Lumbar osteomyelitis and knee septic arthritis caused by Streptococcus agalactiae bacteraemia.

A man in his late 70s presented to the emergency department endorsing a week of malaise. He was recently hospitalised for 2 days for new back pain and was discharged with non-opioid pain medications but continued to seek care as he felt unwell. On presentation, he was afebrile with a leukocytosis. Physical examination revealed a painful left knee with no evidence of trauma. Arthrocentesis revealed purulent fluid with elevated white blood cell consistent with septic arthritis. He was started on broad-spectrum antibiotics and underwent irrigation and synovectomy of the left knee. Aspirate and blood cultures grew Streptococcus agalactiae Transthoracic echocardiogram showed no vegetations; however, an MRI of lumbar spine showed L2-L3 and L4-L5 osteomyelitis. He was treated with intravenous ceftriaxone for 3 weeks and then oral levofloxacin for 3 weeks, for a total 6 week course of antibiotics.

Short-term Effect of Ultrasound-Guided Iliopsoas Peritendinous Corticosteroid Injection.

OBJECTIVES: Treatment for iliopsoas tendinopathy includes ultrasound (US)-guided iliopsoas peritendinous corticosteroid injection. Evidence is lacking regarding US-guided iliopsoas injection efficacy in patients with iliopsoas tendinopathy and intra-articular (IA) hip abnormalities. The purpose of this study was to examine the efficacy of US-guided iliopsoas corticosteroid injection for iliopsoas tendinopathy in patients with and without IA hip abnormalities. METHODS: This work was a prospective study evaluating patients aged 12 to 50 years with iliopsoas tendinopathy. Participants completed a Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire before and 6 weeks after injection. The main outcome measure was the change in HOOS subcategory scores. Independent variables included time and hip status. Normal hips were compared to abnormal hips with IA abnormalities. A 2-way repeated measures analysis of covariance with effect size (η2 ) was used to determine injection effects on HOOS scores before and 6 weeks after injection. RESULTS: A total of 178 patients (154 female and 24 male) were analyzed. Time effects were found for both normal and abnormal hips in all HOOS subcategories: symptoms (P = .041; η2 = 0.050), pain (P = .001; η2 = 0.184), activities of daily living (P = .011; η2 = 0.076), function in sports and recreation (P = .001; η2 = 0.151), and quality of life (QOL; P = .001; η2 = 0.193). Significant differences between normal versus abnormal hips were found in the sports and recreation (P = .032; η2 = 0.056) and QOL scores (P = .001; η2 = 0.135). CONCLUSIONS: In patients with iliopsoas tendinopathy, US-guided iliopsoas corticosteroid injection improved outcomes regardless of coexisting IA hip abnormalities. Patients without IA hip abnormalities showed greater improvement in sports and recreation and QOL scores compared to patients with IA hip abnormalities. Ultrasound-guided iliopsoas injection for iliopsoas tendinopathy may advance short-term care and help continue with nonsurgical treatment regimens.

Can Dynamic Ultrasonography of the Hip Reliably Assess Anterior Femoral Head Translation?

