Child Abuse and Neglect: A Diagnostic Guide for Physicians, Surgeons, Pathologists, Dentists, Nurses and Social Workers

273 Pages·2010·22.08 MB·English

by  Vincent J. Palusci

CHILD ABUSE AND
NEGLECT
A DIAGNOSTIC GUIDE
For physicians, surgeons, pathologists,
dentists, nurses and social workers

Vincent J. Palusci, MD, MS
Howard Fischer, MD
MANSON
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CONTENTS
List of contributors...........................................................................vii
Acknowledgments.............................................................................ix
Preface...............................................................................................x
1 Introduction...........................................................................................1
Vincent J. Palusci MD, MS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
The epidemiology of child maltreatment and the role of the physician . . . . . . . . . . . . . .2
Identification of injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Physical abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Sexual abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Psychological maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Medical diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

2 Bruises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Earl Hartwig MD and Howard Fischer MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Dating bruises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
History and physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
iv Contents
3 Abusive burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Lisa Markman MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
How are children burned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
4 Cutaneous conditions mimicking child abuse . . . . . . . . . . . . . . . . . . .69
Dena Nazer MD and Mary Smyth MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Skin conditions mistaken for abusive bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Skin conditions mistaken for burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
5 Imaging child abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Aparna Joshi MD and Thomas L. Slovis MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
Skeletal injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Head injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
Visceral injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
6 Ocular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
John D. Roarty MD, MPH

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123
Orbital trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
7 Otolaryngologic manifestations of abuse and neglect . . . . . . . . . .135
Russell A. Faust PhD, MDand Philip V. Scribano DO, MSCE
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136
Head and scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136
Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
Oropharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Skin of the head and neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
Contents v
8 Recognition of child abuse by dentists, health care professionals,
and law enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
Pamela Wallace Hammel DDS, DABFO
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
Recognizing inflicted injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
Bite marks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Oral manifestations of sexual abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
Dental neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152
Reporting and referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153
9 Abusive abdominal trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155
Colleen M. Fitzpatrick MD and Scott Langenburg MD, FACS, FAAP
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156
Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156
Clinical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160
10 Anogenital findings and child sexual abuse . . . . . . . . . . . . . . . . . .163
Vincent J. Palusci MD, MS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
The medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
Normal variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165
Other medical conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175
Indeterminate findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180
Findings diagnostic of trauma and/or sexual contact . . . . . . . . . . . . . . . . . . . . . . . . . .183
Laboratory evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
11 Child maltreatment fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193
Carl J. Schmidt MD, MPH
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
Sudden infant death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
Fatal neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200
vi Contents
Fatal burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204
Blunt force injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Sharp force injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212
Gunshot wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
12 Failure to thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215
Lynn C. Smitherman MD, FAAP
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217
Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218
Clinical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
Laboratory investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
13 Munchausen syndrome by proxy . . . . . . . . . . . . . . . . . . . . . . . . . . .229
Howard Fischer MD
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230
Incidence and prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230
Victims and perpetrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231
Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231
The harm done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232

Perpetrator motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232
Suspecting MBP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .233
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234
Confirming the diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234
Treatment and re-unification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257
vii
LIST OF CONTRIBUTORS
Russell A. Faust, PhD, MD is an otolaryngolo- Earl R. Hartwig, MD is Associate Professor of
gist at Nationwide Children’s Hospital and a Pediatrics and Emergency Medicine at Wayne
member of the Departments of Otolaryngology – State University School of Medicine and a Child
Head and Neck Surgery and Oral Biology at the Protection Team Physician at Children’s Hospital
Ohio State University College of Dentistry in of Michigan.
Columbus, Ohio. His clinical expertise is in endo-
scopic skull base and sinus surgery, and he has
research interests in the role of microbial biofilm in Aparna Joshi, MD is a staff radiologist at Chil-
chronic diseases of otolaryngology. He is a member dren’s Hospital of Michigan and an Assistant Pro-
in the International Society for Prevention of fessor of Radiology at Wayne State University
Child Abuse and Neglect, the American College of School ofMedicine in Detroit, Michigan. She has
Legal Medicine, the American Society of Law, co-authored an introductory textbook of pediatric
Medicine, and Ethics and has lectured before the radiology for pediatric health care providers.
American Bar Association.
Scott Langenburg, MD, FACS, FAAP is Assis-
Howard Fischer, MD is Professor of Pediatrics at tant Professor of Surgery at Wayne State University
Wayne State University School of Medicine in the and Pediatric Surgeon and Trauma Director for the
Carman and Ann Adams Department of Pediatrics Children’s Hospital of Michigan.
and Division Co-Chief of Ambulatory Pediatrics
and Adolescent Medicine at Children’s Hospital of
Michigan. He was the medical director of the Lisa Markman, MDis Assistant Clinical Professor
Children’s Hospital of Michigan Child Protection of Pediatrics at the University of Michigan Medical
Team for 14 years and is a member of the Ray Helfer School and Co-Medical Director of the Child

