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Background: The clinical presentation of neuroblastoma can widely vary but can include orthopaedic related complaints. Case details: We present two cases of neuroblastoma diagnosis after an initial presentation of an orthopaedic complaint of limp and hip pain. Both cases varied on laboratory markers and warning symptoms, leading to delays in final diagnosis. Conclusion: These cases demonstrate the importance of orthopaedic surgeons including neuroblastoma in the differential diagnosis of hip pain and limp.

Background: Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. Methods: We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children's Hospital over a 2-year period. We divided the cohort into three groups based on the patient's age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. Results: We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. Conclusions: Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions. [ABSTRACT FROM AUTHOR]

Hip pain in a child can pose a diagnostic conundrum. In most cases, the cause of a painful hip is often attributed to trauma, but a number of these cases will be atraumatic. The main entities to consider are inflammatory, infective and neoplastic causes. Pathologies such as avascular necrosis and slipped upper femoral epiphysis can also present in a similar manner. A detailed history and clinical examination are crucial in narrowing down the differential diagnosis. In addition, understanding the most appropriate imaging modalities and the characteristic radiological findings is key in ensuring timely treatment and management. This article reviews the various disease processes in children who present with hip pain and outlines the most appropriate assessment and imaging modalities that will aid diagnosis. [ABSTRACT FROM AUTHOR]

Background: Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. Methods: We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children’s Hospital over a 2-year period. We divided the cohort into three groups based on the patient’s age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. Results: We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. Conclusions: Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions.

Scurvy results from a deficiency of ascorbic acid. This disease first appeared in children during the 19th century with the emergence of new dietary habits; in particular, heating milk that leads to a loss of ascorbic acid. Even though scurvy has become a rare condition in western countries, many cases are still reported in pediatric patients, especially in those who lack proper nutrition due to neurological or psychiatric illnesses. Symptoms include bleeding and swollen gums, loosening of teeth, bone abnormalities, arthralgia, delayed wound healing, anemia, petechiae, and purpura. Bone lesions are mainly irregularities of long bones metaphyses. We report the case of a five-yearold boy who presented with arthralgia and limb deformation (genu valgum). The patient was investigated for vitamin deficiencies to exclude rickets. The radiologic investigations revealed metaphyseal signs compatible with scurvy. During the hospitalization, the patient was observed to have abnormal eating patterns and the scurvy was attributed to malnutrition. Although the occurrence of scurvy is rare, it remains essential to detect this disease in children at risk of developing vitamin deficiencies. Without targeted treatment, the complications of scurvy can be serious and potentially fatal. [ABSTRACT FROM AUTHOR]

Objectives: Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. Methods: Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. Results: The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. Conclusion: In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy. [ABSTRACT FROM AUTHOR]

Copyright of Health Bulletin / Zdravstveni Glasnik is the property of Faculty of Health Studies, University of Mostar and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Children presenting with joint pain are not uncommon - approximately 5% of all paediatric emergency department encounters are due to atraumatic childhood limp. The majority of these cases are benign and self-limiting; however, a thorough history, examination and selection of appropriate investigations are required in order to exclude rare, serious, and life-threatening underlying pathological conditions. This review article proposes a structured approach to the limping child, risk stratifies disease based on age, radiological and laboratory findings, and provides a standardized algorithm to expedite diagnosis and ensure safe clinical management. [ABSTRACT FROM AUTHOR]

Background: Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs.Objectives: We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion.Methods: This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds.Results: We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82).Conclusions: We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities. [ABSTRACT FROM AUTHOR]

In the Roman world, at the end of the Republic and the beginning of Empire, the fact of limping or wobbling while walking is described as a physical defect, like stuttering, which is referred to with the same words. Latin terms for lameness are used also for a defect of reasoning or speech. By and large, lameness of the legs or of the tongue reveals a lack of self-control. Even if lameness is due to a war wound, it is most of the time concealed by those who suffer from it, because it is considered contrary to the beauty of honourable citizens and therefore subject to mockery. However, lameness can also be treated as a sign of courage and thus be valorized. In both cases, speech allows it, in a way, to be part of the city.

The limping child is a common presentation to paediatric services. In most instances the cause is benign with few, if any, investigations required. There is, however, always that concern that the limping child may have an underlying limb-threatening or life-threatening disease. This poses a challenge to clinicians, who must find that balance between correctly identifying disease early and avoiding the risks and harms of overinvestigation. In this article we discuss the diagnostic approach to the limping child and present a structure for assessment, investigation and risk management. [ABSTRACT FROM AUTHOR]

