Designing the first culturally-sensitive stigma survey tailored for adolescents: RN-CSS.

AIMS: The Red Noses Culturally-Sensitive Stigma Survey (RN-CSS) contributes to the underexplored research domain of adolescents' stigmatising attitudes and behaviours towards peers with mental health difficulties and mental healthcare services. It also addresses the need for comprehensive and culturally-sensitive tools to assess stigma in this context. METHODS: Drawing on insights from focus groups and building upon the existing Stigma in Global Context-Mental Health Study, we have successfully developed and implemented the first culturally-sensitive stigma survey tailored for school-aged adolescents of different migration/cultural backgrounds. The questionnaire includes an unlabelled case vignette depicting a peer with symptoms of depression and gathers data on various domains, including (1) sociodemographic variables; (2) education-related information; (3) COVID-19; (4) perceptions of mental health difficulties and mental healthcare services (i.e. severity assessment, causal attributions, care recommendations, personal stigma, perceived stigma, and service stigma); (5) subjective wellbeing and familiarity with mental health difficulties; (6) social support; (7) school context; (8) bullying; and (9) knowledge of anti-stigma campaigns. RESULTS: Our final sample comprises 5075 pupils from 38 secondary schools in Flanders, Belgium. CONCLUSIONS: In this article, we present the study's background and rationale, the development of the questionnaire, and the sampling and recruitment methods employed. Furthermore, we provide a summary of the sample characteristics and preliminary descriptive results of the RN-CSS. Subsequent empirical studies will address the research objectives outlined in this protocol paper. The research opportunities provided by the developed materials and dataset are being discussed.

"Trying to write a story together": general practitioners' perspectives on culturally sensitive care.

BACKGROUND: Culturally sensitive care is integral to effective and equitable healthcare delivery, necessitating an understanding and acknowledgment of patients' cultural needs, preferences, and expectations. This study investigates the perceptions of cultural sensitivity among general practitioners (GPs), focusing on their intentions, willingness and perceived responsibilities in providing care tailored to cultural needs. METHODS: In-depth interviews were conducted with 21 Flemish GPs to explore their perspectives on culturally sensitive care. Data analysis followed a conventional qualitative content analysis approach within a constructivist framework. A coding scheme was developed to identify recurring themes and patterns in the GPs' responses. RESULTS: Findings reveal that culturally sensitive care provision is perceived as a multifaceted process, initiated by an exploration phase where GPs inquire about patients' cultural needs and preferences. Two pivotal factors shaping culturally sensitive care emerged: patients' specific cultural expectations and GPs' perceived responsibilities. These factors guided the process of culturally sensitive care towards three distinct outcomes, ranging from complete adaptation to patients' cultural requirements driven by a high sense of responsibility, through negotiation and compromise, to a paternalistic approach where GPs expect patients to conform to GPs' values and expectations. Three typologies of GPs in providing culturally sensitive care were identified: genuinely culturally sensitive, surface-level culturally sensitive, and those perceiving diversity as a threat. Stereotyping and othering persist in healthcare, underscoring the importance of critical consciousness and cultural reflexivity in providing patient-centered and equitable care. CONCLUSIONS: This study emphasizes the significance of empathy and underscores the necessity for GPs to embrace the exploration and acknowledgement of patients' preferences and cultural needs as integral aspects of their professional role. It highlights the importance of shared decision-making, critical consciousness, cultural desire and empathy. Understanding these nuances is essential for enhancing culturally sensitive care and mitigating healthcare disparities.

Physical properties of odorants affect behavior of trained detection dogs during close-quarters searches.

Trained detection dogs have a unique ability to find the sources of target odors in complex fluid environments. How dogs derive information about the source of an odor from an odor plume comprised of odorants with different physical properties, such as diffusivity, is currently unknown. Two volatile chemicals associated with explosive detection, ammonia (NH3, derived from ammonium nitrate-based explosives) and 2-ethyl-1-hexanol (2E1H, associated with composition C4 plastic explosives) were used to ascertain the effects of the physical properties of odorants on the search behavior and motion of trained dogs. NH3 has a diffusivity 3.6 times that of 2E1H. Fourteen civilian detection dogs were recruited to train on each target odorant using controlled odor mimic permeation systems as training aids over 6 weeks and then tested in a controlled-environment search trial where behavior, motion, and search success were analyzed. Our results indicate the target-odorant influences search motion and time spent in the stages of searching, with dogs spending more time in larger areas while localizing NH3. This aligns with the greater diffusivity of NH3 driving diffusion-dominated odor transport when dogs are close to the odor source in contrast to the advection-driven transport of 2E1H at the same distances.