Society. Protection Team at the University of Michigan
Medical Center in Ann Arbor, Michigan. She is a
fellow of the American Academy of Pediatrics and
Colleen M. Fitzpatrick, MDwas a pediatric surgery a scholar member of the Ray E. Helfer Society.
fellow at the Children’s Hospital of Michigan.
Dena Nazer, MD is medical director of the Child
Pamela Wallace Hammel, DDS, DABFO is a Protection Center at Children’s Hospital of
Forensic Dental Consultant for the Children’s Hos- Michigan and Assistant Professor of Pediatrics at
pital of Michigan, Detroit, the Macomb County Wayne State University School of Medicine. She is
Medical Examiners Office, Mt. Clemens and the a Fellow of the American Academy of Pediatrics,
Oakland County Medical Examiners Office, a member of the Academic Pediatric Association,
Pontiac, Michigan. She is a Fellow of the American and a scholar member of the Ray E. Helfer Society.
Academy of Forensic Sciences, and a Fellow of the Her current research interests include epidemiology
American College of Dentists, the International of child abuse using the National Child Abuse and
College of Dentists and the Pierre Fauchard Neglect Data System (NCANDS). She attended
Academy.
viii List of contributors
the 2007 Summer Research Institute at Cornell in a program sponsored by the US Department of
University and received the Sarniak Endowment Justice since 1998 that provides assistance for
Fund Award from the Children’s Research Center of forensic issues in Latin America.
Michigan to study seasonal variations in the inci-
dence of child maltreatment using NCANDS.
Philip V. Scribano, DO, MSCE is an Associate
Professor of Clinical Pediatrics and Chief of the
Vincent J. Palusci, MD, MS is Professor of Pedi- Division of Child and Family Advocacy at the
atrics at the New York University School of Medi- Ohio State University College of Medicine. He is
cine and Director of Research at the Frances L. the Medical Director of the Center for Child and
Loeb Child Protection and Development Center at Family Advocacy at Nationwide Children’s
Bellevue Hospital in New York City. He is a Fellow Hospital in Columbus, Ohio.
of the American Academy of Pediatrics, a founding
member of the Ray E. Helfer Society, and a member
of the board of directors of the American Thomas L. Slovis, MD is Professor of Radiology
Professional Society on the Abuse of Children. and Pediatrics at Wayne State University School
With Stephen Lazoritz, MD, he edited The Shaken ofMedicine and former chief of the Department of
Baby Syndrome: A Multidisciplinary Approach, Pediatric Imaging at Children’s Hospital of
published by the Haworth Press in 2002. In 2004, Michigan. He has served as President and Chair-
he received the Ray E. Helfer Award from the man of the Board of the Society of Pediatric Radiol-
National Alliance of Children’s Trust Funds and ogy and is the American editor of Pediatric Radiology
the American Academy of Pediatrics for his work and editor of Caffey’s Pediatric Diagnostic Imaging,
in child abuse prevention. 10th and 11th editions. He trained as a pediatric
resident under the tutelage of Drs Henry Kempe,
Henry Silver, and Ray Helfer.
John D. Roarty, MD, MPHis an Assistant Profes-
sor of Ophthalmology at the Kresge Eye Institute of
Wayne State University and Chief of Ophthalmol- Lynn C. Smitherman, MD, FAAP, is Assistant
ogy at Children’s Hospital of Michigan. Professor of Pediatrics at Wayne State University
School of Medicine in the Carman and Ann
Adams Department of Pediatrics and is Clinical