Unilateral offloading footwear prescribed to patients with diabetic foot ulcers elevates one limb relative to the other, which may lead to limp and abnormal gait. This study investigated whether the unilateral foot ulcer and offloading combination negatively impacts gait function beyond diabetic peripheral neuropathy. Eighty-six participants were recruited in 3 groups: 12 with diabetic peripheral neuropathy and unilateral foot ulcers wearing offloading footwear (offloading group, age = 55.6 ± 9.5 years, BMI = 30.9 ± 4.5 kg/m2), 27 with diabetic peripheral neuropathy (neuropathy group, age = 64.3 ± 7.7 years, BMI = 30.9 ± 5.4 kg/m2), and 47 non-diabetic controls (non-diabetic group, age = 62.9 ± 16.1 years, BMI = 29.0 ± 6.0 kg/m2). Gait function was quantified during a habitual speed walking test using a validated wearable platform. The offloading group exhibited deteriorated gait function compared to the non-diabetic group (p < 0.005, Cohen's effect size d = 0.90–2.61). They also had decreased gait speed (p < 0.001, d = 1.79) and stride length (p < 0.001, d = 1.76), as well as increased gait cycle time (p < 0.001, d = 1.67) and limp (p < 0.050, d = 0.72–1.49) compared to the neuropathy group. The offloading group showed increased gait unsteadiness compared to the neuropathy group, but the difference did not reach statistical significance in our samples. This study demonstrated that while diabetic peripheral neuropathy deteriorates gait function, including increasing gait unsteadiness and limp, the diabetic foot ulcer and offloading combination magnifies the deterioration beyond diabetic peripheral neuropathy. These findings promote caution of the current standards of care for treating diabetic foot ulcers with offloading footwear. However, it is possible that a contralateral shoe lift may remedy deteriorated gait function and improve quality of life for unilateral offloading users. • Unilateral foot ulcers and offloading footwear deteriorate gait beyond neuropathy. • Unilateral foot ulcers and offloading footwear deteriorate gait speed and symmetry. • A contralateral shoe lift may improve gait in unilateral offloading users. [ABSTRACT FROM AUTHOR]

Copyright of Rigakuryoho Kagaku is the property of International Press Editing Center Incorporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This report describes a case of hind limb lameness associated with intra-abdominal torsion of a neoplastic testicle in a dog. An 11-year-old, male, bilaterally cryptorchid dog was referred for third degree lameness in the left hind limb. An orthopaedic and radiographic examination did not reveal any alteration in the limb, whereas transabdominal palpation and ultrasonography showed the presence of retained gonads. The surgical procedure revealed a left testicular torsion adherent to the viscera and peritoneum in the ventral-caudal part of the abdomen. A few days after a bilateral orchiectomy, the lameness was completely resolved. Histopathological investigations allowed diagnosis of intestitial (Sertoli) cell tumours in both testicles. One of the two testes was twisted. Sertolioma often affects undescended testicles and causes additional clinical changes, due to estrogenic steroidogenesis. The hyper-oestrogenism is characterised by alopecia, feminisation, prostatic alteration and haematological disorders. However, in this case these clinical signs were not present. The aim of this case report is to highlight the correlation of the disease and the onset of limp, which is similar to what has been reported in human medicine in patients affected by meralgia paresthetica.

Highlights • The irrigation requirements estimated by LIMP were higher than those by WUCOLS. • WUCOLS was considered to potentially underestimate water requirement in warm months. • Irrigation managers have not accounted rainfall events in irrigation scheduling. • The LIMP method provides more accurate estimations than the WUCOLS method. Abstract Creation and conservation of urban parks is challenging in arid environments where daily thermal extremes, water scarcity, air pollution and shortage of natural green spaces are more conspicuous. Water scarcity in the arid regions of Iran is major challenge for water managers. Accurate estimation of urban landscape evapotranspiration is therefore critically important for cities located in naturally dry environments, to appropriately manage irrigation practices. This study investigated two factor-based approaches, Water Use Classifications of Landscape Species (WUCOLS) and Landscape Irrigation Management Program (LIMP), to measure the water demand of two heterogeneous urban landscapes: a botanic garden and a sparse forest park. The irrigation water volume applied was compared with the gross water demand for the period from 2011 to 2013. In this research, WUCOLS estimated the annual water requirement of a botanic garden and a sparse forest park to be 5% and 44% lower, respectively, than LIMP. Comparison of estimated and applied irrigation showed that water savings can be made by the LIMP method. The outcomes of this research stressed the need to modify the irrigation requirements based on effective rainfall throughout the year, rather relying on long-term average data. [ABSTRACT FROM AUTHOR]

Pyomyositis (PM) is an uncommon primary skeletal muscle infection caused mainly by Staphylococcus aureus that is characterized by single or multiple intramuscular abscess formation. In our ward, between 2013 and 2015, three children (two females and one male) aged from 2 to 12 years were diagnosed and treated for PM. Patients' medical records and imaging studies were examined retrospectively. All patients, otherwise healthy, complained of limp, fever, and severe lower limb pain. Skin scratch lesions were detected in two cases; one of them showed an edematous appearance of the affected area. Multifocal bilateral abscesses of gemini and gastrocnemius were detected in the youngest patient; right obturator and iliac muscles were affected in the second patient; and right gluteus and pyriform muscles were involved in the third patient. All patients showed elevated acute phase reactants and had normal serum creatinine kinase levels. Blood cultures and polymerase chain reaction (PCR) investigations were negative in all cases. Magnetic resonance imaging (MRI) findings included muscle enlargement, deep fascia, high signal in subcutaneous tissues, and postgadolinium abscess formation. No patient required surgical or percutaneous drainage. All three were treated conservatively with intravenous oxacillin, associated with ceftriaxone in the first patient and ceftazidime in the other two, followed by oral antibiotic therapy for a period ranging from 5 to 6 weeks. Pyomyositis must be considered as an unusual cause of limp in children of all ages. When promptly diagnosed and adequately treated, it has a favorable outcome without relapses or sequelae as occurred in all our patients. [ABSTRACT FROM AUTHOR]

