What is Sever's Disease?

Patient Presentation
A 9-year-old male came to clinic with intermittent right heel pain for 2 months. He played soccer on a school team, and many other sports with his family and friends at home. His mother said that over time he seemed to be complaining more overall, and the complaint would occur after shorter periods of activity. The pain seemed to subside fairly quickly after the activity. Over the last week, he had stopped playing during a soccer game because of the pain. The past medical history was non-contributory.

The pertinent physical exam showed a healthy male with growth parameters in the 10-50% and normal vital signs. The pain was reproduced with dorsiflexion of the right heel and pressure on the plantar/posterior area of the heel. There was no edema or erythema noted. The rest of the musculoskeletal and neurological examination was negative. The diagnosis of an overuse injury of the Achilles tendon was made. The patient was instructed to do heel-cord stretching and to cut back on his activities. After two weeks of this treatment, he participated in a soccer tournament and had to stop playing because of pain. The family wanted to consult an orthopaedist who diagnosed the patient with Sever’s disease and in addition to the previous recommendation added a heel cup to his shoe. Over the next couple of months, the pain slowly resolved.

Discussion
Acute and overuse injuries are common reasons that children and adolescents present to the clinic or emergency room. Overuse injuries that cause heel pain includes calcaneal apopysitis, retrocalcaneal bursitis, plantar fasciitis, and Achilles tendonitis. Other causes can include osteomyelitis, osteoid osteoma, and bone coalition (2 or more bones in the midfoot or hindfoot are joined, such as tarsal coalition) or accessory bones (such as os navicularis).

Osteochrondroses are a group of injuries to the physis, epiphysis and apophysis. An apopysis is a secondary ossification center located at the tendinous insertion into a bone. Site irritation is called apophysitis and several proposed causes include genetics, rapid growth, trauma (compression or traction), anatomical differences and diet. Whatever the etiological factors, it causes pain. Examples include Osgood Schlatter disease of the tibial tubercle or Iselin’s disease at the base of the fifth metatarsal.

Learning Point
Calcaneal apopysitis is also known as Sever’s disease. It is often seen in active children during late childhood and early adolescence. Repeated stress of the Achilles tendon into the calcaneus causes microfractures with resultant swelling and pain. Pain is located on the heel inferiorly and posteriorly. Pain is increased with dorsiflexion and exercise, but modification of activity and heel cushioning improves the pain. Good heel cord stretching prior to activity also improves the problem. If conservative treatment does not improve the problem, a period of non-weight bearing with or without immobilization may be required.

Radiographs may or may not be helpful as there is variation among individuals and one study of blindly-read radiographs without any clinical history did not find a correlation with clinical symptoms.

In 1000 consecutive visits to an outpatient general pediatric clinic, 61 were for musculoskeletal complaints with 5 (8.2%) being for heel pain, with 3 for Sever’s disease and 2 for plantar fasciitis. Sever’s disease accounts for ~8% of overuse injuries in children and adolescents.

Questions for Further Discussion
1. What causes forefoot pain?
2. What causes ankle pain?
3. What are indications for orthopedic evaluation for foot pain?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mier RJ, Brower TD, Pediatric Orthopedics A Guide for the Primary Care Physician. Plenum Medical Book Co.. New York NY, 1994;36-37.

de Inocencio J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics. 1998 Dec;102(6):E63.

Kose O, Celiktas M, Yigit S, Kisin B. Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever’s disease)? J Pediatr Orthop B. 2010 Sep;19(5):396-8.

Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010 Sep-Oct;9(5):265-8.

Becerro de Bengoa Vallejo R, Losa Iglesias ME, Rodriguez Sanz D, et al.. Plantar pressures in children with and without Sever’s disease. J Am Podiatr Med Assoc. 2011 Jan-Feb;101(1):17-24.

Scharfbillig RW, Jones S, Scutter S. Sever’s disease: a prospective study of risk factors. J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):133-45.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Can Common Cleaners Kill Warts?

