Child sexual abuse

Child sexual abuse is a worldwide concern. It is an insidious, persistent, and serious problem that, depending on the population studied and definition used, affects 2-62% of women and 3-16% of men as victims. Pain and tissue injury from child sexual abuse can completely heal in time, but psychological and medical consequences can persist through adulthood. Associated sexually transmitted diseases (such as HIV) and suicide attempts can be fatal. All physicians who treat children should be aware of the manifestations and consequences of child sexual abuse, and should be familiar with normal and abnormal genital and anal anatomy of children. This aim is best accomplished through training and routine examination of the anus and genitalia of children. Because as many as 96% of children assessed for suspected sexual abuse will have normal genital and anal examinations, a forensic interview by a trained professional must be relied on to document suspicion of abuse.

Child maltreatment 2002: recognition, reporting and risk

BACKGROUND

Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment.

RESULTS

Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning.

DISCUSSION

Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.

Diaper burn: accident, abuse, or neglect

A 7-year-old, female with mental retardation and seizure disorder was admitted with burns. Reportedly, her brother who was 12 years old was cooking dinner for himself. A towel caught fire. He threw the towel over his head, and the patient's diaper ignited. She had partial thickness second-degree burns over her right elbow, upper abdomen, both inner thighs, and buttocks with multiple blistering, which was estimated to be 7% of the total body surface. The child abuse team took a diaper similar to the one the child was wearing at the time of injury and found that it easily ignited and melted in several seconds. This is the first medically reported burn case due to a disposable diaper.

Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996

The objective of this study was to to determine if physician knowledge of and biases regarding child sexual abuse (CSA) have changed since 1986. A questionnaire, previously used in 1986, was mailed to 370 physicians who see children in Columbus, Ohio. More respondents in 1996 correctly denied an association between specific sociologic factors and the likelihood of CSA. Seventy-two percent of physicians indicated that they check the genitalia of prepubescent females more than 50% of the time, versus 77% in 1986. Physicians who see more than 25 pediatric patients per week were significantly more likely to check the genitalia (p < .001), whereas physicians with more than 10 years experience were less likely to check genitalia (p < .05). Physicians surveyed in 1996 were more knowledgeable about socioeconomic and behavioral aspects of CSA but continued to be deficient in identifying prepubescent female genital anatomy and in reporting suspected abuse. Education is necessary to correct these deficits.

American Academy of Pediatrics. Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths

Although there is a continuing need for timely review of child deaths, no uniform system exists for investigation in the United States. Investigation of a death that is traumatic, unexpected, obscure, suspicious, or otherwise unexplained in a child younger than 18 years requires a scene investigation and an autopsy. Review of these deaths requires the participation of pediatricians and other professionals, usually as a child death review team. An appropriately constituted team should evaluate the death investigation process, review difficult cases, and compile child death statistics.

Child abuse as a stressor of pediatricians

A survey of: 1) sources of perceived stress, 2) stress management, and 3) burnout among members of the American Academy of Pediatrics Sections on Child Abuse and Emergency Medicine indicates that child abuse physicians are stressed by the history, physical examination, and court appearances in abuse cases. Rarely did physicians indicate that this stress adversely affected their sexual life or family life. Both groups considered courtroom appearances most stressful. Both groups claimed to recognize their stressors and use a variety of approaches to decrease stress. Formal training in child maltreatment was unusual among Abuse Section members, whereas Emergency Section members tended to receive this training in Fellowships. Emergency Medicine Section members reported increased perceived levels of stress. Despite recognition of stress, there was no indicated desire to leave either specialty before an average of 11 to 15 years. Emergency Medicine Section members indicated that 5% of their patients are abused. It is important that emergency medicine residency programs include child abuse education. Formal training programs for individuals who wish to limit their practice to child abuse are needed. Stressors need to be recognized and appropriately managed. Stress recognition and management techniques that have been shown to be effective should be taught and used, beginning in medical school and continuing throughout medical practice. This is necessary if the highest quality of professional personal and patient care is to be maintained.