Determination of the hematological profile quail is a necessity because this species is characterized by an intense metabolism. Any nutritional imbalance is reflected on metabolism influencing their health and production. Research has shown that the hemoleucogram is different depending on age and gender. Thus, the red grouts had an increase of 0.77x106 mm³ in quail chicks of one day, reaching 21 days at 1.72 x 106 mm³. In adults, the variation limits were between 4.22 x 106 mm³ in males and 3.31 x 106 mm³ in females. The same evolution occurred in white blood cells, which were 1 day of 10.2 thousand mm3, reaching 21 days at 16.3 thousand mm³. In adults, they were between 24.5 thousand mm3 in males and 26 thousand mm³ in females. Changes related to age and sex also recorded the amount of hemoglobin and hematocrit. Leukocyte values, excluding eosinophils, were 0.8% for the two sexes. Lymphocytes, 26% in males and 25% in females, and neutrophils were 70.8% in males and 70.5% in females. Hematological research has shown that quail blood has a high oxygenation capacity and remarkable lymphocyte character. [ABSTRACT FROM AUTHOR]

Numerical rating scales are frequently used in gait scoring systems as indicators of lameness in dairy animals. The gait scoring systems commonly used in dairy goats are based on 4-point scales that focus on detecting and judging the severity of a definite limp. An uneven gait, such as a shortened stride or not “tracking up,” is arguably the precursor to the development of a limp; thus, identifying such changes in gait could provide opportunity for early treatment. The objectives of this study were (1) to develop a 5-point gait scoring system that included an “uneven gait” category and compare the distribution of gait scores generated using this system to scores generated using a 4-point system, and (2) to determine whether this system could be reliably used. Forty-eight Saanen cross 2- and 3-yr-old lactating does were enrolled from a commercial dairy goat farm. Two observers carried out weekly live gait scoring sessions for 7 wk using the developed 5-point scoring system. The first 2 wk were used as training sessions (training sessions 1–2), with the subsequent 5 wk completed as gait assessments (assessments 1–5). In addition to training session 1 being lived scored, the goats were also videorecorded. This allowed observer 1 to re-score the session 4 times: twice using the developed 5-point system and twice using the previously used 4-point system. Comparisons of score distributions could then be made. Using the 4-point system, 81% of the goats were assigned score 1 (normal gait). Using the 5-point system, only 36% of the goats were assigned score 1 (normal gait), with 50% assigned score 2 (uneven gait). High levels of intra-observer reliability were achieved by observer 1 using both gait scoring systems [weighted kappa (κw) = 1.00: 4-point, κw = 0.96: 5-point]. At training session 1 (wk 1), inter-observer reliability was only moderate (κw = 0.54), but this was improved during the subsequent training session 2 (κw = 0.89). Inter-observer reliability was high among assessments 1 to 5 (κw = 0.90–1.00). During the training sessions, sensitivity for gait scores 1 and 2 was 77 and 65% (training session 1) and 89 and 94% (training session 2), respectively. Sensitivity was high among assessments 1 to 5 (score 1: 83–100%, score 2: 97–100%). This highlights the likely reason why existing gait scoring systems for dairy goats do not include an “uneven gait” category, as distinguishing it from a normal gait was challenging without training. In conclusion, with training, a 5-point gait scoring system could be reliably used. The 5-point system was found to be more sensitive than the 4-point system, allowing for a potential precursor to lameness to be identified. Further work is needed to determine whether the score can be reliably used in an on-farm setting. [ABSTRACT FROM AUTHOR]

