[Analysis of clinical forensic examination reports on sexually abused children]

Clinical forensic examinations of children suspected of having been sexually abused are increasingly part of the routine of medicolegal institutes. The findings collected from 2005 until 2007 at the Institute of Legal Medicine of the Hanover Medical School were analysed retrospectively. Altogether, 91 children (74 females, 17 males, mean age 8.7 years) were examined. In 87.9% of the cases, the examination had been ordered by the police. In 73.6%, the victim knew the suspected perpetrator well or he was a family member. 40.7% of the children were seen within 72 hours after the alleged abuse. 12.1% of the children had extragenital lesions. In 27% of the victims, marked anogenital injuries were found, which were characteristic of sexual abuse in 9%. In 18 cases (20.2%), swabs were taken for spermatozoa detection. 3 of 17 vaginal smears showed positive test results for sperm up to 21 hours after the incident. No spermatozoa could be detected in 4 anal and 2 oral swabs as well as in one swab taken from the skin of the victim's thigh. In summary, the evaluation shows that early clinical forensic examination of children suspected of having been sexually abused is crucial to document evidence that is highly significant for the investigation and court proceedings. Often suspected sexual child abuse cannot be proved by medical findings alone. Of course, the absence of anogenital injuries does nor rule out sexual abuse.

Analysis of clinical forensic examination reports on sexual assault

Medical-forensic examination of sexual assault victims and alleged offenders is a common task of many forensic institutes. In the current study, the results from samples taken at the Institute of Legal Medicine, Hanover Medical School, during a period from 2005 to 2007 were retrospectively evaluated. In total, 292 victims (283 females and nine males) and 88 suspects were examined. At the time of the assault, 41.8% of the victims and 43.2% of the alleged perpetrators were under the influence of alcohol. Injuries were found in 84.9% of the victims and 39.8% of the suspects. Thirty victims (10.3%) reported having been choked or strangled. Cytology was performed in 218 victims. In 81 cases (38.0%), sperm could be detected in vaginal swabs up to 3 days post-assault. In seven (18.9%) out of 37 anal samples, evidence of sperm could be found 24 h post-assault. None of 22 oral samples was positive for sperm. Out of 301 sexual assault cases, 171 could be proved by means of medical-forensic examination. In summary, our evaluation shows that an early medical-forensic examination of both victim and suspect can secure numerous medical findings. Furthermore, persons intoxicated by alcohol, handicapped persons and persons with psychiatric disorders are more vulnerable to become a sexual assault victim.

Eculizumab in atypical hemolytic uremic syndrome: long-term clinical course and histological findings

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy associated with defective regulation of the alternative complement pathway. The prognosis for patients with aHUS is poor, and plasma exchange represents the first-line therapy. Eculizumab is a humanized monoclonal anti-C5 antibody that prevents the activation of the terminal complement pathway. Here, we report the case of a 9-year-old girl with frequent relapsing aHUS due to heterozygous factor H mutation who was initially treated with plasma exchange three times per week with 150% plasma exchange volume. This treatment frequently caused allergic reactions and school absences. Because any reduction in the frequency of plasma exchange immediately induced relapses of the aHUS, treatment with eculizumab, 600 mg every 2 weeks, was started and plasma exchange completely stopped. On this drug regimen the patient showed no evidence of disease activity during a period of more than 24 months. Renal function improved, proteinuria disappeared, the number of antihypertensive medications could be decreased, and the quality of life increased substantially. The inhibition of the terminal complement pathway by eculizumab was also confirmed by renal biopsy, which showed the absence of thrombotic microangiopathy 2 months after the initiation of eculizumab therapy. This case illustrates the long-term favorable outcome of aHUS with eculizumab treatment.

Clinical aspects, diagnostic challenges and management of patients with neuroendocrine tumors (NETs)

Neuroendocrine tumor (NET) entities are rare malignancies. Higher awareness and improved diagnostic methods have led to an increasing incidence of these diseases, and most oncologists deal with such patients in their daily practice. The symposium on NETs that was held in Merano (Italy) in October 2009 was organized by the German-speaking European School of Oncology (dESO) and gathered specialists from different disciplines of transalpine countries to bring together experiences and observations regarding these tumors. The goal of the meeting and of this review was to illustrate both well- and poorly differentiated NETs and to encourage interdisciplinary approaches.