PSA levels and the rate of positive surgical margins in radical prostatectomy specimens preceded by androgen blockade in clinical B2 (T2bNxMo) prostate cancer. The Lupron Depot Neoadjuvant Study Group

OBJECTIVES

Neoadjuvant hormonal therapy reduces positive margins in patients undergoing radical prostatectomy. All patients experience a decrease in serum prostate specific antigen (PSA), but not always to a level that is nondetectable. The results of several prospective, randomized trials indicate that the incidence of positive margins decreases with the use of androgen deprivation prior to radical prostatectomy. It has been suggested that a greater decline in PSA levels would result in fewer positive margins. In a recent US trial of patients with T2bNxMO prostate cancer, we reported that 18% of patients randomized to receive 3 months of leuprolide acetate and flutamide had positive margins, compared to 48% of those who had radical prostatectomy alone (P < 0.001). We correlated the PSA levels prior to and following androgen deprivation and the presence of a positive margin following radical prostatectomy (RP).

METHODS

One hundred and thirty-seven of 149 patients randomized to receive presurgery androgen deprivation (AD) underwent radical prostatectomy. Of these, 135 had a PSA level obtained both prior to androgen deprivation and prior to surgery. We analyzed the percent positive margins in patients whose PSA values became undetectable and in those whose values remained above 0.1 ng/mL despite androgen deprivation.

RESULTS

Eight of 43 patients (19%) with a nadir PSA < or = 0.1 ng/mL had a positive surgical margin and 16/92 (17%) with a nadir PSA > 0.1 ng/mL had tumor at the margin. There were no statistical differences in these two groups (P = 1.0 by Fisher's Exact Test [two-tailed], and the Pearson correlation was -0.015).

CONCLUSIONS

There was no correlation between an undetectable PSA and a PSA > 0.1 ng/mL and the presence of tumor at the margin when 3 months of AD was given prior to RP. It is possible that longer periods of AD prior to RP will reduce PSA to an undetectable level in a higher percent of patients. However, these data suggest that an undetectable level will not result in less positive margins.

Infrared light-emitting diode radiation causes gravitropic and morphological effects in dark-grown oat seedlings

Oat (Avena sativa cv Seger) seedlings were irradiated with IR light-emitting diode (LED) radiation passed through a visible-light-blocking filter. Infrared LED irradiated seedlings exhibited differences in growth and gravitropic response when compared to seedlings grown in darkness at the same temperature. Thus, the oat seedlings in this study were able to detect IR LED radiation. These findings call into question the use of IR LED as a safe-light for some photosensitive plant response experiments. These findings also expand the defined range of wavelengths involved in radiation-gravity (light-gravity) interactions to include wavelengths in the IR region of the spectrum.

Optimization of moisture content for wheat seedling germination in a cellulose acetate medium for a space flight experiment

The Porous Tube Plant Nutrient Delivery System (PTPNDS), a hydrophilic, microporous ceramic tube hydroponic system designed for microgravity, will be tested in a middeck locker of the Space Shuttle. The flight experiment will focus on hardware operation and assess its ability to support seed germination and early seedling growth in microgravity. The water controlling system of the PTPNDS hardware has been successfully tested during the parabolic flight of the KC-135. One challenge to the development of the space flight experiment was to devise a method of holding seeds to the cylindrical porous tube. The seed-holder must provide water and air to the seed, absorb water from the porous tube, withstand sterilization, provide a clear path for shoots and roots to emerge, and be composed of flight qualified materials. In preparation for the flight experiment, a wheat seed-holder has been designed that utilizes a cellulose acetate plug to facilitate imbibition and to hold the wheat seeds in contact with the porous tube in the correct orientation during the vibration of launch and the microgravity environment of orbit. Germination and growth studies with wheat at a range of temperatures showed that optimal moisture was 78% (by weight) in the cellulose acetate seed holders. These and other design considerations are discussed.

The incidence of unsuspected metastases from clinically benign prostate glands with latent prostate carcinoma

OBJECTIVE

To determine how many latent prostate gland carcinomas (unsuspected carcinomas in clinically benign prostate glands) metastasize.

DESIGN

The prostate glands and the pelvic and paraaortic lymph nodes were removed at autopsy from 209 consecutive patients with clinically benign prostate glands. The prostate glands were completely sectioned and examined microscopically using full cross sections. Pelvic and para-aortic lymph nodes were identified and examined microscopically for metastases.

RESULTS

Seventy-nine (38%) of the prostate glands had latent prostate carcinomas. None of the pelvic or paraaortic lymph nodes contained metastases.

CONCLUSION

This study suggests that few latent prostate-gland carcinomas metastasize.

