Sara H. Sinal

Victimization, use of violence, and drug use at school among male adolescents who engage in same-sex sexual behavior

OBJECTIVE To examine the relationship between the number of male sexual partners of adolescent males and the frequency of victimization at school, missed school because of fear, used drugs at school, and engagement of fighting and weapon carrying both in and out of school. STUDY DESIGN Sexually active male adolescents (N = 3886) in 8th through 12th grades were administered the 1995 Vermont Youth Risk Behavior Survey. RESULTS A total of 8.7% of male adolescents reported one or more male sexual partners. Alcohol, marijuana, and smokeless tobacco use at school, not attending school because of fear, having been threatened or injured with a weapon at school, and weapon carrying at school accounted for 15.8% of the variation in the number of male sexual partners (p < 0.0001). Suicide attempts, school absence because of fear, cigarette smoking, alcohol use, and smokeless tobacco use at school, frequency of fighting requiring medical treatment, carrying a weapon,aand carrying a weapon at school accounted for 17.2% out of 100% of the variation in the number of male sexual partners (p < or 0.00001). CONCLUSION The number of male sexual partners reported by sexually active male adolescents correlated with a higher frequency of victimization, use of violence and drug use at school. Frequency of suicide attempts and fighting outside of school were also correlated with the number of same-sex sexual partners.

Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.

Objectives. To evaluate human papillomavirus (HPV) presentation among children <13 years of age and its association with suspected child sexual abuse (CSA), and to assess sexual abuse consideration among different clinical services treating these children. Methods. Records of children <13 years of age from 1985 to 2003 were selected for review if the children had a HPV-related International Classification of Diseases, Ninth Revision, code or had been examined in the CSA clinic. Abstracted data included demographic features, clinical findings, clinical services involved, age at diagnosis, age when care was first sought, and age when symptoms were first noted. Results. HPV was identified by clinical examination and/or biopsy for 124 children, 40 with laryngeal lesions, 67 with anogenital lesions, 10 with oral lesions, and 7 with both anogenital and oral lesions. The mean age at HPV diagnosis was 4.0 ± 2.9 years, compared with 6.4 ± 3.0 years for 1565 HPV-negative children. Among 108 HPV cases with data for age when symptoms were first noted, the mean age was 3.3 ± 2.9 years (median: 2.2 years) for children with anogenital and oral HPV and 2.4 ± 2.3 years (median: 1.9 years) for children with laryngeal HPV. Among HPV-positive patients, 56% were female, compared with 82% of HPV-negative children. Fifty-five (73%) of 75 children with anogenital HPV infections were referred to the CSA clinic for evaluation, compared with none of 49 children with laryngeal or oral HPV infections treated by the otolaryngology service. Laryngeal cases presented earlier than anogenital and oral lesions. Abuse was considered at least possible for 17 of 55 children with any CSA evaluation. The mean age of likely abused, HPV-positive children was 6.5 ± 3.8 years (median: 5.3 years), compared with 3.6 ± 2.3 years (median: 2.6 years) for likely not abused, HPV-positive children. The likelihood of possible abuse as a source of HPV infection increased with age. The positive predictive value of HPV for possible sexual abuse was 36% (95% confidence interval: 13–65%) for children 4 to 8 years of age and 70% (95% confidence interval: 35–93%) for children >8 years of age. Conclusions. The data from this epidemiologic study of HPV suggest that many anogenital and laryngeal HPV infections among preadolescent children are a result of nonsexual horizontal transmission, acquired either perinatally or postnatally. It seems that many children >2 years of age acquire HPV infection from nonsexual contact. Different subspecialties vary greatly in their suspicion and evaluation of CSA. At this time, there remains no clear age below which sexual abuse is never a concern for children with anogenital HPV infections. Every case needs a medical evaluation to determine whether enough concern for abuse exists to pursue additional investigations.

Hypomorphic Rag mutations can cause destructive midline granulomatous disease

Destructive midline granulomatous disease characterized by necrotizing granulomas of the head and neck is most commonly caused by Wegener granulomatosis, natural killer/T-cell lymphomas, cocaine abuse, or infections. An adolescent patient with myasthenia gravis treated with thymectomy subsequently developed extensive granulomatous destruction of midface structures, palate, nasal septum, airways, and epiglottis. His lymphocyte numbers, total immunoglobulin G level, and T-cell receptor (TCR) repertoire appeared normal. Sequencing of Recombination activating gene-1 (Rag1) showed compound heterozygous Rag1 mutations; a novel deletion with no recombinase activity and a missense mutation resulting in 50% Rag activity. His thymus was dysplastic and, although not depleted of T cells, showed a notable absence of autoimmune regulator (AIRE) and Foxp3(+) regulatory T cells. This distinct Rag-deficient phenotype characterized by immune dysregulation with granulomatous hyperinflammation and autoimmunity, with relatively normal T and B lymphocyte numbers and a diverse TCR repertoire expands the spectrum of presentation in Rag deficiency. This study was registered at www.clinicaltrials.gov as #NCT00128973.