Limb ischemia reperfusion (I/R) injury is associated with serious local and systemic effects. Reperfusion may augment tissue injury in excess of that produced by ischemia alone. The hippocampus has been reported to be vulnerable to I/R injury. Alpha lipoic acid (ALA) is an endogenous antioxidant with a powerful antioxidative, anti-inflammatory, and antiapoptotic properties. We studied the probable restorative effect of ALA on limb I/R-induced structural damage of rat hippocampus. Forty adult male albino rats were divided equally into four groups: group I (sham); group II (I/R-1 day) has undergone bilateral femoral arteries occlusion (3 h), then reperfusion for 1 day; group III (I/R-7 days) has undergone reperfusion for seven days; group IV (I/R-ALA) has undergone I/R as group III and received an intraperitoneal injection of ALA (100 mg/kg) for 7 days. I/R groups revealed degenerative changes in the pyramidal neuronal perikarya of CA3 field in the form of dark-stained cytoplasm, dilated RER cisternae, mitochondrial alterations, and dense bodies’ accumulation. Their dendrites showed disorganized microtubules. Astrogliosis is featured by an increased number and increased immunoreactivity of astrocytes for glial fibrillary acid protein. Morphometric data revealed significant reduction of light neurons, surface area of neurons, and thickness of the CA3 layer. Most blood capillaries exhibited narrow lumen and irregular basal lamina. ALA ameliorated the neuronal damage. Pyramidal neurons revealed preservation of normal structure. Significant increase in the thickness of pyramidal layer in CA3 field and surface area and number of light neurons was observed but astrogliosis persisted. Limb I/R had a deleterious remote effect on the hippocampus aggravated with longer period of reperfusion. This work may encourage the use of ALA in the critical clinical settings with I/R injury. [ABSTRACT FROM PUBLISHER]

Copyright of Revista Española de Cirugía Ortopédica y Traumatologia (English Edition) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The child with joint pain is a common presenting complaint in the acute setting. It has a variety of causes from the benign to the life-threatening which can be difficult to tease apart. In this article, we give an overview of some of the more common and concerning causes. We also provide a structured approach to history, examination and investigation for the clinician faced with the undifferentiated atraumatic joint pain in children of different ages. [ABSTRACT FROM AUTHOR]

Acute limp in a child presents a diagnostic conundrum and can result from a variety of causes. The underlying etiology is often referable to the hip, but the spine, abdomen, pelvis, or knee can be alternatively implicated. An adequate clinical history and satisfactory physical examination are often difficult in younger children. Consequently, there is disproportionate reliance on imaging to arrive at the correct diagnosis. The potential for rapid clinical deterioration and long-term sequelae is a risk with some of the conditions presenting with acute hip (septic hip, osteomyelitis). This review article describes the imaging appearance of common etiologies for acute limp in the ambulatory preschool (1-5 years) and school-age child (5-12 years). The ultimate goal is to familiarize the interpreting radiologist with the imaging appearance of specific clinical entities that lead to acute limp while providing a readily accessible resource on how to image the patient most appropriately and judiciously. [ABSTRACT FROM AUTHOR]

Children with musculoskeletal symptoms are commonly seen by general practitioners (GPs). Those that present with atraumatic limp pose a particular diagnostic challenge. Although uncommon, Perthes disease (PD) is an important cause of atraumatic limp in children and may result in debilitating consequences if missed. We put forward a case of delayed diagnosis of PD in a child, thus highlighting the need for a greater index of suspicion among GPs in approaching any child with a limp. [ABSTRACT FROM AUTHOR]

Acute lymphoblastic leukemia is the most common form of childhood cancer. It presents with nonspecific symptoms, such as bone pain, that can be easily misdiagnosed at initial presentation. We present a 2-year-old boy with bilateral foot pain that worsened over 6 months. X-rays of the feet showed no obvious abnormalities. Magnetic resonance imaging revealed abnormal bone marrow consistent with an infiltrative process. The patient was found to have precursor B-cell acute lymphoblastic leukemia. Cases such as these highlight the possible future use of magnetic resonance imaging in the early diagnostic workup for bone and muscle pain. [ABSTRACT FROM AUTHOR]

Purpose: Hip pain with limping is a common presentation in childhood. The most common diagnosis in young children is transient synovitis of the hip (TSH), a benign and self-limiting condition. In our clinical practice, we observed eosinophilia in children presenting with irritable hip more commonly than would otherwise be expected. The aims of this study were to assess the prevalence of eosinophilia in children with TSH, and to evaluate the clinical outcomes of this sub-group of patients. Methods: This study retrospectively examined the data of all paediatric patients admitted to Christchurch Public Hospital, Christchurch, New Zealand. TSH cases were compared with age- and sex-matched controls. Results: A total of 103 patients were included. Compared with controls, TSH patients had significantly higher eosinophil counts (303 ± 236 vs. 380 ± 337 cells/μL, respectively, p = 0.049). Fourteen patients (15.6 %) had eosinophilia, with a mean eosinophil count of 986 (±321) cells/µL. Children who had eosinophilia did not differ from the rest of the sample in their age (mean 4.6 vs. 4.4 years, p = 0.74) or ethnicity (85.7 vs. 85.5 % European, p = 0.99). Eosinophilic children were not more likely to be atopic (i.e. have history of allergic rhinitis, asthma and/or eczema) than non-eosinophilic children (21.4 vs. 10.5 %, p = 0.37). There was a shorter hospital stay in eosinophilic children (mean 16.3 ± 6 h) than in non-eosinophilic children (mean 21.5 ± 18.8 h), although this was not statistically significant ( p = 0.058). Conclusions: To the authors' knowledge, this is the first study to explore the relationship between TSH and eosinophilia. We found a sizeable minority (15.6 %) of children with TSH to have eosinophilia. While the difference in hospital stay was not statistically significant, a correlation between peripheral eosinophilia and length of hospital stay of TSH patients is possible. Whether this correlation is clinically meaningful remains to be answered. Level of evidence: Retrospective prognostic study; level II. [ABSTRACT FROM AUTHOR]