Child abuse and neglect in Japan: coin-operated-locker babies

The coin-operated-locker baby is a type of child abuse that may be unique to Japan. The term refers to newborns who are placed, while alive or dead, in coin-operated lockers. This practice has been decreased by specific measures. It is likely that social and economic variables in Japan account for differences in the frequency and types of child abuse cases when compared to American or European societies as social conditions in Japan change the reported incidence of child abuse may increase in the future. Recently, the government of Osaka organized a group specifically designed to deal with the detection and protection of abused and neglected children. In 1993, they published a manual on how to deal with child abuse, but the Japanese judicial administration still uses old laws for abuse cases. The development of new laws is occurring in parts of the country now. This paper introduces the present status of coping with child abuse and neglect in Japan.

Physicians and medical neglect: variables that affect reporting

Variables that affect the propensity to report medical neglect were surveyed among 52 physicians on the staff of a pediatric hospital. Death was one of the 52 potential consequences of neglect listed for 7 of the 46 diseases analyzed. The time allotted before neglect would be considered varied with the stage and seriousness of the disease. Caretakers were less likely to be considered neglectful if the symptoms of the disease were minor, not obvious, or required technical sophistication for recognition. The number of acceptable reasons for missing appointments varied. The natural course of the disease process, efficacy and safety of treatment, parents' religion, intellectual level, and economic situation affected neglect reporting propensity. Definitions of medical neglect for common diseases must be standardized. Training of lay caretakers of ill children and communication of clear and reasonable expectations are necessary to help prevent medical neglect.

Stage at presentation and survival of white and black patients with prostate carcinoma

BACKGROUND

Black men are known to have a higher incidence and mortality from prostate carcinoma than white men and are more likely to have a more advanced stage or grade of disease diagnosed.

METHODS

In a Veterans Administration Medical Center where black and white men have the same eligibility for medical care, the authors reviewed the stage at presentation of 861 consecutive cases of prostate carcinoma diagnosed from 1969-1990. In addition, survival, stratified by race, stage, and grade, was determined on all men in whom prostate cancer was diagnosed from 1969-1985 (525 patients).

RESULTS

It was found that 26% of white and 52% of black men with prostate carcinoma presented with Stage D disease. Similar proportions of white and black men with prostate carcinoma presented with Stage D disease between 1969-73 as between 1986-90. The overall survival was poorer for black men because of their higher proportion of Stage D disease, but stratified for grade and stage, survival was similar in both races.

CONCLUSIONS

This study suggests that factors other than eligibility for medical care may be responsible for the higher proportion of black men with prostate carcinoma presenting with Stage D prostate carcinoma.

Renin-secreting juxtaglomerular tumor causing severe hypertension: diagnosis by computerized tomography-directed needle biopsy

Renin-secreting tumors are a rare cause of severe hypertension accompanied by hypokalemia. Typically, these tumors have been difficult to diagnose preoperatively by standard radiographic and hormonal studies. We describe a 44-year-old man who was hospitalized for paroxysmal hypertension and who had a 2.3 cm. mid upper pole renal mass on sonography. Computerized tomography-directed needle biopsy revealed a juxtaglomerular tumor and surgical excision of the tumor was curative. We discuss the unique diagnostic aspects of this case.

Inflicted injury versus accidental injury

The morbidity and mortality that are associated with child abuse is a serious concern for the practicing pediatrician. If abuse is to be prevented, physicians must become skilled in recognizing factors that place a child at risk for abuse. Early and minor signs of abuse and neglect must be recognized and reported to assure services if more serious abuse and neglect are to be prevented. Instruments that are used to strike children or burn them leave their imprint on the child. Marks on the skin may signal the existence of internal injuries. Nonaccidental injuries may be difficult to distinguish from accidental injuries. Physicians must approach an injury as a symptom requiring a diagnosis of cause. This is best accomplished by careful examination and documentation of each injury. If the injury is not in keeping with the history given or the child's level of development, abuse must be considered as a cause. A suspicion of abuse should result in a report.