Long-term course of lung clearance index between infancy and school-age in cystic fibrosis subjects

Multiple breath washout (MBW) measurements have recently been shown to be sensitive for detection of early cystic fibrosis (CF) lung disease, with the lung clearance index (LCI) being the most common measure for ventilation inhomogeneity. The aim of this observational study was to describe the longitudinal course of LCI from time of clinical diagnosis during infancy to school-age in eleven children with CF. Elevated LCI during infancy was present in seven subjects, especially in those with later clinical diagnosis. Tracking of LCI at follow-up was evident only in the four most severe cases. We provide the first longitudinal data describing the long-term course of LCI in a small group of infants with CF. Our findings support the clinical usefulness of MBW measurements to detect and monitor early lung disease in children with CF already present shortly after clinical diagnosis.

Clinical performance of wide-body implants with a sandblasted and acid-etched (SLA) surface: results of a 3-year follow-up study in a referral clinic

PURPOSE: The aim of this study was to evaluate the 3-year success rates of wide-body implants with a regular- or wide-neck configuration and a sandblasted, large grit, acid-etched (SLA) surface. MATERIALS AND METHODS: A total of 151 implants were consecutively placed in posterior sites of 116 partially edentulous patients in a referral clinic at the School of Dental Medicine, University of Bern. All implants were restored with cemented crowns or fixed partial dentures after a healing period of 6 to 8 weeks (for implants placed without simultaneous bone augmentation) or 10 to 14 weeks (for implants with simultaneous bone augmentation). All patients were recalled 36 months following implant placement for a clinical and radiographic examination. RESULTS: One implant failed to integrate during healing, and 11 implants were lost to follow-up and considered dropouts. The remaining 139 implants showed favorable clinical and radiographic findings and were considered successfully integrated at the 3-year examination. This resulted in a 3-year success rate of 99.3%. Radiographic evaluation of 134 implants indicated stability of the crestal bone levels: During the study period, the crestal bone level changed less than 0.5 mm for 129 implants. CONCLUSION: Successful tissue integration was achieved with wide-body implants with a regular or a wide-neck configuration and an SLA surface with high predictability. This successful tissue integration was well maintained for up to 3 years of follow-up.

Short-term effects of hygiene education for preschool (kindergarten) children: a clinical study

AIM: To evaluate the outcomes of short (15 minutes) oral hygiene vs. hand hygiene education for preschool children 4 weeks after these interventions. MATERIALS AND METHODS: Sixty-one preschool children (age range 4-6 years) attending four kindergarten classes participated in a 15-minute health education programme on the importance of body cleanliness for general health. In addition, specific instructions on oral hygiene were provided for two randomly selected classes (30 children), while the remaining two classes (31 children) were given instruction of hand and nail cleaning. The oral hygiene status was assessed usingthe plaque control record (PCR). The cleanliness of the hands and fingernails was determined using a hand hygiene index (HHI) and a nail hygiene index (NHI). All three parameters were assessed before the intervention as well as 4 weeks thereafter. RESULTS: Four weeks after education, the PCR had improved for all children from 79.95% to 72.35% (p < 0.001). The NHI had improved from 74.91% to 61.71% (p < 0.001). In addition, the mean PCR of the children given oral hygiene instruction decreased from 83.67% to 72.40%, while the mean PCR of the children given hand and nail cleaning instruction decreased from 76.23% to 72.29% (interaction effect 'time x type of instruction': p = 0.044). Girls' PCR improved significantly more than boys' PCR (Girls, 80.98 vs. 69.71; boys, 78.33 vs. 75.31; p = 0.021). CONCLUSIONS: The results of the study show that even a short, school-based educational intervention at an early age may affect children's oral health promotion significantly. Teachers should, therefore, be encouraged to educate children from an early age about oral hygiene promotion.