    Patient Presentation
    A 12-year-old male came to clinic and had a plantar wart treated by cryotherapy. As part of the patient instructions, the attending physician mentioned that the patient should wear clean socks to help prevent footwear contamination, and that the family could also try Lysol® brand spray disinfectant. The attending clearly stated that he did not have laboratory evidence that this worked, but that he felt he had seen a decrease in spread of the warts to the same foot and cross contamination of the other. The resident and attending seeing the patient later decided to look up this question and see if there was any evidence which might support this other than experience. They found that the disinfectant had alcohol that can be used to treat human papilloma virus but at a lower concentration than should be effective. The attending remarked that after this he might recommend to disinfect with isopropyl alcohol but that this commonly still had a lower concentration than necessary to disinfect.

    Discussion

    There are differences between cleaning, disinfecting and sanitizing.

    • Cleaning removes dirt, germs, and other foreign material from objects and surfaces. Germs are not necessarily killed but cleaning lowers their numbers. Cleaning usually involves soap, water or variations of these.
    • Disinfecting kills germs on surfaces or objects using chemicals. This does not necessarily clean the objects and surfaces of dirt and other foreign material.
    • Sanitizing lowers the number of germs on surfaces or objects to a safe level using a variety of cleaning and disinfecting methods, as judged by public health standards or requirements.

    Lysol® is a commercially-available disinfectant for home use. The manufacturer claims it has disinfecting activity against a variety of germs including bacteria (e.g. Staphylococcus aureus including MRSA, Streptococcus pyogenes, Escherichia coli 0157:H7, etc.), fungi (e.g. Trichophyton mentagrophytes, mildew, etc.) and viruses (e.g. Influenza A, B, Respiratory Syncytial Virus, Rhinovirus and Rotavirus). The manufacturer does not claim that Lysol has activity against HPV and is not unique in not claiming this. Another widely used hospital disinfectant, Virex®, also does not claim disinfecting against HPV, but does work for other difficult pathogens such as Hepatitis B, HIV, and tuberculosis. Lysol’s manufacturer has specific recommendations on how the product should be used on various non-porous surfaces for disinfecting activity. The manufacturer does says it can also be used on soft surfaces such as pillows, cushions, upholstery, backpacks, etc. but does not make recommendations specifically for non-porous surfaces.

    Human papilloma virus (HPV) “…can be transmitted through direct virus-cell contact, such as skin-skin contact, sexual activity, and prolonged exposure to contaminated clothing as the virus may be carried on fomites…” It is resistant to drying and heat and able to survive on clothing and laboratory equipment although exact survival time is unknown. HPV is susceptible to a variety of disinfectants including “… 90% ethanol for at least 1 minute, 2% glutaraldehyde, 30% Savlon [chlorhexidine gluconate and cetrimide], and/or 1% sodium hypochlorite can disinfect the pathogen….”

    Footwear potentially can be difficult to prevent contamination because of difficulty in cleaning of the contact surface materials (i.e. leather, suede), deters general cleaning and/or disinfecting. People also often do not wash footwear as often as other garments. Shoes are moist, warm environments which facilitates viability of the virus.

    Prevention of warts includes keeping feet clean and dry, using flip-flops/sandals in public pools and locker rooms or other moist wet areas, avoiding contact with other warts including not picking at the wart, not using the same file, pumice stone or nail clipper that are used on health skin and nails, and washing hands after touching warts. Frequent washing of potentially contaminated objects such as socks is also appropriate.

    Learning Point
    Lysol® disinfecting spray contains 40-60% alcohol and 0.1-1% quaternary ammonium compounds, benzyl-C12-18-alkyldimethyl, and salts with 1,2-benzisothiazol-3(2H)-one 1,1-dioxide. This alcohol concentration is too low to disinfect for HPV using the information above. The author was unable to locate other information about the disinfecting ability of a lower concentration of alcohol but for a longer contact time. For example using Lysol® disinfecting spray or household rubbing alcohol (isopropyl alcohol, commonly 70%) but to put the treated shoes in an airtight plastic container for several hours.

    Questions for Further Discussion
    1. Would you recommend any disinfection methods for the contact surfaces for plantar warts? If yes, what methods?
    2. What is the scientific basis that home treatments such as using potatoes or vinegar could work to treat warts?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Human Papilloma Virus

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Virex® Tb. Johnson Wax Professional. Available from the Internet at http://www.johnsondiversey.com/wcmt/ProductAttachments/en-US/PIS/SPC214.pdf (rev. 2003, cited 12/5/2011).