The role of auxin efflux carriers in the reversible loss of polar auxin transport in the pea (Pisum sativum L.) stem

Correlatively inhibited pea shoots (Pisum sativum L.) did not transport apically applied (14)C-labelled indol-3yl-acetic acid ([(14)C]IAA), and polar IAA transport did not occur in internodal segments cut from these shoots. Polar transport in shoots and segments recovered within 24 h of removing the dominant shoot apex. Decapitation of growing shoots also resulted in the loss of polar transport in segments from internodes subtending the apex. This loss was prevented by apical applications of unlabelled IAA, or by low temperatures (approx. 2° C) after decapitation. Rates of net uptake of [(14)C]IAA by 2-mm segments cut from subordinate or decapitated shoots were the same as those in segments cut from dominant or growing shoots. In both cases net uptake was stimulated to the same extent by competing unlabelled IAA and by N-1-naphthylphthalamic acid. Uptake of the pH probe [(14)C]-5,5-dimethyloxazolidine-2,4-dione from unbuffered solutions was the same in segments from both types of shoot. Patterns of [(14)C]IAA metabolism in shoots in which polar transport had ceased were the same as those in shoots capable of polar transport. The reversible loss of polar IAA transport in these systems, therefore, was not the result of loss or inactivation of specific IAA efflux carriers, loss of ability of cells to maintain transmembrane pH gradients, or the result of a change in IAA metabolism. Furthermore, in tissues incapable of polar transport, no evidence was found for the occurrence of inhibitors of IAA uptake or efflux. Evidence is cited to support the possibility that the reversible loss of polar auxin transport is the result of a gradual randomization of effluxcarrier distribution in the plasma membrane following withdrawal of an apical auxin supply and that the recovery of polar transport involves reestablishment of effluxcarrier asymmetry under the influence of vectorial gradients in auxin concentration.

Walker-related burns in infants and toddlers

During one year, four (6.5%) of the 61 children who were hospitalized for burns at a children's hospital sustained their injuries in a walker. Records from a total of nine children hospitalized with walker burns were compared to those from other hospitalized burned children. Patients who were burned while in a walker had a greater body surface area burned (11.6%) than those with burns from abuse (1.7%), neglect (2.5%), or other accidents (6.2%). A higher percentage of males were burned, and the burn patterns differed among all four groups. Seven of the nine walker burns resulted from scalds, with three scalds from hot grease. Walker-related burn patients required more physical or occupational therapy and a longer mean hospital stay. Social histories of infants with walker and other accidental burns differed from those associated with abuse or neglect. Walkers expose infants to unnecessary hazards, including potentially serious burns; their use should be discouraged.

The hand as a target organ in child abuse

The authors reviewed the abuse reports submitted by the staff of The Children's Hospital, Columbus, Ohio, to determine the incidence and types of injuries inflicted to children's hands. The authors did not study hand injuries in children who were not reported as physically abused. The authors examined two time periods to ascertain changes injury severity. Of the 631 abuse reports submitted from 1980 to 1982, there were 52 injuries (8.2%) involving the hands. From July 1987 to July 1988 there were 42 hand injuries (13.4%) among 313 reports. In the 94 total cases, 19 (2%) children sustained injury to the hand only, including eight with burns, two with bruises, two with human bites, two with erythema, two with fractures, and one with a laceration. Children with burns to the hand alone were significantly younger than those with other types of injuries. Of the 94 children with hand and other injuries, 18 (20%) required hospital admission. Of the 19 with injuries to the hand only, five required hospital admission. A variety of instruments were used to injure these children. The hand is a delicate organ, and it is frequently the primary or incidental target of child abuse. Familiarity with the patterns and types of hand injury suffered in child abuse is essential for early recognition, reporting, and child protection.

Applicability of the chemiosmotic polar diffusion theory to the transport of indol-3yl-acetic acid in the intact pea (Pisum sativum L.)