Drop landing analysis of rotational osteotomies.

Pathomechanics resulting from rotational deformities of the long bones in an idiopathic population have not been extensively studied, and are chiefly limited to level over ground walking. Thirty-five adolescents with excessive idiopathic outward tibial torsion (TT), femoral rotation, or both (pan genu) were studied both before and after corrective surgery. Data collected included computational motion analysis of a drop jump and patient-reported outcomes consisting of PODCI and Goal Attainment Scores. Results were compared to an age-matched typically developing cohort (n = 25). Subjects with femoral anteversion (FA) exhibited compensatory hip rotations to normalize knee progression angles at landing. Subjects with only TT did not compensate at the hip, landing with typical knee progression but excessive outward foot progression. These strategies resulted in elevated frontal plane knee moments for FA (P = 0.008), and elevated lateral knee forces in all groups compared to typical, with the TT group reaching significance (P < 0.001). Rotational osteotomies successfully restored elevated kinematics and kinetics to within or below typically developing ranges. Patient-reported outcomes generally improved after surgery across all domains studied. Drop jump testing elucidated compensation strategies employed by these cohorts. Compensation did not fully alleviate elevated forces at the knees. Surgical intervention normalized pathokinematics and pathokinetics, reduced pain, and improved patients' perception of their functional abilities. Greater improvements were found in individuals in the two groups with FA compared to the group with TT only.

Hemiepiphysiodesis for Lower Extremity Coronal Plane Angular Correction in the Distal Femur and Proximal Tibia in Children With Achondroplasia.

BACKGROUND: Achondroplasia is the most prevalent form of skeletal dysplasia, affecting more than 250,000 individuals. Lower extremity angular deformities, particularly genu varum, are common in children with achondroplasia, often resulting in pain and limitation of function. The authors aim to determine the utility of lower extremity growth modulation with hemiepiphysiodesis in children with achondroplasia for correction of coronal plane deformities about the knee. METHODS: The authors performed a retrospective chart review of a single center from 1/1/2000 to 12/31/2020 to identify pediatric patients with achondroplasia treated with hemiepiphysiodesis as their initial procedure at the distal femur and/or proximal tibia. Patients with adequate records and who had completed their treatment were included. Data collected included duration of treatment, complications, need for osteotomy, and radiographic measurements including initial and final mechanical axis deviation, knee mechanical axis zone, mechanical lateral distal femoral angle and medial proximal tibia angle. RESULTS: Ten patients with 17 limbs met our criteria. Nine patients (15 limbs) were treated for genu varum and 1 patient (2 limbs) was treated for genu valgum. Prior to treatment, the mechanical axis fell in zone 3 in 59% of limbs and zone 2 in 41%. Average correction in mechanical axis deviation was 26.1 mm. Average change in mechanical lateral distal femoral angle was 10.3 degrees per limb, and average change in medial proximal tibia angle was 7.1 degrees per limb. Average treatment duration was 909 days. At final follow up, 81% (14/17) of limbs had the mechanical axis in zone 1, with the remaining 18% (3/17) in zone 2. No patient/limb underwent subsequent distal femur or proximal tibia osteotomy for coronal plane alignment. CONCLUSIONS: Children with achondroplasia can successfully be treated with hemiepiphysiodesis to correct coronal plane deformities at the distal femur and proximal tibia. Using this technique, no patient in our series required an osteotomy for genu varum/valgum. LEVEL OF EVIDENCE: Therapeutic level IV, Case series.

Perceived Teacher Discrimination and Depressive Feelings in Adolescents: The Role of National, Regional, and Heritage Identities in Flemish Schools.

