Lawrence R. Ricci

Development and Preliminary Psychometric Properties of the Multidimensional Neglectful Behavior Scale-Child Report

This article describes the development and psychometric properties of the Multidimensional Neglectful Behavior Scale-Child Report (MNBS-CR). The measure is broadly conceptualized to tap child neglect across four core domains: cognitive, emotional, physical and supervisory neglect, and it assesses exposure to violence, alcohol-related neglect, abandonment, and children’s appraisals of parenting. Features include pictorial items, audio computer-assisted testing, and programming by age and gender of the child and caregiver. A clinical sample of 144 children, age 6 to 15 years, and a comparison sample of 87 children were tested. Results showed that the MNBS-CR has high reliability, with higher reliability found for older children (alpha = .94) than for younger children (alpha = .66). Among older children, the MNBS-CR Supervisory scale was significantly associated with the Child Behavior Check List (CBCL), and total MNBS-CR scores were significantly associated with clinician reports of behavioral disorders. Younger and older neglected children scored significantly higher on the MNBS-CR than community children.

The diagnostic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic

OBJECTIVE This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. METHOD A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. RESULTS The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. CONCLUSIONS This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.

Abusive head trauma in Maine infants: medical, child protective, and law enforcement analysis

OBJECTIVE To collect and compare the results of medical, child protective, and law enforcement evaluation of a sample of Maine children who were victims of abusive head trauma (AHT) in order to describe the clinical and evaluative characteristics as they relate to victims, families and perpetrators of such trauma and to improve the professional response to AHT in Maine. METHOD Retrospective chart review of medical, child protective, and law enforcement records of all AHT victims admitted to two tertiary care hospitals in Maine or seen by the state medical examiner from 1991 to 1994. RESULTS Nineteen children (age range 2 weeks to 17 months) were identified as victims of AHT (out of a total of 94 head trauma admissions) accounting for 20 hospitalizations during the study period. There was a history of prior injury in 30%, history of prior medical evaluations for possibly abuse related problems in 65%, while, on presentation, 75% had evidence or history of prior injury. The hospitals notified child protective services (CPS) in all 20 cases and correctly identified abuse in 18 (90%). Parental risk factors for abuse identified in CPS records included substance abuse (53%), domestic violence (42%), criminal history (32%), unrealistic expectations (42%), and attachment problems (32%). However, risk factors were inadequately assessed in 53% of homes. Law enforcement identified a likely perpetrator in 79% of cases and in the majority the identified suspect was the father. In the 15 cases where a perpetrator was identified by law enforcement, that person was alone with the child at symptom onset in 14 (93%). CONCLUSIONS The medical response, at least at the inpatient level, was generally well done with regard to suspicion and reporting. Cases are possibly being missed at the outpatient level. Child protective risk assessment was limited overall yet in a third of the homes where AHT occurred, few if any risk factors were present to aid in identification and prevention. Law enforcement results suggest that a primary suspect for AHT is the caretaker alone with the child at the time of symptom onset.

Prostatic acid phosphatase and sperm in the post-coital vagina

Sperm and prostatic acid phosphatase identified in vaginal fluid after an alleged sexual assault constitute important physical evidence useful in courts of law during rape trials. The purpose of this study was to define a normal and abnormal range for acid phosphatase in the post-coital vagina for our emergency department and to compare the sensitivity of acid phosphatase versus sperm in determining recent coitus. Vaginal swabs obtained from 90 patients were analyzed for acid phosphatase activity by the Sigma p-nitrophenyl phosphate technique. Swabs were stored in a bovine albumin preservative broth. Pap smears for sperm identification were also performed. Acid phosphatase values greater than 50, especially those greater than 138 Sigma units/cc, correlated with intercourse within the preceding 24 hours (P .005). Values greater than 20 but less than 50 correlated with intercourse within 48 hours (P .005). The presence or absence of sperm was found to be less sensitive, and correlated poorly with the time since intercourse [of 12 cases less than or equal to 24 hours, 11 were acid phosphatase-positive (91.7%) while seven were sperm-positive (58.4%)].

Medical forensic photography of the sexually abused child.

The dramatic increase in reports of sexual abuse has resulted in increasing referrals to physicians for medical evaluation and has placed demands on physicians to adequately and expertly assess these children. High quality, close-up photographs of significant lesions can be an important part of this evaluation. Camera systems recommended vary from colposcopes to close-up 35-mm systems to instant cameras. Physicians who examine sexually abused children should have ready access to an adequate photographic system, as well as basic knowledge of camera operation, film procedures, and medicolegal implications. Case studies and discussion are used to review colposcopic and close-up 35-mm camera techniques available to the physician to photograph the sexual abuse victim.

Ethanol-induced hypoglycemic coma in a child

Reported is a case of ethanol-induced hypoglycemic coma in a 33-month-old boy after accidental ingestion of ethanol. Blood glucose was 10 mg% and blood ethanol was 71 mg%. He responded promptly to an IV bolus of 50% dextrose. The pathophysiology and clinical presentation of this not uncommon metabolic disorder are discussed. A plan for early recognition and management is presented.

