National Institutes of Health National Cancer Institute, the
American Cancer Society Mentored Research Scholar Grant in
Applied and Clinical Research, and the University of Wisconsin
Institute for Clinical and Translational Research through the
National Center for Advancing Translational Sciences.
Medical Mimics of Child Abuse
It’s common knowledge throughout
the medical community that physicians
have an ethical and legal mandate to identify abused children and to think broadly
about differential diagnoses. The medical
literature is replete with examples of medical diseases that mimic abuse, potentially
leading to misdiagnoses and subsequent
harm to children and families.
The authors of this review highlight
some of the common and uncommon
diseases that may present similar to physical and sexual abuse of
children. For example, accidental bruising is nearly universal in active ambulatory children but notably rare in preambulatory infants.
Children, especially infants, with severe bleeding disorders have
more and larger bruises than do healthy children. Patterns and location of bruises can help to identify inflicted bruises; however, it is
not always possible to distinguish child abuse from congenital
bleeding disorders solely on clinical grounds.
Similarly, subdural hemorrhage is a hallmark of trauma in all age
groups and for decades has been identified as a hallmark of abusive
head trauma. The list of medical conditions associated with subdural
hemorrhage in infants and young children is extensive and includes
hematologic and oncologic disease, metabolic and genetic diseases,
congenital malformations, autoimmune diseases, vasculitis, poisoning, iatrogenic complications, and birth and accidental trauma.
There is overwhelming evidence that child abuse is common,
and even those children with underlying diseases are not immune to
abuse. Differentiating conditions requires an awareness of alternative diseases and a willingness to consider alternative diagnoses, a
recognition of social biases that affect medical decision making, an
objective and rational approach to medical evaluation, and an understanding of injury epidemiology, mechanisms, and consequences.
There are often epidemiologic, clinical, laboratory, and radiographic
clues to these diagnoses, and their recognition requires attention to
detail and a collaborative consultative approach to medical care.
AJR in Brief continued from p. 20
Lung Cancers Manifesting as
Part-Solid Nodules in the
National Lung Screening Trial
A team of researchers charged with
reviewing lung cancers that appear as
part-solid nodules recommended a conservative approach in the management
and treatment of these patients especially when the solid component is small.
To an extent, guidelines published
by the International Early Lung and
Cardiac Action Program and the Lung
CT Screening Reporting and Data
System recommend focusing on the size of the solid component in
the part-solid nodule instead of on the overall nodule size. The critical issue going forward will be further refinements for the follow-up of part-solid nodules based on the size or volume of the solid
component that allow a process of shared decision making in management and treatment.
The research was based on a review of data collected in the
National Lung Screening Trial (NLST), a National Cancer
Institute study. Of the 26,722 participants who were randomly
assigned to the C T screening arm of the NLS T, 985 ( 3.7%) were
found to have at least one mixed nodule identified on a screening
C T study.
AJR study authors reviewed the NLST data to determine
how often death occurred from lung cancers that manifested as
part-solid nodules. All lung cancers classified as mixed nodules
by NLST radiologists were reviewed by four experienced radiologists and reclassified as solid, nonsolid, or part-solid nodules. When possible, volume doubling times were calculated
separately for the entire nodule and for the solid component of
None of the patients with lung cancer manifesting as a solitary or dominant part-solid nodule had lymph node enlargement
or metastases at pathology, and none died of lung cancer within
the follow-up time of the NLS T.n
Cindy W. Christian
The medical literature is replete with examples of medical diseases that mimic abuse, potentially
leading to misdiagnoses and subsequent harm to children and families.—Cindy W. Christian
AJR study authors reviewed the NLST data
to determine how often death occurred from
lung cancers that manifested as part-solid