Nontraumatic pediatric hip pain and related hip pathology have a broad differential and often present a diagnostic dilemma. The age of the child; history and physical examination; and, if needed, laboratory and imaging studies can guide diagnosis. This article reviews the common etiologies for hip complaints occurring in the absence of trauma in children. The clinical presentation, evaluation, and management will be discussed as well as relevant existing literature to assist the physician in distinguishing between hip pathologies. [ABSTRACT FROM AUTHOR]

Purpose: Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle-related complaints, as these individuals may be at increased risk for inferior outcomes.Methods: In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle-related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant.Results: The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively).Conclusions: Approximately one third of patients presenting to the ED with foot and ankle-related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at $1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable.Levels Of Evidence: Prognostic, Level IV study. [ABSTRACT FROM AUTHOR]

Children presenting with a limp pose a diagnostic dilemma for the clinician. Children may present to a number of specialities, hence, confidence in the examination of the joints, and the musculoskeletal system is essential. There should be a high index of clinical suspicion for infection of the bones or joints, in the acute presentation of a child with a painful limp, and particularly, in the non weight-bearing child. This article will discuss the clinical presentations of paediatric bone and joint infections. The approach to clinical assessment, laboratory and radiological investigations, and management of these conditions, will be discussed. Caring for patients with bone and/or joint infections, often involves several specialities; emergency department doctors, general paediatricians, orthopaedic surgeons, radiologists, paediatric rheumatologists, and the paediatric physiotherapy teams. Early and close collaboration between teams will result in prompt investigation and age appropriate care. [ABSTRACT FROM AUTHOR]

This report describes a case of hind limb lameness associated with intra-abdominal torsion of a neoplastic testicle in a dog. An 11-year-old, male, bilaterally cryptorchid dog was referred for third degree lameness in the left hind limb. An orthopaedic and radiographic examination did not reveal any alteration in the limb, whereas transabdominal palpation and ultrasonography showed the presence of retained gonads. The surgical procedure revealed a left testicular torsion adherent to the viscera and peritoneum in the ventral-caudal part of the abdomen. A few days after a bilateral orchiectomy, the lameness was completely resolved. Histopathological investigations allowed diagnosis of intestitial (Sertoli) cell tumours in both testicles. One of the two testes was twisted. Sertolioma often affects undescended testicles and causes additional clinical changes, due to estrogenic steroidogenesis. The hyper-oestrogenism is characterised by alopecia, feminisation, prostatic alteration and haematological disorders. However, in this case these clinical signs were not present. The aim of this case report is to highlight the correlation of the disease and the onset of limp, which is similar to what has been reported in human medicine in patients affected by meralgia paresthetica. [ABSTRACT FROM AUTHOR]

Background: Lobosphaera incisa, formerly known as Myrmecia incisa and then Parietochloris incisa, is an oleaginous unicellular green alga belonging to the class Trebouxiophyceae (Chlorophyta). It is the richest known plant source of arachidonic acid, an ω-6 poly-unsaturated fatty acid valued by the pharmaceutical and baby-food industries. It is therefore an organism of high biotechnological interest, and we recently reported the sequence of its chloroplast genome. Results: We now report the complete sequence of the mitochondrial genome of L. incisa from high-throughput Illumina short-read sequencing. The circular chromosome of 69,997 bp is predicted to encode a total of 64 genes, some harboring specific self-splicing group I and group II introns. Overall, the gene content is highly similar to that of the mitochondrial genomes of other Trebouxiophyceae, with 34 protein-coding, 3 rRNA, and 27 tRNA genes. Genes are distributed in two clusters located on different DNA strands, a bipartite arrangement that suggests expression from two divergent promoters yielding polycistronic primary transcripts. The L. incisa mitochondrial genome contains families of intergenic dispersed DNA repeat sequences that are not shared with other known mitochondrial genomes of Trebouxiophyceae. The most peculiar feature of the genome is a repetitive palindromic repeat, the LIMP (L. Incisa Mitochondrial Palindrome), found 19 times in the genome. It is formed by repetitions of an AACCA pentanucleotide, followed by an invariant 7-nt loop and a complementary repeat of the TGGTT motif. Analysis of the genome sequencing reads indicates that the LIMP can be a substrate for large-scale genomic rearrangements. We speculate that LIMPs can act as origins of replication. Deep sequencing of the L. incisa transcriptome also suggests that the LIMPs with long stems are sites of transcript processing. The genome also contains five copies of a related palindromic repeat, the HyLIMP, with a 10-nt motif related to that of the LIMP. Conclusions: The mitochondrial genome of L. incisa encodes a unique type of repetitive palindromic repeat sequence, the LIMP, which can mediate genome rearrangements and play a role in mitochondrial gene expression. Experimental studies are needed to confirm and further characterize the functional role(s) of the LIMP. [ABSTRACT FROM AUTHOR]