Effect of bacterial filter on measurement of interrupter resistance in preschool and school-aged children

BACKGROUND: The interrupter technique is increasingly used in preschool children to assess airway resistance (Rint). Use of a bacterial filter is essential for prevention of cross-infection in a clinical setting. It is not known how large an effect this extra resistance and compliance exert upon interrupter measurements, especially on obstructive airways and in smaller children. We aim to determine the contribution of the filter to Rint, in a sample of children attending lung function testing at an asthma clinic. METHODS: Interrupter measurements were performed according to ATS/ERS guidelines during quiet normal breathing at an expiratory flow trigger of 200 ml s(-1), with the child seated upright with cheeks supported and wearing a nose clip. A minimum of 10 interrupter measurements was made with and without a bacterial filter. Spirometric and plethysmographic tests were also performed. RESULTS: A small but significant difference (0.12 (95% CI 0.06-0.17) kPa s L(-1), P = 0.0002) with 2x SD of 0.34 kPa s L(-1) was observed between Rint with and without filter in 39 children, with a large spread. This difference was not dependent on Rint magnitude, age or height, nor on lung function parameters (effective resistance, forced expiratory volume in 1 sec, and maximal expiratory flow at 50% of expired vital capacity). CONCLUSIONS: A bacterial filter causes a small difference but is not clinically significant, with a wide spread comparable to the variability of the technique and recommended cut-offs for assessing repeatability and bronchodilation. Age, height or severity of obstruction need not be corrected for in general.

Clinical presentation of celiac disease and the diagnostic accuracy of serologic markers in children

There has been growing recognition of a changing clinical presentation of celiac disease (CD), with the manifestation of milder symptoms. Serologic testing is widely used to screen patients with suspected CD and populations at risk. The aim of this retrospective analysis was to evaluate the clinical presentation of CD in childhood, assess the diagnostic value of serologic tests, and investigate the impact of IgA deficiency on diagnostic accuracy. We evaluated 206 consecutive children with suspected CD on the basis of clinical symptoms and positive serology results. Ninety-four (46%) had biopsy-proven CD. The median age at diagnosis of CD was 6.8 years; 15% of the children were <2 years of age. There was a higher incidence of CD in girls (p = 0.003). Iron deficiency and intestinal complaints were more frequent in children with CD than those without CD (61% vs. 33%, p = 0.0001 and 71% vs. 55%, p = 0.02, respectively), while failure to thrive was less common (35% vs. 53%, p = 0.02). The sensitivity of IgA tissue transglutaminase (IgA-tTG) was 0.98 when including all children and 1.00 after excluding children with selective IgA deficiency. The specificity of IgA-tTG was 0.73 using the recommended cut-off value of 20 IU, and this improved to 0.94 when using a higher cut-off value of 100 IU. All children with CD and relative IgA deficiency (IgA levels that are measurable but below the age reference [n = 8]) had elevated IgA-tTG. In conclusion, CD is frequently diagnosed in school-age children with relatively mild symptoms. The absence of intestinal symptoms does not preclude the diagnosis of CD; many children with CD do not report intestinal symptoms. While the sensitivity of IgA-tTG is excellent, its specificity is insufficient for the diagnostic confirmation of a disease requiring life-long dietary restrictions. Children with negative IgA-tTG and decreased but measurable IgA values are unlikely to have CD.

Cluster randomized clinical trials in orthodontics: design, analysis and reporting issues

Cluster randomized trials (CRTs) use as the unit of randomization clusters, which are usually defined as a collection of individuals sharing some common characteristics. Common examples of clusters include entire dental practices, hospitals, schools, school classes, villages, and towns. Additionally, several measurements (repeated measurements) taken on the same individual at different time points are also considered to be clusters. In dentistry, CRTs are applicable as patients may be treated as clusters containing several individual teeth. CRTs require certain methodological procedures during sample calculation, randomization, data analysis, and reporting, which are often ignored in dental research publications. In general, due to similarity of the observations within clusters, each individual within a cluster provides less information compared with an individual in a non-clustered trial. Therefore, clustered designs require larger sample sizes compared with non-clustered randomized designs, and special statistical analyses that account for the fact that observations within clusters are correlated. It is the purpose of this article to highlight with relevant examples the important methodological characteristics of cluster randomized designs as they may be applied in orthodontics and to explain the problems that may arise if clustered observations are erroneously treated and analysed as independent (non-clustered).