Expression profiling of in vivo ductal carcinoma in situ progression models identified B cell lymphoma-9 as a molecular driver of breast cancer invasion

IntroductionThere are an estimated 60,000 new cases of ductal carcinoma in situ (DCIS) each year. A lack of understanding in DCIS pathobiology has led to overtreatment of more than half of patients. We profiled the temporal molecular changes during DCIS transition to invasive ductal carcinoma (IDC) using in vivo DCIS progression models. These studies identified B cell lymphoma-9 (BCL9) as a potential molecular driver of early invasion. BCL9 is a newly found co-activator of Wnt-stimulated β-catenin-mediated transcription. BCL9 has been shown to promote progression of multiple myeloma and colon carcinoma. However BCL9 role in breast cancer had not been previously recognized.MethodsMicroarray and RNA sequencing were utilized to characterize the sequential changes in mRNA expression during DCIS invasive transition. BCL9-shRNA knockdown was performed to assess the role of BCL9 in in vivo invasion, epithelial-mesenchymal transition (EMT) and canonical Wnt-signaling. Immunofluorescence of 28 patient samples was used to assess a correlation between the expression of BCL9 and biomarkers of high risk DCIS. The cancer genome atlas data were analyzed to assess the status of BCL9 gene alterations in breast cancers.ResultsAnalysis of BCL9, by RNA and protein showed BCL9 up-regulation to be associated with DCIS transition to IDC. Analysis of patient DCIS revealed a significant correlation between high nuclear BCL9 and pathologic characteristics associated with DCIS recurrence: Estrogen receptor (ER) and progesterone receptor (PR) negative, high nuclear grade, and high human epidermal growth factor receptor2 (HER2). In vivo silencing of BCL9 resulted in the inhibition of DCIS invasion and reversal of EMT. Analysis of the TCGA data showed BCL9 to be altered in 26 % of breast cancers. This is a significant alteration when compared to HER2 (ERBB2) gene (19 %) and estrogen receptor (ESR1) gene (8 %). A significantly higher proportion of basal like invasive breast cancers compared to luminal breast cancers showed BCL9 amplification.ConclusionBCL9 is a molecular driver of DCIS invasive progression and may predispose to the development of basal like invasive breast cancers. As such, BCL9 has the potential to serve as a biomarker of high risk DCIS and as a therapeutic target for prevention of IDC.

Child sexual abuse: The emergency department response

Each child who presents with a suspicion of sexual abuse must have immediate access to a complete medical evaluation performed by a competent and knowledgeable examiner. This evaluation should include, at a minimum, a history, a complete physical examination with a detailed genital examination, treatment of identified medical problems, and collection of evidence. It is not appropriate to perform a cursory examination simply because there was a time delay between the abuse and the examination or because the history is suspect. Each sexual abuse workup must be medically and forensically complete. In addition, each child presenting with suggestive complaints should have sexual abuse strongly considered in the differential diagnosis. A report to the appropriate social and legal agencies is indicated even if the suspicion cannot be confirmed. If sexually abused children are to be examined in hospital emergency departments, a protocol should be developed to ensure rapid, thorough, uniform, and caring evaluation. With planning, preparation, and education, most current inadequacies in the emergency medical assessment of sexually abused children can be resolved so that child victims receive sensitive and comprehensive medical care.

Penile fracture and magnetic resonance imaging

A thirty-three-year-old male presented to an outside emergency department with scrotal swelling and pain after intercourse. A scrotal ultrasound revealed hematoma, with no other abnormalities and the patient was discharged. He then presented to our institution where examination showed diffuse ecchymosis through the shaft of the penis, suprapubic region, and scrotum without a palpable cavernosal defect. Magnetic resonance imaging (MRI) without contrast was obtained after the injection of 10 micrograms of intracavernosal alprostadil. The low signal tunica albuginea is easily demarcated compared to the high T2 and intermediate T1 signal of the corpora cavernosum (Figures 1-3) (1,2). Hematoma shows heterogeneous intermediate T1 and T2 signal (Figures 2 and 3) (1). Penile fracture is rupture of the corpus cavernosum from blunt trauma to the erect penis (3,4). Typical presentation is a pop during intercourse, immediate detumescence with edema, hematoma and penile deformity (3,4). In atypical presentations, radiological studies may be useful to determine the diagnosis. MRI provides the ability to identify disruption of the corpus cavernosum due to excellent tissue contrast and Penile Fracture and Magnetic Resonance Imaging _______________________________________________

Documentation and Preservation of Visual Evidence in Child Abuse

Careful documentation of injuries provides key information for assessment and evidence in child abuse cases. Visual images of medical findings may influence courts and can be used for consultation, peer review, and teaching. Electronic documentation technologies such as still cameras, video cameras, colposcopes, and computer-based imaging allow medical practitioners to preserve visual evidence in an increasingly sophisticated manner. This article discusses the justification for and equipment used to obtain and preserve visual evidence in either still or video format. It also explores a variety of processing, storage, duplication, and computer transmission modalities.