Adolescents' identities are multiple, yet there is very little research that investigates the importance of intersecting identities, especially in relationship to teacher ethnic/racial discrimination and mental health. Multiplicity is often approached bi-dimensional (heritage and national identities) yet this study highlights the importance of regional identity. Regions are distinct socio-political contexts in relation to migration and integration dynamics. Hence, this study investigates for different combinations of national, heritage and regional identities (i.e. Flemish, Belgian and Turkish or Moroccan) the relationship between students' experiences with teacher ethnic/racial discrimination and students' depressive feelings. Latent Class Analysis of survey data involving a sample of 439 adolescents (Mage = 18, SD = 0.93; Girls = 49%) with Turkish (41%) or Moroccan origin in Flanders, shows three identification classes: full integration (35%), national integration (40%) and (weak) separation (24%). All these identity profiles had in common that heritage identification was high, yet they were highly distinct due to variation in national and regional identification. Additional, multilevel modelling showed that nationally integrated adolescents were less depressed than fully integrated adolescents. This finding illustrates the importance of adolescents' identity multiplicity for understanding their resilience in relation to teacher discrimination.

Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity.

Objective: There are several alternative methods for accomplishing epiphysiodesis of the longer limb to address limb length discrepancy (LLD). Consensus is lacking regarding the optimal timing of the intervention and which method is most efficacious. We reviewed a large group of patients with anisomelia treated by tethering with tension band plates (TBP) and who had attained skeletal maturity. We discuss our preferred timing and technique while noting the complications and how they were managed. Materials and methods: With IRB approval, we reviewed 66 subjects including 32 boys and 34 girls, ranging in age from 3 to 16.6 years at the time of physeal tethering, who were destined to have between 2 and 9 cm LLD at maturity. Inclusion criteria were: (1) at least 1 year of predicted growth at the time of tethering; (2) minimum 18-month follow-up and (3) minimum Risser stage 1 (R1) in the last radiologic study. There were 35 distal femoral, 25 pan genu and five proximal tibial procedures. Patients were seen bi-annually with weight-bearing full-length radiographs to ascertain neutral alignment and assess limb lengths. Results: We defined a successful outcome to be <1.5 cm of residual discrepancy. Iatrogenic mechanical axis deviation, observed in nine patients (five varus and four valgus), was successfully managed by repositioning the implants. While the under-corrected patients presented too late to achieve equalization, they benefited from partial improvement. Due to lack of timely follow-up, one patient over-corrected by 2 cm and had a femoral shortening at the time of correcting contralateral femoral anteversion. One patient required a distal femoral osteotomy to correct recurvatum at maturity. Conclusion: Properly timed and executed, TBP is an efficacious and reversible means of growth deceleration, rather than growth arrest, that may be applied in a wide age range of patients with modest anisomelia regardless of aetiology. This method offers potential advantages over purportedly rapid and definitive techniques such as percutaneous epiphysiodesis (PE) or percutaneous epiphysiodesis with transphyseal screws (PETS). Level of evidence: Level III. Retrospective series without controls. How to cite this article: Stevens P, Desperes M, McClure PK, et al. Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity. Strategies Trauma Limb Reconstr 2022;17(1):26-31.

Evolution and development of inflorescences and floral symmetry in Solanaceae.

PREMISE: The inflorescences of Solanaceae are unique and complex, which has led to long-standing disputes over floral symmetry mainly due to different interpretations of the cyme-like inflorescence structure. The main disagreements have been over how the phyllomes associated with the flower were arranged relative to the inflorescence axis especially during early flower initiation. METHODS: Here we investigated the evolution of inflorescences in Solanaceae by analyzing inflorescence structure in the context of phylogeny using ancestral state reconstruction (ASR) to determine the evolutionary transitions between loosely arranged and tightly clustered inflorescences and between monochasial-like and dichasial-like cymes. We also reconstructed two- and three-dimensional models for 12 solanaceous species that represent both inflorescence and phylogenetic diversity in the family. RESULTS: Our results indicate that the most recent common ancestor of Solanaceae had a loosely arranged and monochasial-like cyme, while tightly clustered inflorescences and dichasial-like cymes were derived. Compared to the known process of scorpioid cyme evolution, Solanaceae achieved their scorpioid cyme-like inflorescences through a previously undescribed way. Along the pedicel, the two flower-preceding prophylls are not in the typical transverse position of dicotyledonous plants; they frequently have axillary buds, and the main inflorescence axis continues in a sympodial fashion. As a result, the plane of symmetry of the flower is 36° from the median, and the inflorescence axis and the two flower-preceding prophylls are symmetrically located along that plane. CONCLUSIONS: A better understanding of the morphological evolution of solanaceous inflorescence structure helped clarify the floral symmetry of Solanaceae.