The transport of exogenous indol-3yl-acetic acid (IAA) from the apical tissues of intact, light-grown pea (Pisum sativum L. cv. Alderman) shoots exhibited properties identical to those associated with polar transport in isolated shoot segments. Transport in the stem of apically applied [1-(14)C]-or [5-(3)H]IAA occurred at velocities (approx. 8-15 mm·h(-1)) characteristic of polar transport. Following pulse-labelling, IAA drained from distal tissues after passage of a pulse and the rate characteristics of a pulse were not affected by chases of unlabelled IAA. However, transport of [1-(14)C]IAA was inhibited through a localised region of the stem pretreated with a high concentration of unlabelled IAA or with the synthetic auxins 1-napthaleneacetic acid and 2,4-dichlorophenoxyacetic acid, and label accumulated in more distal tissues. Transport of [1-(14)C]IAA was also completely prevented through regions of the intact stem treated with N-1-naphthylphthalamic acid (NPA) and 2,3,5-triiodobenzoic acid.Export of IAA from the apical bud into the stem increased with total concentration of IAA applied (labelled+unlabelled) but approached saturation at high concentrations (834 mmol·m(-3)). Transport velocity increased with concentration up to 83 mmol·m(-3) IAA but fell again with further increase in concentration.Stem segments (2 mm) cut from intact plants transporting apically applied [1-(14)C]IAA effluxed 93% of their initial radioactivity into buffer (pH 7.0) in 90 min. The half-time for efflux increased from 32.5 to 103.9 min when 3 mmol·m(-3) NPA was included in the efflux medium. Long (30 mm) stem sections cut from immediately below an apical bud 3.0 h after the apical application of [1-(14)C]IAA effluxed IAA when their basal ends, but not their apical ends, were immersed in buffer (pH 7.0). Addition of 3 mmol·m(-3) NPA to the external medium completely prevented this basal efflux.These results support the view that the slow long-distance transport of IAA from the intact shoot apex occurs by polar cell-to-cell transport and that it is mediated by the components of IAA transmembrane transport predicted by the chemiosmotic polar diffusion theory.

Nursing Diagnosis Anyone? Do Staff Nurses Use Nursing Diagnosis Effectively?

The use of nursing diagnosis by staff nurses in a 225-bed metropolitan hospital was examined. The sample consisted of 82 newly hired nurses who had participated in a mandated staff development program on nursing process theory and use of nursing diagnosis, with an emphasis on transfer of knowledge to practice. The data collected included demographic information, attitudes concerning nursing diagnosis, pretest and posttest scores, and percent completed on the audits of chart documentation. A cross-tabulation by clinical arena was performed on the forms used to document utilization of nursing diagnosis. Analysis of the data indicated that a greater proportion of the charts for the nurses in the maternal/child clinical arena evidenced use of nursing diagnosis as a component of practice. The nurses in the critical care arena scored slightly lower. The nurses in the medical/surgical arena had the lowest compliance of both completion and utilization of nursing diagnosis. This study demonstrated that nurses can be taught to use nursing diagnosis in the clinical setting.

Constricting bands. Manifestations of possible child abuse. Case reports and a review

Bands around extremities may be from congenital, infectious, accidental, or purposeful causes. The older child may reveal the cause of self-inflicted or caregiver-inflicted banding. Banding in a nonverbal child will challenge the diagnostic acumen of the physician. Bands of unknown cause, or bands that may have been placed purposefully by a caretaker, must be reported as possible child abuse. Failure of the caretaker to seek help for the consequences of a band may suggest that the bands were intentionally placed. This failure may also be construed as medical neglect. Four cases of banding, which were referred to a child abuse program for consultation, are described.

Computed tomography diagnosis of traumatic rupture of congenital hydronephrotic renal pelvis

Computed tomography (CT) permitted preoperative diagnosis of traumatic rupture of a congenital hydronephrotic renal pelvis. In cases in which renal pelvic rupture is suspected CT may obviate traditional cystoscopy and retrograde pyelography.

Regulation of auxin transport in pea (Pisum sativum L.) by phenylacetic acid: inhibition of polar auxin transport in intact plants and stem segments

The transport of [(14)C]phenylacetic acid (PAA) in intact plants and stem segments of light-grown pea (Pisum sativum L. cv. Alderman) plants was investigated and compared with the transport of [(14)C]indiol-3yl-acetic acid (IAA). Although PAA was readily taken up by apical tissues, unlike IAA it did not undergo long-distance transport in the stem. The absence of PAA export from the apex was shown not to be the consequence of its failure to be taken up or of its metabolism. Only a weak diffusive movement of PAA was observed in isolated stem segments which readily transported IAA. When [1-(14)C]PAA was applied to a mature foliage leaf in light, only 5.4% of the (14)C recovered in ethanol extracts (89.6% of applied (14)C) had been exported from the leaf after 6.0 h. When applied to the corresponding leaf, [(14)C]sucrose was readily exported (46.4% of the total recovered ethanol-soluble (14)C after 6.0 h). [1-(14)C]phenylacetic acid applied to the root system was readily taken up but, after 5.0 h, 99.3% of the recovered (14)C was still in the root system.When applied to the stem of intact plants (either in lanolin at 10 mg·g(-1), or as a 10(-4) M solution), unlabelled PAA blocked the transport through the stem of [1-(14)C]IAA applied to the apical bud, and caused IAA to accumulate in the PAA-treated region of the stem. Applications of PAA to the stem also inhibited the basipetal polar transport of [1-(14)C]IAA in isolated stem segments. These results are consistent with recent observations (C.F. Johnson and D.A. Morris, 1987, Planta 172, 400-407) that no carriers for PAA occur in the plasma membrane of the light-grown pea stem, but that PAA can inhibit the carrier-mediated efflux of IAA from cells. The possible functions of endogenous PAA are discussed and its is suggested that an important role of the compound may be to modulate the polar transport and-or accumulation by cells of IAA.

