Sinal S H, Lawless M R, Rainey D Y, Everett V D, Runyan D K, Frothingham T, Herman-Giddens M, St Claire K
Department of Pediatrics, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, USA.
Arch Pediatr Adolesc Med. 1997 May;151(5):497-501. doi: 10.1001/archpedi.1997.02170420067011.
To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings.
Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed.
All clinicians involved perform child sexual abuse examinations at tertiary care centers.
A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse.
Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39).
Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.
评估经验丰富的临床医生对儿童性虐待病例体格检查结果解读的一致性，并确定临床病史知识是否会影响对体格检查结果的解读。
经验丰富的临床医生对阴道镜照片按1至5分进行评分，1分为正常，5分为有明确的穿透性损伤证据。为回答临床病史是否影响解读这一额外研究问题，4名临床医生对69例不知患者病史的病例以及70例有患者病史的病例进行评分。然后，另外3名临床医生对同样的病例进行评分，此次有无病史的情况相反。
所有参与的临床医生均在三级医疗中心进行儿童性虐待检查。
共有139名处于坦纳1期或2期生殖器发育阶段的女孩，她们被转介到一所学术医疗中心的普通儿科诊所，以检查是否可能遭受性虐待。
一半的照片被解读为几乎没有或没有虐待证据。在两位读者都能解读的照片组中，39%的解读完全一致，77%的解读相差不超过1个等级。所有可能的读者对之间的完全一致率为34.5%。当患者临床病史未知时，一致性更好（29.3%对38.9%，P = 0.005）。kappa值（一种评估评分者间可靠性的指标）表明临床医生之间的一致性较差。第一组临床医生在不知临床病史时的综合kappa值为0.22，知道临床病史时为0.11。对于第二组临床医生，不知临床病史时的kappa值为0.31，知道临床病史时为0.15。不考虑临床病史，所有7名临床医生的总体kappa值为0.20。第1类（正常，kappa = 0.28）和第5类（有明确的穿透性损伤证据，kappa = 0.39）的一致性最佳。
在评估儿童性虐待方面受过教育且经验丰富的临床医生，对于处于坦纳1期或2期生殖器发育阶段女孩的生殖器检查照片解读，并未完全达成一致。当有患者临床病史时，临床医生之间的一致性更低。应致力于规范体格检查结果，并避免在儿童性虐待病例中过度强调体格检查结果。