Prospective Study on Tension Band Plating: Most Patients are Not Returning to Normal Activities 1 Month Following Surgery.

BACKGROUND: Tension band plating for temporary hemiepiphysiodesis has been reported by several authors as simple and effective for treating angular deformities of the lower limb. Anecdotally, patients have reported higher pain levels than expected given the small size of incision and relatively minimal amount of dissection, and we sought to investigate this further. METHODS: Patients 16 years old or less with lower extremity angular deformities or limb length inequality were prospectively enrolled before tension band plating from 2 pediatric institutions from July 2016 to December 2018. Participants completed postoperative questionnaires regarding their pain and activity level. Pain was assessed using the FACES Pain Scale. Patients were included if they completed the 1 month survey. RESULTS: Of the 48 patients that met inclusion criteria (mean age at surgery: 13.1 y; range: 7 to 16 y), 39 patients completed the survey at 3 months postoperatively. There was a significant change in pain level between 1 week and 1 month postoperatively (P<0.001). Eighty-three percent (34/41) of patients were still taking pain medication at 1 week, which decreased to 38% (18/48) at 1 month. At 3 months, 21% (8/39) patients reported they were still using pain medication. At 1 month, 65% of patients (31/48) had not returned to their prior activity level. Of the 39 patients who played sports, 59% (23/39) still had not fully returned to sports at 1 month. CONCLUSION: At 1 month following tension band plating, 65% of patients had not returned to their preoperative activity level, and 38% were taking pain medications. Although the tension band plate and surgical incision is small in size, patients and parents should be counseled that there are significant activity limitations and pain levels for a month or longer in many patients. LEVEL OF EVIDENCE: Level II.

Assessing the safety of an epiphyseal plate biopsy in a translational lamb model.

The literature demonstrates that obtaining a biopsy of the physis may be beneficial for diagnostic purposes. A small biopsy of the epiphyseal plate may allow for earlier detection of certain conditions and be used to monitor the healing of diseased and/or damaged physes. However, due to the fear of a growth arrest in a growing child, biopsies are not currently performed. In this study, we investigated the effects of a biopsy of the epiphyseal plate in 3-month-old lambs. A total of 4.2 mm biopsy samples were captured in the proximal tibiae and distal femora physes. The lambs were monitored 12- and 24-week post-biopsy. Computed tomography (CT) and micro-CT scans were obtained to determine if any angular deformities occurred, while scanning electron microscope (SEM) and histological analysis were utilized to assess the bone response due to the biopsy. The contralateral limbs served as unaltered controls for direct comparison within each lamb. The data demonstrated no signs of angular deformities following a 4.2 mm biopsy of the physis. Bone growth/elongation was confirmed by CT, SEM, and fluorochrome analyses and indicated that the lambs were in fact immature and still growing at the time of the biopsy. Clinical Significance: This investigation demonstrated that a small biopsy of the epiphyseal plate can be obtained safely without the cause of growth arrest and angular deformities. The ability to precisely diagnose, treat, and/or monitor at-risk children at an earlier timepoint by way of a biopsy sample could be an important advancement in regard to researching diseased and/or damaged physes.

Phylogeny, divergence times, and diversification in Calophyllaceae: Linking key characters and habitat changes to the evolution of Neotropical Calophylleae.