Regulation of auxin transport in pea (Pisum sativum L.) by phenylacetic acid: effects on the components of transmembrane transport of indol-3yl-acetic acid

Phenylacetic acid (PAA), a naturally-occurring acidic plant growth substance, was readily taken up by pea (Pisum sativum L. cv. Alderman) stem segments from buffered external solutions by a pH-dependent, non-mediated diffusion. Net uptake from a 0.2 μM solution at pH 4.5 proceeded at a constant rate for at least 60 min and, up to approx. 100 μM, the rate of uptake was directly proportional to the external concentration of the compound. The net rate of uptake of PAA was not affected by the inclusion of indol-3yl-acetic acid (IAA) in the uptake medium (up to approx. 30 μM) and, unlike the net uptake of IAA, was not stimulated by N-1-naphthylphthalamic acid (NPA) or 2,3,5-triiodobenzoic acid. At an external concentration of 0.2 μM and pH 4.5, the net rate of uptake of PAA was about twice that of IAA. It was concluded that the uptake of PAA did not involve the participation of carriers and that PAA was not a transported substrate for the carriers involved in the uptake and polar transport of IAA. Nevertheless, the inclusion of 3-100 μM unlabelled PAA in the external medium greatly stimulated the uptake by pea stem segments of [1-(14)C]IAA (external concentration 0.2 μM). It was concluded that whilst PAA was not a transported substrate for the NPA-sensitive IAA efflux carrier, it interacted with this carrier to inhibit IAA efflux from cells. Over the concentration range 3-100 μM, PAA progressively reduced the stimulatory effect of NPA on IAA uptake, indicating that PAA also inhibited carrier-mediated uptake of IAA. The consequences of these observations for the regulation of polar auxin transport are discussed.

Do physicians recognize sexual abuse?

The dramatic increase in the incidence of reports of sexual abuse has placed demands on physicians to assess children for possible sexual abuse. We conducted a survey of urban pediatricians to determine their knowledge of and attitudes about sexual abuse. These physicians were found to have limited knowledge about the social and medical aspects of sexual abuse. The lack of knowledge these physicians display about prepubescent female anatomy and about the association of venereal diseases with sexual abuse decreases their recognition and reporting of sexual abuse. There is a need for physicians to improve their knowledge and skills in the diagnosis of sexual abuse if further abuse and its serious consequences are to be minimized.

The metastatic potential of prostate carcinomas composed entirely of single malignant glands

Consecutive staging lymphadenectomies on 1046 patients with prostate carcinoma identified 275 patients with metastases in a total of 1115 regional lymph nodes. No prostate carcinomas composed entirely of single malignant glands metastasized and no patient had metastases composed entirely of single malignant glands. All prostate carcinomas that metastasized had cribriform and/or undifferentiated histological patterns in the prostate and in the metastases. These findings suggest that identification of cribriform and/or undifferentiated histological patterns, through rebiopsy or further examination of the surgical specimen, should be considered prior to subjecting patients with prostate carcinomas composed entirely of single malignant glands to therapy or procedures directed against the possibility of metastatic disease.

Child abuse diagnosis and the emergency department chart

Failure to uncover and report nonaccidental injury may have serious consequences for the child and the physician. To determine if the information recorded in the emergency department record was adequate to eliminate the possibility of nonaccidental injury, the charts of 333 children under five years of age were reviewed. No charts contained all the information deemed necessary; in 12.6% a diagnosis of nonaccidental injury could not be eliminated. In three cases, the injury was inconsistent with the history. Missing historical information included where the injury occurred, the presence of witnesses, notation of previous injuries, and old chart review. Information regarding size, color, and age of the injury was incomplete. A complete examination was recorded 22.3% of the time. The private-pay category charts and those recorded by staff were most complete. Remedial actions, guided by periodic chart reviews, are suggested.