Carl J. Schmidt, MD, MPH grew up in Latin Chief of the Division of Ambulatory Pediatrics at
America where he graduated from medical school Children’s Hospital of Michigan.
at the Universidad Anahuac. After 2 years of
general surgery training and 2 years of graduate
school in neurobiology, he trained in pathology at Mary E. Smyth, MD is Medical Director of the
the Medical College of Ohio in Toledo, OH, now Child Advocacy and Protection Team at William
the University of Toledo Medical Center. He did Beaumont Hospital in Royal Oak, Michigan and
his fellowship in forensic pathology at the Wayne Clinical Assistant Professor in the Department of
County Medical Examiner’s Office in Detroit, Pediatrics at Wayne State University School of
where he became the chief medical examiner in Medicine. Dr Smyth is a fellow of the American
2003. His main interests are pediatric trauma, Academy of Pediatrics, a member of the State of
forensic toxicology, and the neurobiology of Michigan Department of Human Services Medical
addiction. He is Clinical Assistant Professor in the Advisory Team and the Michigan Chapter of the
Department of Pathology at the Wayne State American Professional Society on the Abuse of
University School of Medicine. He has participated Children (MiPSAC) Board of Directors.
ix
ACKNOWLEDGMENTS
We are very grateful to Children’s Hospital of Michigan, Bellevue Hospital Center, William Beaumont
Hospital, and a number of colleagues forproviding illustrative material. These include ourchapter authors,
as well as Kirk Barber MD, Waldo Nelson Henriquez Barraza MD, Jaenlee F.Carver MD, Martin Finkel DO,
Deepak Kamat MD, PhD, Abu Khan MD, Alexander C. Leung MD, Laura Mankley MD, Margaret
McHugh MD, MPH, Stephen Messner MD, Hisham Nazer MD, Sushma Nuthakki MD, Daniele Pacaud
MD, Tor A. Shwayder MD, and the CHM Medical Photography Unit. Figures are reproduced with permis-
sion of the author and/or publisher
List of Image Contributors
Abu Khan 237. Alexander C. Leung 217-218. Aperna Joshi 251-258, 260-293, 296-315, 317-324.404-413,
508-567. Carl Schmidt 404-413, 508-567. Children’s Hospital of Michigan 22-23, 37, 80-85, 107-108, 110-
116, 119-127, 134-157, 164, 166-188. Daniele Pacaud 219. Deepak Kamat 225. Dena Nazur 190, 192, 248.
Earl Hartwig 1-14, 18-21, 25-34, 38-49, 51-65, 67-79, 86-104, 189, 193, 196, 200-202, 206, 209, 212-215,
222, 226, 240-241. Hisham Nazer 245-247. Howard Fischer 15-16, 35, 117-118, 128-133, 160-163, 197-198,
568, 577. Jaenlee F. Carver 249. John Roarty 325-362. Kirk Barber 236, 238-239. Laura Mankley 210-211.
Lynn Smitherman 569-576. Margaret McHugh 415-416, 432-433, 451-454, 456-458, 465, 479. Mary Smyth
17, 36, 66, 109, 165, 191, 203-205, 207, 216, 242-243, 250, 440, 459-461, 475-476, 502-503. Pamela
Hammel 373-403. Philip Scribano 363-372. Stephen Messner 194-195. Sushma Nuthakki 244. Thomas
Slovis 259, 294-295, 316. Tor A Shwayder 199, 208, 220, 223-224, 227-232, 234-235. Vincent Palusci 24,
50, 105-106, 158-159, 221, 414, 417-431, 434-439, 441-450, 455, 462-464, 466-474, 477-478, 480-501, 504-

507. Waldo Nelson Henriquez Barraza 233.
.