The clusioid clade comprises five monophyletic families: Bonnetiaceae, Calophyllaceae, Clusiaceae s.s., Hypericaceae, and Podostemaceae. Even though the circumscription of these families is well established, phylogenetic relationships within some families remain unresolved. This study aims to infer phylogenetic relationships within the Neotropical Calophylleae based on a broad sampling of taxa and a multilocus approach. We then use our phylogenetic framework as basis to investigate the evolution and biogeography of Calophylleae and diversification shifts in Calophyllaceae. To reconstruct the phylogeny of the Neotropical Calophylleae, we used five plastid (matK, ndhF, rbcL, psbA-trnH, and trnK), two mitochondrial (matR and rps3), and two nuclear (EMB2765 and ITS) markers, including previously published and newly generated sequences. We sampled 74 species, increasing sampling of Neotropical taxa by 500%. Our phylogenetic hypothesis for Calophyllaceae provides additional support for the monophyly of all genera and allowed us to identify four main clades: Calophyllum, Kayea, Mammea, and the Neotropical clade. The Neotropical clade includes three main lineages, a small clade composed of Clusiella and Marila, and a large HaCaKi clade (i.e., Haplocarpa, Caraipa, and Kilmeyera) that is sister to Mahurea exstipulata. The evolution of three morphological traits (i.e., fleshy fruits, anther glands, and winged seeds) were shown to be associated with changes in evolutionary dynamics in Calophyllaceae, while a biome shift was detected in Kielmeyera, affecting net diversification within this genus. Major geological and climatic events such as the Andean uplift and a gradual decrease in temperatures seem to have influenced diversification rates within the Neotropical Calophylleae.

Guided Growth for Tibial Recurvatum.

AIM AND OBJECTIVE: Sagittal guided growth of the distal anterior femur has been shown to be effective for the correction of fixed knee flexion deformity that is encountered in clinical practice. The opposite deformity, namely genu recurvatum, is comparatively uncommon in children. The most common aetiology is post-traumatic. Acute correction by means of osteotomy has significant associated risks. Our objective was to determine whether a posterior 8-plate would suffice in correcting tibial recurvatum and obviate the need for an osteotomy. MATERIALS AND METHODS: We included a total of five deformities, three boys (one bilateral) and one girl, managed by means of tethering of the posterior proximal tibial physis with a tension band plate. Standard radiographs obtained preoperatively and at follow-up included a standing anteroposterior (AP) of the legs noting limb lengths and the mechanical axis. We also obtained standing lateral views of each knee in maximal extension to measure and compare the posterior proximal tibial angle (PPTA). RESULTS: The same-day surgery was well tolerated and there were no surgical or post-operative complications. The preoperative PPTA ranged from 106° to 117° and averaged 84° at follow-up. Correction occurred in an average of 20 months (range of 18-24 months). The patient with bilateral recurvatum due to Hurler's syndrome developed unilateral recurrent recurvatum culminating in percutaneous reinsertion of the metaphyseal screw. For each patient, knee hyperextension and associated pseudo-laxity resolved and limb lengths remained equal at follow-up. CONCLUSION: Children with progressive genu recurvatum typically present with an insidious onset of symptoms. Guided growth of the posterior proximal tibia is a safe and effective means of correcting the deformity; osteotomy was avoided in this series. LEVEL OF EVIDENCE: III - retrospective case series - no controls. HOW TO CITE THIS ARTICLE: Stevens P, Stephens A, Rothberg D. Guided Growth for Tibial Recurvatum. Strategies Trauma Limb Reconstr 2021;16(3):172-175.

Talar-tarsal Stabilisation: Goals and Initial Outcomes.

BACKGROUND: While surgical stabilisation of the subtalar joint (arthroeresis) in children remains controversial in the USA, it is widely practised worldwide, with reportedly good outcomes. We are presenting a series of patients who met our criteria for calcaneal lengthening, but whose parents chose the less invasive option of talo-tarsal stabilisation (TTS). The goal of this surgery was to forestall or prevent hindfoot osteotomy. MATERIALS AND METHODS: With IRB approval, we conducted this retrospective review of 32 patients (60 ft), who underwent TTS for flexible planovalgus deformity and had a minimum of 1-year follow-up. The aetiology was idiopathic for the majority, with a few being neurogenic or syndromic. The age range was 6-15 years; the younger patients had neuromuscular aetiology or underlying syndromes. Concomitant procedures included percutaneous Achilles lengthening (33 ft), Kidner (9 ft) and guided growth for ankle valgus (2). RESULTS: In the early post-immobilisation phase, peroneal spasm occurred in four patients (6 ft). This resolved with Botox injection in the peroneus brevis in three patients and required transfer of the peroneus brevis to the peroneus longus in one patient. At follow-up, ranging from 1 to 4.5 years, 50 implants (83.4%) were retained and the patients reported satisfactory outcomes. Henceforth, those patients will be monitored on a p.r.n. basis. Due to lingering discomfort, implants were repositioned in one and removed in five patients (10 ft = 16.6%). Upon further follow-up, these patients have not manifested recurrent deformity. Therefore, subsequent salvage by osteotomy and/or lengthening of the calcaneus has not been necessary. CONCLUSION: TTS for the symptomatic flatfoot, combined with other procedures as indicated, offers advantages over the currently more accepted methods of medial shift osteotomy or calcaneal lengthening. The outcome at 1 year is a good forecast of whether or not further treatment will be required. This is a simpler and preferred option as compared to other methods of surgical management and, in our experience, has obviated the need for osteotomy or lengthening of the calcaneus. LEVEL OF EVIDENCE: IV retrospective case series. HOW TO CITE THIS ARTICLE: Stevens P, Lancaster A, Khwaja A. Talar-tarsal Stabilisation: Goals and Initial Outcomes. Strategies Trauma Limb Reconstr 2021;16(3):168-171.

