picture test significantly overestimated VA by 0.098 logMAR (95% limits of agreement (LOA), 0.13) in the amblyopic eye and 0.088 logMAR (95% LOA, 0.13) in the fellow eye, respectively (p<0.001). No interactions were found from occlusion therapy, refractive correction or type of amblyopia on VA results (p>0.23). For both the amblyopic and fellow eyes, Bland-Altman plots demonstrated a systematic and predictable difference between Kay Picture and Keeler Letter charts across the range of acuities tested (Keeler acuity: amblyopic eye 0.75 to -0.05 logMAR; fellow eye 0.45 to -0.15 logMAR). Linear regression analysis (p<0.00001) and also slope values close to one (amblyopic 0.98, fellow 0.86) demonstrate that there is no proportional bias. CONCLUSIONS: The Kay Picture test consistently overestimated VA by approximately 0.10 logMAR when compared with the Keeler Letter test in young children with amblyopia. Due to the predictable difference found between both crowded logMAR acuity tests, it is reasonable to adjust Kay Picture acuity thresholds by +0.10 logMAR to compute expected Keeler Letter acuity scores.

Impact of telemedicine on the quality of forensic sexual abuse examinations in rural communities.

To assess the quality and diagnostic accuracy of pediatric sexual abuse forensic examinations conducted at rural hospitals with access to telemedicine compared with examinations conducted at similar hospitals without telemedicine support. Medical records of children less than 18 years of age referred for sexual abuse forensic examinations were reviewed at five rural hospitals with access to telemedicine consultations and three comparison hospitals with existing sexual abuse programs without telemedicine. Forensic examination quality and accuracy were independently evaluated by expert review of state mandated forensic reporting forms, photo/video documentation, and medical records using two structured implicit review instruments. Among the 183 patients included in the study, 101 (55.2%) children were evaluated at telemedicine hospitals and 82 (44.8%) were evaluated at comparison hospitals. Evaluation of state mandatory sexual abuse examination reporting forms demonstrated that hospitals with telemedicine had significantly higher quality scores in several domains including the general exam, the genital exam, documentation of examination findings, the overall assessment, and the summed total quality score (p<0.05 for each). Evaluation of the photos/videos and medical records documenting the completeness and accuracy of the examinations demonstrated that hospitals with telemedicine also had significantly higher scores in several domains including photo/video quality, completeness of the examination, and the summed total completeness and accuracy score (p<0.05 for each). Rural hospitals using telemedicine for pediatric sexual abuse forensic examination consultations provided significantly higher quality evaluations, more complete examinations, and more accurate diagnoses than similar hospitals conducting examinations without telemedicine support.

Using telemedicine to improve the care delivered to sexually abused children in rural, underserved hospitals.

OBJECTIVE: We used live telemedicine consultations to assist remote providers in the examination of sexually assaulted children presenting to rural, underserved hospitals. We hypothesized that telemedicine would increase the ability of the rural provider to perform a complete and accurate sexual assault examination. PATIENTS AND METHODS: Child abuse experts from a university children's hospital provided 24/7 live telemedicine consultations to clinicians at 2 rural, underserved hospitals. Consultations consisted of videoconferencing to assist in the examination and interpretation of findings during live examinations. Consecutive female patients <18 years of age presenting to the 2 participating hospitals were included. We developed and used an instrument to assess the quality of care and the interventions provided via telemedicine as it related to patient history, physical examination, colposcopic and manual manipulation techniques, interpretation of findings, and treatment plans for victims of child sexual abuse. RESULTS: Data from 42 live telemedicine consultations were analyzed. The mean duration of the consultations was 71 minutes (range: 25-210 minutes). The consultations resulted in changes in interview methods (47%), the use of the multimethod examination technique (86%), and the use of adjunct techniques (40%). There were 9 acute sexual assault telemedicine consults that resulted in changes to the collection of forensic evidence (89%). Rankings of practitioners' skills and the telemedicine consult effectiveness were high, with the majority of cases scoring > or =5 on a 7-point Likert scale. CONCLUSIONS: The use of telemedicine to assist in the examination of sexually assaulted children presenting to underserved, rural communities results in significant changes in the methods of examination and evidence collection. It is possible that this model of care results in increased quality of care and appropriate forensic evidence collection.

Comparison of examination methods used in the evaluation of prepubertal and pubertal female genitalia: a descriptive study.

OBJECTIVE: To compare the effectiveness of three different examination methods in their ability to help the examiner detect both acute and non-acute genital injuries in prepubertal and pubertal girls suspected of having been sexually abused. METHODS: Forty-six prepubertal and 74 pubertal girls, whose ages ranged from 4 months to 18 years, were evaluated to determine the relative effectiveness of three different examination methods. RESULTS: All the girls had sustained a recent genital injury from various causes. The mean time between an injury and the first examination was 24h for the prepubertal girls and 27h for the pubertal girls. The three "multimethod" examination approaches used were the supine labial separation method; the supine labial traction technique; and the prone knee-chest position. The supine labial separation method was useful in identifying an injury on the external portion of the genitalia in both groups of girls. Injuries within the vestibule, on the hymenal surface, or in the fossa navicularis required greater separation of the labia. This was accomplished through the use of either the supine labial traction technique or the prone knee-chest position. The prone knee-chest position was the most successful method for identifying hymenal lacerations in both groups of girls. Of the 10 hymenal lacerations detected in the prepubertal girls 20% were identified during the use of the supine labial separation method, 60% with the supine labial traction technique, and 100% with the prone knee-chest position approach. Of the 49 hymenal lacerations detected in the pubertal girls 24% were identified with the supine labial separation method, 65% with the supine labial traction technique, and 90% with the prone knee-chest position approach. The data from this study has shown that the results of a medical examination will vary by the method employed. CONCLUSIONS: While no single technique detected all the injuries, the use of the multimethod examination approach did prove to be a valuable adjunct in the evaluation of both the prepubertal and the pubertal girl's genitalia, particularly in the identification of a hymenal laceration. PRACTICE IMPLICATIONS: This approach uses three different examination methods: the supine labial separation method, the supine labial traction technique, and the prone knee-chest position. According to the results of this study, without the combined use of these three methods a significant number of injuries, particularly hymenal lacerations, could be missed in both the child and the adolescent.

Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study.

OBJECTIVE: The objective of this study was to identify the healing process and outcome of nonhymenal injuries in prepubertal and pubertal girls. METHODS: This multicenter, retrospective project used photographs to document the healing process and outcome of nonhymenal genital injuries in 239 prepubertal and pubertal girls whose ages ranged from 4 months to 18 years. RESULTS: The genital injuries sustained by the 113 prepubertal girls consisted of 21 accidental or noninflicted injuries, 73 injuries secondary to abuse, and 19 injuries of unknown cause. All 126 pubertal girls were sexual assault victims. These nonhymenal genital injuries healed at various rates depending on the type and severity. There was no statistical difference in the rate of healing between the 2 groups. Abrasions disappeared by the third day after injury. Edema was no longer present by the fifth day. Ecchymosis (bruising) resolved within 2 to 18 days depending on the severity. One prepubertal girl still had a labial hematoma at 2 weeks. Submucosal hemorrhages of the vestibule and fossa navicularis resolved between 2 days and 2 weeks. Petechiae and blood blisters proved useful for approximating the age of an injury. Petechiae were gone by 24 hours, whereas blood blisters were detected at 30 days in a prepubertal girl and 24 days in a pubertal girl. The depth of a laceration determined the time required for it to heal. Superficial vestibular lacerations seemed healed in 2 days, whereas deep perineal lacerations required up to 20 days. The appearance of new blood vessel formation was detected only in prepubertal girls, whereas scar tissue formation occurred only after a deep laceration in both groups. CONCLUSIONS: The majority of these nonhymenal genital injuries healed with little or no evidence of previous trauma. The time required for resolution varied by type, location, and severity.

Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study.

OBJECTIVE: The objective of this study was to identify the healing process and outcome of hymenal injuries in prepubertal and adolescent girls. METHODS: This multicenter, retrospective project used photographs to document the healing process and outcome of hymenal trauma that was sustained by 239 prepubertal and pubertal girls whose ages ranged from 4 months to 18 years. RESULTS: The injuries that were sustained by the 113 prepubertal girls consisted of 21 accidental or noninflicted injuries, 73 secondary to abuse, and 19 "unknown cause" injuries. All 126 pubertal adolescents were sexual assault victims. The hymenal injuries healed at various rates and except for the deeper lacerations left no evidence of the previous trauma. Abrasions and "mild" submucosal hemorrhages disappeared within 3 to 4 days, whereas "marked" hemorrhages persisted for 11 to 15 days. Only petechiae and blood blisters proved to be "markers" for determining the approximate age of an injury. Petechiae resolved within 48 hours in the prepubertal girls and 72 hours in the adolescents. A blood blister was detected at 34 days in an adolescent. As lacerations healed, their observed depth became shallower and their configuration smoothed out. Of the girls who sustained "superficial," "intermediate," or "deep" lacerations, 15 of 18 prepubertal girls had smooth and continuous appearing hymenal rims, whereas 24 of 41 adolescents' hymens had a normal, "scalloped" appearance and 30 of 34 had no disruption of continuity on healing. The final "width" of a hymenal rim was dependent on the initial depth of the laceration. No scar tissue formation was observed in either group of girls. CONCLUSIONS: The hymenal injuries healed rapidly and except for the more extensive lacerations left no evidence of a previous injury. There were no significant differences in the healing process and the outcome of the hymenal injuries in the 2 groups of girls.

Anogenital injuries in child pedestrians run over by low-speed motor vehicles: four cases with findings that mimic child sexual abuse.

OBJECTIVE: Differentiating between child sexual abuse and nonintentional causes of anogenital injury can be challenging, and a misdiagnosis can have a profound impact on the child and family. This case series documents an important nonintentional mechanism of anogenital injury that mimics the physical findings of child sexual abuse. METHODS: Four children were examined after being run over by a slow-moving motor vehicle. In each case, the wheel of the vehicle passed longitudinally over the child's torso. RESULTS: Two children had perianal lacerations, and 2 had hymenal lacerations. One child with hymen injuries was followed for 4 weeks and developed findings identical to those seen in healed sexual abuse. CONCLUSIONS: Children run over by motor vehicles should be evaluated for anogenital injury. If such injury is suspected, it should be fully delineated and documented with colposcopy and follow-up examination. Although the possibility of sexual abuse must be considered, awareness of the occurrence of anogenital injuries in children run over by motor vehicles may prevent the misdiagnosis of acute sexual abuse in children. Conversely, children presenting for evaluation of acute or past sexual abuse should be questioned as to whether they were ever run over by a motor vehicle.