While the use of evapotranspiration-based or ET-based scheduling to improve on the efficient use of water for irrigation has advanced considerably in recent decades, there is still a need to improve the estimation of ET in regions with multiple microclimates and where the vegetation is mixed or fetch is inadequate for measurement of ET using traditional methods. This paper describes the Landscape Irrigation Management Program (LIMP) model, which addresses these problems. More importantly, the paper describes methods to adjust reference evapotranspiration (ET o ) for microclimate and to measure ET from small fields to provide “site-specific” coefficients for estimating ET. The LIMP model was developed as a scientific approach to estimating landscape water requirements, and the methodology is also helpful for estimating crop ET in regions with multiple microclimates and where crops differ in morphology, physiology, plant density, sensitivity to water stress, etc. A similar approach to LIMP was described in the Irrigation Association book “Irrigation Sixth Edition”. Although the LIMP model is useful, there is a paucity of literature on how to correct ET o for microclimate or how to determine the input coefficients for LIMP to estimate ET. In this paper, we discuss a method to estimate microclimate coefficients to account for spatial ET o variation and we discuss the use of the surface renewal method to measure in-situ ET, which can help to determine “site-specific” coefficients for locations with inadequate fetch to use other ET measurement methods. In addition to using the presented techniques for landscape ET estimation, the procedures are equally useful for estimation of ET in small cropped fields of uniform or mixed vegetation, riparian vegetation, climate controlled greenhouses, in undulating terrain, and regions with multiple microclimates. [ABSTRACT FROM AUTHOR]

Abstract: Joint pain is a common complaint in children and occasionally – although rarely – a symptom of serious disease. It can affect up to 20% of children at any one time. We have attempted to present important points in the history, examination and investigation to help the clinician dealing with a child presenting with non-traumatic joint pain to distinguish those at risk of serious pathology from those children with a benign cause. We also present a management plan in the form of a flow chart for the children who present to the emergency department with a painful joint. [Copyright &y& Elsevier]

Abstract This resource is a comprehensive web-based educational tool that focuses on the core objectives of undergraduate pediatric education with extensive student involvement. This learning module features a podcast that reviews both the approach to the evaluation of limp for medical students and the common and more serious causes of limp. Subsequently, the case presents a previously well 6-year-old boy who presents with a 5-day history of left knee pain. The case evaluates the proper evaluation and workup of an acute limp. This module is part of the PedsCases series, which has been integrated into the third-year undergraduate pediatric medical education curriculum at the University of Alberta. The series is one of the main sources recommended to students to assist in covering the core objectives of the clinical pediatric rotation and in preparing for the final examinations. Since the focus of medical education has shifted towards independent learning, PedsCases has become a complementary educational tool and has filled a niche.

Scurvy is a well-known clinical condition caused by vitamin C deficiency. Although considered a rare disease in high-income countries, it has been recently increasingly reported in children, especially in those with abnormal dietary habits, mental or physical disabilities. We performed an extensive review of the literature analyzing studies published in the last 20 years focusing on clinical features, differential diagnosis and diagnostic delay. Fifteen articles were selected, collectively reporting a total of 166 children. Because of the wide clinical spectrum (musculoskeletal complaints and/or mucocutaneous lesions or systemic symptoms), scurvy can mimic several conditions, including autoimmune diseases, infections, and neoplasia. In addition, frequent findings such as normal nutritional status, anemia or elevated inflammatory markers may guide clinicians towards the abovementioned misdiagnoses. Scurvy should be considered in patients presenting with musculoskeletal complaints, not only in those with risk factors but also in healthy children. A focused dietary history and a careful physical examination, assessing other signs of vitamin C deficiency, are mandatory in these patients. When suspected, the dosage of serum vitamin C is the diagnostic gold standard; furthermore, imaging studies, performed by an expert radiologist, can reveal the typical features of scurvy. Only early diagnosis can avoid unnecessary investigations and potentially fatal complications of the disease. [ABSTRACT FROM AUTHOR]

This is a case of an 8-year-old girl who presents to the emergency department unable to walk due to right hip and left ankle pain for 3 days. Her examination is notable for polyarthralgia with significant tenderness of the left ankle and a heart murmur. Arthrocentesis of the ankle was performed, and initial results were inconclusive. Magnetic resonance imaging of the left ankle demonstrated findings consistent with an infection of the joint space. Subsequent laboratory results were also diagnostic for acute rheumatic fever. This patient was treated for both septic arthritis and acute rheumatic fever. This case report reviews the differential diagnosis for arthritis as well as the diagnostic criteria for acute rheumatic fever. The case highlights the need to search for a second diagnosis if a unifying diagnosis fails to explain all of a patient''s signs and symptoms. [Copyright &y& Elsevier]