BACKGROUND: Hip microinstability has gained attention recently as a potential cause of hip pain. Currently there is a lack of evidence-based objective diagnostic criteria surrounding this diagnosis. Previous studies have shown translation of the femoral head during extreme hip positions. However, reliable assessment of femoral head translation is lacking. QUESTIONS/PURPOSES: (1) How precise is musculoskeletal ultrasound for measuring anterior femoral head translation during the hip anterior apprehension test? (2) What is the intra- and interrater reliability of dynamic ultrasonography in assessing anterior femoral head translation? METHODS: We recruited 10 study participants (20 hips) between the ages of 22 and 50 years with no history of hip pain or functional limitations. Test-retest methodology was used. Seven females and three males were enrolled. The mean age of study participants was 27 years (SD 8.7 years); mean body mass index was 22.6 kg/m (SD 2.2 kg/m). All study participants underwent dynamic hip ultrasonography by three different physicians 1 week apart. Each hip was visualized in two neutral positions (neutral and neutral with the contralateral hip flexed [NF]) and two dynamic positions, which sought to replicate the apprehension test, although notably study participants had no known hip pathology and therefore no apprehension. The first maintained the hip in extension and external rotation off to the side of the examination table (EER1), and the second held the hip off of the bottom of the examination table (EER2). One hundred twenty ultrasound scans (480 images) were performed. Mean and SD were calculated using absolute values of the difference in ultrasound measurements (mm) between positions NF and EER1 and NF and EER2 calculated for each physician as well as an average of all three physicians. Intraclass correlation coefficient (ICC) analysis was used to examine intra- and interrater reliability. RESULTS: The mean absolute difference for NF and EER1 was 0.84 mm (SD 0.93 mm) and for NF and EER2 0.62 mm (SD 0.40 mm) on Study Day 1. Similarly, on Study Day 2, the mean absolute difference for NF and EER1 position was 0.90 mm (SD 0.74 mm) and for NF and EER2 1.03 mm (SD 1.18 mm). Cumulative values of ICC analysis indicated excellent intrarater reliability in all four positions: neutral 0.794 (95% confidence interval [CI], 0.494-0.918), NF 0.927 (95% CI, 0.814-0.971), EER1 0.929 (95% CI, 0.825-0.972), and EER2 0.945 (95% CI, 0.864-0.978). Similarly, interrater ICC analysis cumulative values were excellent for NF, EER1, and EER2 and fair to good for the neutral position: neutral 0.725 (95% CI, 0.526-0.846), NF 0.846 (95% CI, 0.741-0.913), EER1 0.812 (95% CI, 0.674-0.895), and EER2 0.794 (95% CI, 0.652-0.884). CONCLUSIONS: This study offers the first ultrasound protocol of which we are aware for measuring anterior femoral head translation. Hip dynamic ultrasound may assist in providing precise objective clinical-based diagnostic evidence when evaluating complex hip pain and suspected microinstability. Musculoskeletal ultrasound is a reliable office-based method of measuring anterior femoral head translation that can be utilized by physicians with varying experience levels. Future studies are needed to investigate ultrasound anterior femoral head translation taking into account sex, prior hip surgery, hip osseous morphology, and ligamentous laxity. LEVEL OF EVIDENCE: Level III, diagnostic study.

Using urinary bFGF and TIMP3 levels to predict the presence of juvenile pilocytic astrocytoma and establish a distinct biomarker signature.

OBJECTIVE The authors report the use of urinary biomarkers as a novel, noninvasive technique to detect juvenile pilocytic astrocytomas (JPAs), capable of distinguishing JPAs from other CNS diseases, including other brain tumors. Preliminary screening of an array of tumors implicated proteases (including matrix metalloproteinases [MMPs]) and their inhibitors (tissue inhibitors of metalloproteinase [TIMPs]) as well as growth factors (including basic fibroblast growth factor [bFGF]) as candidate biomarkers. These data led the authors to hypothesize that tissue inhibitor of metalloproteinase 3 (TIMP3) and bFGF would represent high-probability candidates as JPA-specific biomarkers. METHODS Urine was collected from 107 patients, which included children with JPA (n = 21), medulloblastoma (n = 17), glioblastoma (n = 9), arteriovenous malformations (n = 25), moyamoya (n = 14), and age- and sex-matched controls (n = 21). Biomarker levels were quantified with enzyme-linked immunosorbent assay, tumor tissue expression was confirmed with immunohistochemical analysis, and longitudinal biomarker expression was correlated with imaging. Results were subjected to univariate and multivariate statistical analyses. RESULTS Using optimal urinary cutoff values of bFGF > 1.0 pg/µg and TIMP3 > 3.5 pg/µg, multiplexing bFGF and TIMP3 predicts JPA presence with 98% accuracy. Multiplexing bFGF and MMP13 distinguishes JPA from other brain tumor subtypes with up to 98% accuracy. Urinary biomarker expression correlated with both tumor immunohistochemistry and in vitro tumor levels. Urinary bFGF and TIMP3 decrease following successful tumor treatment and correlate with changes in tumor size. CONCLUSIONS This study identifies 2 urinary biomarkers-bFGF and TIMP3-that successfully detect one of the most common pediatric brain tumors with high accuracy. These data highlight potential benefits of urinary biomarkers and support their utility as diagnostic tools in the treatment of children with JPA.