Assessing the effect of physeal biopsy on angular deformity in a rabbit model.

Obtaining a biopsy of the physis in a pediatric/juvenile could provide the ability to diagnose and manage children with physeal abnormalities. However, it has not yet been determined whether a physeal biopsy procedure affects angular deformity. We employed a rabbit model to collect biopsies of the distal femoral and proximal tibial physes on anesthetized, 8-week old New Zealand rabbits. The contralateral limb served as a control. At 8 (n = 5) and 16 (n = 5) weeks postbiopsy, animals were euthanized. Micro-computed tomography (CT) was employed to estimate percentage of the physis biopsied and assess structural abnormalities resulting from biopsy. Bone samples were embedded in polymethylmethacrylate and analyzed. The percentage of physis sampled was ≤1.5% of the total femoral physis while all but one of the tibiae had ≤2.3% removed. There were no iatrogenic clinical or radiographic deformities (frontal or sagittal). Micro-CT and histological analysis suggested that physeal defects had signs of healing that did not lead to subsequent angular deviation. A defect caused by physeal biopsy may not lead to angular deformity. Long-term data could help determine the safety and efficacy of collecting biopsies for histological analyses. Advanced imaging may demonstrate a detailed picture of anatomic or structural alteration of a given physis, but provides no functional information. The diagnostic and therapeutic information that could be gleaned from one or more serial biopsy samples could be invaluable in decision making and clinical management (e.g. skeletal dysplasias and metabolic conditions), so long as subsequent deformity is not a future possibility.

Psychologically informed practice (PIP) within the offender personality disorder pathway: Towards establishing an evidence base for approved premises.

The United Kingdom (UK) government has commissioned numerous interventions across all stages of the criminal justice pathway for managing offenders likely to have a personality disorder, with the intention to reduce reoffending, improve psychological wellbeing, and develop workforce capabilities. Psychologically Informed Practice (PIP) models underpin these. To evaluate a modified PIP model within the post-imprisonment community stage of the Offender Personality Disorder (OPD) pathway, specifically workforce development, within all London (UK) probation supervised hostels (approved premises), we used both non-equivalent control group and pre-post repeated measure designs to compare changes in staff and offender outcomes before and after introduction of a PIP model across all 12 London approved premises. Findings revealed statistically significant improvements in a number of workforce outcomes (measured using the Personality Disorder - Knowledge, Attitudes and Skills Questionnaire and Maslach Burnout Inventory) which were moderated by age and gender. Data did not support associated improvements in resident offender outcomes (progressive moves, rearrests/reoffences, or breaches leading to recalls). The modified PIP is an effective intervention model for improving some workforce outcomes among probation supervised hostel staff, particularly for women, but our findings suggest that intervention development may be required for significant improvements to be observed in resident offending outcomes. In addition, further research is necessary to determine the longer term effects of PIP on absenteeism, employee turnover, quality of resident-staff interactions, and overall culture change among staff working within the post-imprisonment community stage of the OPD pathway.

Genotype phasing in pedigrees using whole-genome sequence data.