Abstract: Children presenting with a limp pose a diagnostic dilemma for the clinician. Children may present to a number of specialities, hence, confidence in the examination of the joints, and the musculoskeletal system is essential. There should be a high index of clinical suspicion for infection of the bones or joints, in the acute presentation of a child with a painful limp, and particularly, in the non weight-bearing child. This article will discuss the clinical presentations of paediatric bone and joint infections. The approach to clinical assessment, laboratory and radiological investigations, and management of these conditions, will be discussed. Caring for patients with bone and/or joint infections, often involves several specialities; emergency department doctors, general paediatricians, orthopaedic surgeons, radiologists, paediatric rheumatologists, and the paediatric physiotherapy teams. Early and close collaboration between teams will result in prompt investigation with age appropriate care. [Copyright &y& Elsevier]

Hematogenous Pseudomonas aeruginosa osteomyelitis of the talus is a rare cause of ankle swelling and limping in children. The case presented herein is that of chronic osteomyelitis of the talus with sequestrum formation. The patient was successfully treated with sequestrectomy and curettage, immobilization, and antibiotic therapy. One year following the operation, the patient displayed mild restriction of ankle dorsiflexion, without evidence of inflammation or arthritis, and radiographs revealed remodeling of the talar neck with increased radiographic density at the site of sequestrectomy. There was no evidence of avascular necrosis or disturbance of the growth of the talus. Although rare, osteomyelitis of the talus should be considered in children and adolescents who present with ankle swelling and an antalgic gait. Level of Clinical Evidence: 4 [Copyright &y& Elsevier]

Abstract: Scurvy, a disease of vitamin C deficiency, is purportedly rare in the United States yet frequently may be misdiagnosed. Presenting symptoms include bone pain, limping, rashes, or spongy bleeding gingiva. These symptoms mimic many other disorders, which often results in numerous unnecessary, invasive, and expensive procedural investigations. The strongest indication of a scurvy diagnosis is the dramatic response to the administration of vitamin C. This case report demonstrates the complexities involved in determining the cause of one child''s symptoms. A thorough nutritional history and a shrewd clinician are essential to the early diagnosis and treatment of scurvy. [Copyright &y& Elsevier]

Objectives: To examine the utility of clinical findings, laboratory markers and X-ray radiographs (X-ray) in the assessment of children presenting with an acute non-traumatic limp. Methods: A retrospective review of all children who received hip X-rays over a 2 year period in the Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand. Children were identified from the radiology database and clinical notes reviewed. Children aged 0–12 years old were included if the limp was acute (less than 2 weeks of duration) with no history of trauma. X-rays were reported by a consultant paediatric radiologist. Univariate and multivariate analysis was performed to determine predictors of osteomyelitis and septic arthritis. Receiver operator curves were used to assess the optimum cut-off points for C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white cell count (WCC). Results: A total of 350 patients were enrolled. There were 21 (6%) abnormal X-rays . Fever, non-weight bearing, raised white cell count, raised erythrocyte sedimentation rate and raised CRP were all associated with increased risk of septic hip or osteomyelitis. The optimum inflammatory marker cut-off was a CRP of 12 with a sensitivity of 87% and specificity of 91%. Conclusion: In acute non-traumatic limp, X-rays of the hips diagnose slipped upper femoral epiphysis, as such they should be routinely used from the age of 9 years upwards. Below this age they are of little value. Inflammatory markers have utility in risk-stratifying children and selecting a group in whom to proceed with definitive tests to exclude osteomyelitis or septic hip. Children with a short history and minimal symptoms can be managed with appropriate follow up and no investigations. [ABSTRACT FROM AUTHOR]

Abstract: The management of the acutely injured child can be a daunting task for any junior doctor. This need not be the case if a calm and methodical approach is employed throughout the assessment. The principles of taking a complete history, including the mechanism of injury, will provide indicators as to the pattern of injury, and a thorough examination will confirm your suspicions. The incidence of fractures in children is twice that of adults1 therefore any doctor working in an emergency environment needs to be confident in dealing with the injured child. Paediatric trauma personnel should also have knowledge of advanced paediatric life support, which is beyond the scope of this article and should be read further elsewhere. [Copyright &y& Elsevier]

The acutely limping child presents a significant diagnostic challenge. The purpose of this study was to create a clinically useful algorithm to allow exclusion of ‘musculoskeletal sepsis’ as a differential diagnosis in the child presenting with limp. Data were collected on all 286 limping children admitted to our centre over a 3-year-period. Using logistic regression analysis, the predictive model was constructed, to exclude infection. Duration of symptoms, constitutional symptoms, temperature, white cell count and ESR were significantly different in children with musculoskeletal infection ( P < 0.05). Multivariate analysis demonstrated that when all three variables of duration of symptoms >1, <5 days; temperature >37.0°C; and ESR >35 mm/h were present, the predicted probability of infection was 0.66, falling to 0.01 when none were present. This multivariate model enables us to rule out musculoskeletal infection with 99% certainty in limping children with none of these three presenting variables. [ABSTRACT FROM AUTHOR]

The article offers information on how an advanced practice nurse should evaluate a child with a limp. The evaluation should include gathering a history of the disability and conducting a thorough physical examination watching the child for nonverbal cues. The examination should also explore possible trauma, infectious etiologies and external issues such as splinters or blisters.