Coping with sports injuries: an examination of the adolescent athlete ☆

Forty-eight injured adolescent athletes completed questionnaires over 3 months after injury to assess psychosocial outcomes. Depressive symptoms decreased over time, and the lack of positive stress and high athletic identity were associated with early depressive symptoms after accounting for injury severity. Increased social support was associated with lower initial depressive symptoms.

Is race or ethnicity a predictive factor in Shaken Baby Syndrome

OBJECTIVE Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered. METHODS A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0-4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed. RESULTS The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mothers boyfriend. CONCLUSION Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.

Venereal Warts in Children

1. Kelly A. Sinclair, MD* 2. Charles R. Woods, MD, MS† 3. Sara H. Sinal, MD§ 1. *Emergency Medical Services, The Childrens Mercy Hospital and Clinics, Kansas City, MO. 2. †Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY. 3. §Department of Pediatrics, Wake Forest University Health Sciences, Winston-Salem, NC. After completing this article, readers should be able to: 1. Describe the natural history and epidemiology of anogenital human papillomavirus infection. 2. Discuss diagnosis and treatment options for children who have anogenital warts. 3. Recognize when anogenital warts are suggestive of child sexual abuse and what steps are needed to manage this clinical problem. More than 24 million cases of human papillomavirus (HPV) infection occur in adults in the United States, with an estimated 1 million new cases developing each year. The number of outpatient visits for adults who have venereal warts (condyloma acuminata) increased fivefold from 1966 to 1981. (1) HPV infections in children may present as common skin warts, anogenital warts (AGW), oral and laryngeal papillomas, and subclinical infections. The increased incidence of AGW in children has paralleled that of adults. AGW in children present a unique diagnostic challenge: Is the HPV infection a result of child sexual abuse (CSA), which requires reporting to Child Protective Services (CPS), or acquired through an otherwise innocuous mechanism? Practitioners must balance “missing” a case of CSA if they do not report to CPS against reporting to CPS and having parents or other caregivers potentially suffer false accusation and its potential ramifications, which may include losing custody of children. In the past, simply identifying AGW in a young child was considered indicative of CSA by some experts. However, there is no defined national standard beyond the limited guidance provided in the 2005 American Academy of Pediatrics (AAP) Policy Statement, which states that AGW are suspicious for CSA if not perinatally acquired and the …

Cockroach: the omnivorous scavenger. Potential misinterpretation of postmortem injuries.

Interpretation of postmortem injuries, including their differentiation from those produced antemortem, may be difficult even for experienced forensic pathologists. A variety of animals or insects residing in the death environment may alter the appearance of the deceased. Dictyoptera blattaria (the cockroach) is common in the residential setting. Three cases of sudden and unexpected infant death are presented in which postmortem injuries inflicted by cockroaches initially raised concern of nonaccidental injury. The true nature of the lesions was not recognized by the people at the death scene and, in one case, observation of neck injuries raised suspicion of possible strangulation. In another, the lesions were thought to be burns of different ages. Cockroaches are omnivorous scavengers that devour keratin. They will bite human flesh in both the living and dead with resultant injury. Recognition of cockroach bites will help in the evaluation of injuries discovered during child death investigations.

Initial Treatment of Cystic Fibrosis Frequency of Transient Bulging Fontanel

Four infants with newly diagnosed cystic fibrosis developed a bulging anterior fontanel within days of starting enzyme replacement treatment. In the same time period, 41 hospitalized patients less than 1 year of age were diagnosed as having cystic fibrosis and treated, suggesting that increased intracranial pressure is common in this setting (9.7%). The clinical course of the four infants was similar: the bulging fontanel became apparent 1-6 days after initiation of pancreatic enzyme replacement and resolved within 1 week in three patients and within 4 months in the other patient. Two patients became mildly irritable. Computed cranial tomography and lumbar puncture were done in three patients, with completely normal findings except elevated cerebrospinal fluid pressure in two infants. There was no apparent difference in the treatment or clinical course before diagnosis between the four infants who developed a transient bulging fontanel compared with the overall group of cystic fibrosis patients.

Reflex Sympathetic Dystrophy in an Adolescent

The clinical course of an adolescent with reflex sympathetic dystrophy of the foot is presented. The potential problems of establishing objective diagnostic criteria for reflex sympathetic dystrophy are related to the dynamic nature of the disorder. Serial radiographic studies, radionuclide scans, and quantitative densitometric measurements may be useful in combination; isolated cold stress testing and laser Doppler fluxmetry are useful in assessing thermoregulation and vasomotor instability. A regimen of amitriptyline and phenytoin plus physical therapy with stress loading was useful in this patient, but in many patients the course is progressive, leading to chronic pain and debilitation.

Chronic Salmonellosis in Infancy

a fi‘~e-day course of intramuscular Kanamycin in a dosage of 22.5 mg every 12 hours. He improved transiently but then persistent diarrhea recurred. At eight weeks of age, he was hospitalized for studies because he was lethargic and appeared severely malnourished. His weight was 2.9 kg, as compared with his birth weight of 3.9 kg. Pulse rate was 120 per minute; respirations, 25 per minute, and rectal temperature, 100.4 F. No other abnormalities were detected on physical , examination.