The implementation of a tobacco dependence education curriculum in a Swiss Dental Hygiene School - an 8-year review

OBJECTIVE The aim of our investigation was to review the implementation of a comprehensive tobacco dependence education (TDE) curriculum at the Medi School of Dental Hygiene (MSDH), Bern, Switzerland, 2001-2008. METHODS In 2001, new forms to record patients' tobacco use history and willingness to quit were created for all the MSDH patients. In 2002, a new theoretically based tobacco dependence treatment protocol was implemented into the MSDH curriculum. Students received instruction on how to provide brief tobacco use dependence interventions as well as maintain detailed records of patient tobacco use and cessation interventions for every smoker at all dental hygiene visits. RESULTS In 2002, 17 lecture hours were added to the following subjects: pathology, periodontology, preventive dentistry, pharmacology and psychology. During the same time period, 2213 patients (56.9% women) have visited the MSDH. Smoking status was recorded in 85.7% of all the patients (30.2% smokers). Brief tobacco use interventions were recorded in 36.8% of all smokers while 7.6% of these have reported to quit smoking. CONCLUSIONS Overall, the new TDE curriculum was successfully implemented and accepted by the MSDH faculty. Applications in the clinical practice, however, may still be improved to better identify smokers and increase initial and follow-up interventions potentially leading to higher quit rates.

Dental knowledge and attitude toward school dental-health programs among parents of kindergarten children in Winterthur.

The current study investigated the attitudes and knowledge regarding diet and oral hygiene of parents with kindergarten children. The parents' statements were evaluated in terms of their socioeconomic background and were compared with the annual clinical examination of the children. The objective of the study was to assess the effectiveness of the school dental-health program and adapt it to today's societal needs. Of those who participated in the interview, 61% were Swiss, 16% were from former Yugoslavia or Turkey, and 12% each from the EU or other countries. Of the children examined, 39% already had caries, and 18% of those showed more than two lesions. The parents' knowledge correlated with the severity of the child's caries as well as with the parents' income, country of origin, and education. There was a correlation between the child's dental decay and lower income, as well as lower education and non-Swiss nationality of the parents. Parents with higher income and better education more often participated in the preschool's preventive program. Parents from former Yugoslavia or Turkey participated less frequently than parents from other countries. The study demonstrated that parents who especially needed instruction and prophylaxis are contacted too late or not at all through the dental-health program at kindergarten and that new approaches to prevention should be implemented to more effectively reach the parents.

Cortical thickness decreases with age in very preterm born school-children but not in term born controls

Background: Cortical gray matter thinning occurs during childhood due to pruning of inefficient synaptic connections and an increase in myelination. Preterms show alterations in brain structure, with prolonged maturation of the frontal lobes, smaller cortical volumes and reduced white matter volume. These findings give rise to the question if there is a differential influence of age on cortical thinning in preterms compared to controls. Aims: To investigate the relationship between age and cortical thickness in preterms when compared to controls. Study design and outcome measures: The automated surface reconstruction software FreeSurfer was applied to obtain measurements of cortical thickness based on T1-weighted MRI images. Subjects: Forty-one preterms (< 32 weeks gestational age and/or < 1500 gram birth weight) and 30 controls were included in the study (7-12 years). Results: Cortical thickness was lower in bilateral frontal and left parietal regions and higher in left temporal gyri in preterms compared to controls. However, these differences depended on age. In preterms, age correlated negatively with cortical thickness in right frontal, parietal and inferior temporal regions. Accordingly, cortical thickness was higher in young compared to old preterms in bilateral frontal, parietal and temporal regions. In controls, age was not associated with cortical thickness. Conclusion: In preterms, cortical thinning still seems to occur between the age of 7 and 12 years, mainly in frontal and parietal areas whereas in controls, a substantial part of cortical thinning appears to be completed before they reach the age of 7 years. These data indicate slower cortical thinning in preterms than in controls.

Oral Health Education Program on Dental Caries Incidence for School Children.

OBJECTIVE This 3-year retrospective controlled clinical trial assessed the effect of a school-based oral health education program on caries incidence in children. STUDY DESIGN A total of 240 students, aged 5 to 7 years, from two public schools in Monte Sião, Brazil, were included in this study. A school-based oral health education program was developed in one of the schools (experimental group), including 120 students, while the 120 students from the other school did not participate in the program (control group). All children were initially examined for dental caries (dmf-t), and after 3 years, 98 children from the experimental group and 96 from the control group were again examined and answered a questionnaire on oral health issues. The between-groups difference in caries incidence on permanent teeth was calculated using Poisson regression analyses. Logistic regression was used to observe the association between caries incidence and other variables. RESULTS More students from the experimental group stated knowing what was dental caries and declared that they use dental floss daily, but no significant differences in caries incidence was observed between the experimental and control groups. CONCLUSION The school-based oral health education program is not adequately efficient to decrease caries incidence after three years, but some issues about oral health knowledge could be slightly improved.