Phasing is the process of inferring haplotypes from genotype data. Efficient algorithms and associated software for accurate phasing in pedigrees are needed, especially for populations lacking reference panels of sequenced individuals. We present a novel method for phasing genotypes from whole-genome sequence data in pedigrees, called PULSAR (Phasing Using Lineage Specific Alleles/Rare variants). The method is based on the property that alleles specific to a single founding chromosome within a pedigree are highly informative for identifying haplotypes that are shared identical by descent. Simulation studies are used to assess the performance of PULSAR with various pedigree sizes and structures, and the effect of genotyping errors and the presence of nonsequenced individuals is investigated. In pedigrees with complete sequencing and realistic genotyping error rates, PULSAR correctly phases >99.9% of heterozygous genotypes, excluding sites at which all individuals are heterozygous, and does so with a switch error rate frequently below 10-4. PULSAR is highly accurate, capable of genotype error correction and imputation, and computationally competitive with alternative phasing software applicable to pedigrees. Our method has the significant advantage of not requiring reference panels that are essential for other population-based phasing algorithms. A software implementation of PULSAR is freely available.

Cozen's deformity: resolved by guided growth.

Proximal tibial metaphyseal fractures in children can lead to progressive and symptomatic tibial valgus. Corrective osteotomy has been abandoned, due to frequent complications, including recurrent valgus deformity. While spontaneous remodelling has been reported, this is not predictable. For children with persistent deformities, we have resorted to guided growth of the tibia. We present 19 patients who were successfully treated with guided growth, tethering the proximal medial physis. There were ten boys and nine girls, ranging in age from two to 13.6 years at the time of intervention. The mean follow-up from injury was 7.3 years. We documented the intermalleolar distance, mechanical axis deviation (by zone), medial proximal tibial angle (MPTA), and leg length discrepancy. Removal of the plate, or more recently, the metaphyseal screw, was undertaken upon normalization of the mechanical axis. Including the four patients who have undergone repeat tethering for recurrent valgus (one patient-twice), we are effectively reviewing 24 Cozen's phenomena, making this the largest series reported in the literature. Correction of the mechanical axis and the proximal medial tibial angle was achieved in all but one patient. Limb length inequality at follow-up ranged from 0.1 to 1.5 cm, with a mean of 0.5 cm. There have been five recurrences in four patients to date; four corrected with repeat tethering and one is pending. Two patients developed significant over correction because of parental failure to pursue timely follow-up. Both have corrected to neutral with lateral tibial physeal tethering. Ten patients have attained skeletal maturity and required no further treatment. The remaining nine patients will be followed until maturity. Guided growth is an excellent choice for the management of post-traumatic tibial valgus. Our rationale for restricting medial overgrowth is twofold: (1) to restore the MPTA and (2) to reduce the length discrepancy due to tibial overgrowth caused by the fracture. Recognizing the potential for recurrent deformity following implant removal, our standard practice now includes removal of just the metaphyseal screw and subsequent reinsertion, in the event of rebound valgus deformity.Level of evidence Therapeutic IV, retrospective series/no control cohort.

Evolution of the process underlying floral zygomorphy development in pentapetalous angiosperms.

PREMISE OF THE STUDY: Observations of floral ontogeny indicated that floral organ initiation in pentapetalous flowers most commonly results in a median-abaxial (MAB) petal during early development, a median-adaxial (MAD) petal being less common. Such different patterns of floral organ initiation might be linked with different morphologies of floral zygomorphy that have evolved in Asteridae. Here, we provide the first study of zygomorphy in pentapetalous angiosperms placed in a phylogenetic framework, the goal being to find if the different patterns of floral organ initiation are connected with particular patterns of zygomorphy. METHODS: We analyzed patterns of floral organ initiation and displays of zygomorphy, extracted from floral diagrams representing 405 taxa in 330 genera, covering 83% of orders (30 out of 36) and 37% of families (116 out of 313) in core eudicots in the context of a phylogeny using ancestral state reconstructions. KEY RESULTS: The MAB petal initiation is the ancestral state of the pattern of floral organ initiation in pentapetalous angiosperms. Taxa with MAD petal initiation represent ∼30 independent origins from the ancestral MAB initiation. There are distinct developmental processes that give rise to zygomorphy in different lineages of pentapetalous angiosperms, closely related lineages being likely to share similar developmental processes. CONCLUSIONS: We have demonstrated that development indeed constrains the processes that give rise to floral zygomorphy, while phylogenetic distance allows relaxation of these constraints, which provides novel insights on the role that development plays in the evolution of floral zygomorphy.