A limp suggests an underlying pathology causing the abnormal gait pattern. There is a long list of possible causes. The challenge for the physician is to identify the cause and act accordingly. The purpose of this article is to instruct on the assessment of a child with a limp. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: A retrospective study was carried out on children between the ages of 1 and 6 years who had radiological investigations for an acute atraumatic limp. The study focused on children who had a whole leg X-ray but also included those having specific radiographic projections with a hip ultrasound scan. Children under the age of 1 year were excluded from the study as the possibility of non-accidental injury may warrant a whole leg X-ray in the absence of trauma. The study aimed to determine if there is a relationship between pain and radiological findings and to establish whether the absence of pain is predictive of a normal radiological investigation. The study also sought to compare the value of plain radiographs and ultrasound in the investigation of these children. Methods: Records and radiographs of children presenting to a Paediatric Accident and Emergency department were reviewed in order to identify those meeting the eligibility criteria. Results: A total of 107 limping children were included in the study. Forty-five (42%) were pain free, and 87 (85%) had normal radiological investigations. Five (5%) had unexpected findings; two (2%) on plain radiographs and three (3%) on ultrasound. Seventy children (65%) had complete resolution of symptoms within 1 week and four (4%) had positive findings on follow-up investigations. Conclusions: The findings in this study suggested that the association between pain and radiological findings was highly significant (P <0.05). Plain radiographs and possibly ultrasound scan of the hips in a limping child who is not experiencing any pain, can be deferred until review, and it is not likely to be detrimental to the management of that child. Furthermore, plain radiographs for those children who are experiencing pain on physical examination can be limited to the affected area. If the pain is in the hip joint, an ultrasound scan is more sensitive than plain radiographs (in %, 100:26.6) and would be the better investigation to exclude hip joint pathology. [Copyright &y& Elsevier]

: ObjectivesThe aim of our study was to assess whether acute, short-term hyperglycemia affects platelet reactivity in patients with Type II diabetes mellitus (T2DM).: BackgroundHyperglycemic spikes are thought to precipitate ischemic events in T2DM. Previous studies have shown in vivo platelet activation in diabetes; however, no studies have assessed whether acute in vivo hyperglycemia induces further activation of platelets.: MethodsIn a cross-over, randomized, double-blind study, 12 patients with T2DM underwent 4 h of either acute hyperglycemia (13.9 mmol/l, 250 mg/dl) or euglycemia (5.5 mmol/l, 100 mg/dl). Shear stress-induced platelet activation, P-selectin and lysosomal integral membrane protein (LIMP) expression on platelets in the bleeding-time blood, urinary 11-dehydro-thromboxane B2 (TxB2) excretion, von Willebrand factor:antigen (vWF:Ag), and von Willebrand factor:activity (vWF:activity) were measured before and after hyperglycemia or euglycemia.: ResultsShear stress-induced platelet activation, P-selectin and LIMP expression on platelets in the bleeding-time blood, and urinary 11-dehydro-TxB2 excretion increased significantly after hyperglycemic clamping, whereas no changes were observed after euglycemic clamping. Plasma vWF:Ag and vWF:activity increased strikingly in parallel fashion after hyperglycemic clamping, whereas no changes were observed after euglycemic clamping.: ConclusionsOur data demonstrate that acute, short-term hyperglycemia induces an increased activation of platelets exposed to high shear stress conditions in vitro (filtration method) or in vivo (bleeding time). In vivo platelet activation is reflected by an increased urinary excretion of 11-dehydro-TxB2. The increased levels of vWF in the circulation correlate with the increase in platelet activation markers and may indicate some degree of causation. Acute, short-term hyperglycemia in T2DM may precipitate vascular occlusions by facilitating platelet activation. [Copyright &y& Elsevier]

The principal causes in children of a non-acute painful hip are Perthes disease and synovitis (irritable hip). The 99mTc methylene diphosphonate (MDP) bone scan appearances in Perthes disease are well-known; in synovitis, the hip may show a diffuse increase in activity or may be normal. The significance of bone scintigraphy in the clinical setting of non-acute hip symptoms with normal skeletal radiography has been evaluated in 36 symptomatic children. The mean duration of symptoms prior to scan was 3 months (range 1 week-17 months). On the basis of final diagnosis, established by clinical findings, bone scan, X-ray and follow-up, the children were divided into two groups: synovitis or Perthes disease. Of the 33 scans in the 32 children with synovitis, 18 were normal and 15 showed diffusely increased activity on the painful side. All four patients with Perthes disease had focal femoral head abnormalities in the painful hip. Of the 18 children with normal scans, none went on to develop a skeletal disorder. In children with hip pain of over 1 week's duration, the main value of the bone scan is the early detection of Perthes disease. Diffuse increased activity on the painful side suggests synovitis. A normal scan virtually excludes significant skeletal abnormality. [ABSTRACT FROM AUTHOR]