Self-inflicted foreign bodies involving lower urinary tract and male genitals

A great variety of self-inflicted foreign bodies have been removed from the lower urinary tract and male external genitalia. These foreign bodies were inserted or applied for autoerotic, psychiatric, therapeutic, or no definite reasons by the patient. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred from the foreign body such as difficulty voiding, hematuria, pain or swelling, extravasation, or abscess formation. Inspection and palpation diagnosed foreign bodies involving the male external genitalia in 3 patients and anterior urethra in 6. Radiographic studies with and without contrast medium and endoscopy were required to diagnose foreign bodies in the posterior urethra and bladder in 9 patients, and the exact location, shape, and orientation of the foreign bodies in all sites, radiolucent objects, and the complications of mucosal laceration and extravasation. All 16 foreign bodies in the anterior urethra (below urogenital diaphragm) were removed by endoscopic manipulation in the 6 patients. Nine foreign bodies in the posterior urethra or bladder (above the urogenital diaphragm) were removed by endoscopic manipulation in 2 females and 2 males, while suprapubic cystostomy was required in 1 female and 4 males. The 3 foreign bodies applied to the external genitalia of 3 males were removed carefully to avoid injury to the underlying skin. Foreign bodies lying below the urogenital diaphragm were palpable and readily removed endoscopically while foreign bodies above the urogenital diaphragm required greater endoscopic manipulation or open surgical procedures.

Incidence of urinary tract complications with myelomeningocele

Children born with myelomeningocele face the morbidity of urinary tract complications after they have survived the neurologic complications of the first years of life. The incidence of urinary tract complications was evaluated in 258 children before any operation or intermittent catheter management was performed. In 119 children under one year of age the incidence of urinary tract infection of more than 10(5) colonies was 23 per cent, reflux was 22 per cent, and upper tract dilatation was 6 per cent. In children of all ages the incidence of urinary tract infection of more than 10(5) colonies was 26 per cent, reflux 34 per cent, upper tract dilatation 18 per cent, and urinary incontinence 87 per cent. In 11 children with complete denervation of the pelvic floor muscles reflux developed in 2 (18%) and upper tract dilatation in 1 (9%). In 13 children with slight or moderate denervation of the pelvic floor muscles reflux developed in 5 (38%) and upper tract dilatation in 7 (54%). The development of upper tract changes with myelomeningocele was mainly related to some innervation of the pelvic floor muscles (including periurethral striated muscle) with incoordinate detrusor/sphincter activity. These changes mainly occurred in the first two to four years of life.

To report or not to report. Physicians' attitudes toward discipline and child abuse

Interviews were conducted with 58 physicians to ascertain what factors influenced their reporting of child abuse. When physicians were presented with sample cases of injured children, factors that influenced their decision to report suspected abuse included their attitudes toward physical discipline, seriousness of the injury, presence of other injuries, their familiarity with the family, appropriate parental concern, compatibility of the history and physical examination findings, and the child's behavior. Results indicated that inappropriate discipline was usually not equated with reportable child abuse. Physicians believed that abuse is not often reported because of its low incidence in the private practice setting, the fear of losing patients, the need for certainty, and the lack of confidence in community agencies. These beliefs may conflict with the welfare of young patients.

Management of the neurogenic bladder in 413 children

During the last 10 years the management of the neurogenic bladder in children has changed from indwelling urethral catheterization or urinary diversion to intermittent catheterization or artificial sphincter implantation. Neurogenic bladder dysfunction in 413 children was caused by myelomeningocele in 323, traumatic paraplegia in 47, spastic quadriplegia in 11, sacral agenesis in 18 and spinal cord disease in 14. Management included indwelling urethral catheterization in 27 children, urinary diversion in 193, intermittent catheterization in 84, an artificial sphincter in 11 and undiversion in 6. No single treatment was completely effective or without significant complications.

A 22-year followup of ileal conduits in children with a neurogenic bladder

Previously, the ileal conduit had been used in children for diversion of urine from the neurogenic bladder to prevent deterioration of the upper urinary tracts and to manage urinary incontinence. Long-term results after ileal conduits in children have revealed upper tract deterioration and a high complication rate. The complications and renal deterioration rates in 139 children with ileal conduits followed up to 22 years were evaluated. Of 224 complications 114 required surgical correction. Upper urinary tract deterioration occurred in 16.5 per cent of 50 children followed for 10 or more years (mean 13.3 years). The ileal conduit has been replaced by clean intermittent catheterization, ureteral reimplantation for reflux, the artificial sphincter and undiversion in the management of neurogenic bladders in children. Long-term followup will be necessary to compare the results of these procedures to the known long-term results of the ileal conduit to determine the appropriate role of the ileal conduit in the management of children with neurogenic bladders.

Clean intermittent catheterization in the management of the neurogenic bladder in children

Clean intermittent catheterization has been successful in the management of urinary incontinence and upper tract changes associated with a neurogenic bladder. The results of clean intermittent catheterization controlling urinary incontinence, ureteral reflux, upper tract dilatation and urinary infection in 84 children with a neurogenic bladder were evaluated for up to 3 years of followup. Of the children 41 (49 per cent) were totally incontinent and 14 (17 per cent) were slightly damp. Preexisting ureteral reflux deteriorated in 25 per cent of the patients, ceased in 35 per cent and was unchanged in 40 per cent, while pre-existing upper tract dilatation improved in 12.5 per cent and was unchanged in 87.5 per cent. On clean intermittent catheterization and antibacterial medication 90 per cent of the children had sterile urine and 7.5 per cent had 10(5) or more colonies per ml. Complications occurred on 54 occasions but were minor in nature and were corrected easily. Half of the parents, schools and children found clean intermittent catheterization very acceptable or acceptable but a quarter of the parents and patients found it unacceptable or slightly unacceptable, or were undecided. Initial management of urinary complications associated with neurogenic bladder in children has changed to the clean intermittent catheterization program, with greatly improved results compared to Credé's expression of the bladder, an indwelling urethral catheter or urinary diversion. However, the clean intermittent catheterization regimen was not effective completely, not without complications and not accepted completely by parents, schools and children.

Contralateral renal and ureteral displacement following flank incisional hernia

A case is reported of contralateral displacement of the kidney and ureter due to a left flank incisional hernia following a simple nephrectomy for a staghorn calculus in a massively obese female. Two previously reported cases of pseudocrossed renal ectopia due to renal displacement from incisional hernias in obese females are reviewed.

Students' knowledge of child health and development: effects on approaches to discipline

Unrealistic developmental and behavioral expectations of children, which are associated with child abuse, are related to a lack of knowledge about child development and child rearing. The Iowa Child Development Test (ICDT) was administered to college students to determine their knowledge of child health and development and effects on disciplinary approaches. The results indicated that college students had inadequate knowledge and those who most frequently chose harsh disciplinary methods in simulated child management situations were least knowledgeable. This finding is similar to that reported in an earlier study of high school seniors. College men knew less than college women about child development and health, and more frequently selected harsh punishment. Although noneducation and education majors did not differ with regard to level of knowledge on the ICDT, noneducation majors more frequently chose punish and abuse responses. The findings suggest a need to provide broad-based programs in child rearing education prior to parenthood to reduce the potentiating effects of inadequate knowledge of child health and development on the incidence of child abuse.

Nonoperative management of bladder rupture from external trauma

Nonoperative (catheter) management was used in 18 patients with extraperitoneal rupture of the bladder with limited extravasation of dye found by retrograde cystogram. Complications occurred in 4 of the 18 patients. A review of the literature shows a 20 to 25-per cent complication rate with nonoperative management of bladder rupture. However, with a small extraperitoneal rupture with limited extravasation, especially in a female, the nonoperative (catheter) management will give a satisfactory result.

Effect of high school students' knowledge of child development and child health on approaches to child discipline

Because there is an association between the lack of knowledge of normal child development, high and unrealistic expectations for a child's performance, and child abuse, a questionnaire about normal child development, child health maintenance, child discipline aspects of childrearing, and child development was given to a representative sample of high school students in Iowa. Though high school students in Iowa rank high in academic performance, the results of this study indicated that students in grades 9 through 12 had a poor knowledge of child development and child health maintenance. Students whose highest probability of response to a child discipline problem was either to punish or abuse knew less about child development and child health maintenance than their peers. Boys at all grade levels knew less about child development and child health maintenance and were more likely to choose punishment and abuse than girls. Though the causes for child abuse are multifactorial and complex, there is a need to guarantee that all who are at risk for parenthood be informed about child development, child health maintenance, and child discipline to minimize the effects that ignorance of these factors may have on their approaches to discipline and their potential for child abuse.