    LYSOL® Disinfectant Spray. Reckitt Benckiser. Available from the Internet at http://www.lysol.com/cleaning-products/disinfecting-sprays/disinfectant-spray (rev. 2010, cited 12/5/2011).

    Material Safety Data Sheet. LYSOL® Disinfectant Spray. Reckitt Benckiser. Available from the Internet at http://www.rbnainfo.com/MSDS/US/Lysol-Brand-III-Disinfectant-Spray-US-English.pdf (rev. 7/9/2010, cited 12/5/2011).

    Centers For Disease Control. How to Clean and Disinfect Schools to Help Slow the Spread of Flu.
    Available from the Internet at http://www.cdc.gov/flu/pdf/school/cleaning_disinfecting_schools.pdf (rev. 10/2011, cited 12/5/2011).

    Public Health Agency of Canada. Human Papilloma Virus Pathogen Safety Data Sheet.
    Available from the Internet at http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/papillome-eng.php (rev. 4/19/2011, cited 12/5/2011).

    ACGME Competencies Highlighted by Case

  • Patient Care
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Long After You Start Levothyroxine Should the Labs Be Checked?

    Patient Presentation
    A 17-year-old female came to clinic in March for an upper respiratory infection. The mother said that she was concerned because her daughter had been having constipation for the past several months and was always cold. The patient stated that she had infrequent bowel movements that were soft, but slightly drier and harder to pass. She had larger amounts of stool that did not clog the toilet and denied large circumference stools, overflow diarrhea, blood, mucous or recent travel. She also said that she always felt cold and that her skin seemed drier since moving to the upper Midwest of the United States from a warm weather region of the world about 6 months ago. She denied weight changes or needing to change clothes sizes. She also denied general fatigue, problems concentrating or menstrual irregularities. The past medical history showed a healthy female with a history of malaria at 6 and 9 years of age. The family history was positive for diabetes, stroke, and hypothyroidism in 2 maternal aunts. The review of systems was otherwise negative, including no galactorrhea, or visual changes.

    The pertinent physical exam showed a BMI of 85%. There was a 1 pound weight gain from 3 months previous. Her vital signs were normal. HEENT showed clear rhinrorhea and slightly pink pharynx. She had a diffusely enlarged thyroid without discrete palpable masses within it or external to it. Her hair was slightly coarse consistent with her race and her mother’s appearance. Abdominal examination revealed palpable stool in the right lower quadrant. She was Tanner stage V. Neurological examination showed normal strength, tone and deep tendon reflexes. She had generally dry skin, but no observable edema. The diagnosis of a diffuse goiter along with constipation, cold intolerance and dry skin was made. Although the cold intolerance and dry skin might have been environmentally caused, and the constipation due to nutrition, the goiter and family history raised the concern for acquired hypothyroidism. The relevant work-up confirmed this diagnosis with a thyroid stimulating hormone (TSH) of 49.6 micro-international units/dL (normal up to 4.2) and thyroxine (T4) of .68 nanograms/dL (normal down to .92). The laboratory evaluation demonstrated no thyroid antibodies and an ultrasound showed no specific thyroid nodules. Complete blood count, cholesterol and a random glucose were negative. She was started on levothyroxine with followup in 4 weeks to retest the T4 and TSH. An endocrinology consultation was also ordered. Miralax® was given to help with the constipation while the levothyroxine was taking effect.

    Discussion
    The thyroid gland synthesizes T4 (the predominate product) and some triiodothyronine (T3). Serum T4 is usually bound to T4-binding globulin (TBG) and transported to the peripheral tissue where it is deiodinated into T3, the more biologically active product. T3 regulates a number of biological processes depending on the end organ. Thyroid releasing hormone (TRH) is made in the hypothalamus, and travels to the pituitary to stimulate TSH release. Serum T4 regulates TRH and TSH by a negative feedback loop. Therefore, classically in hypothyroidism, TSH is high and T4 is low as in this patient.

    Acquired hypothyroidism can be found in up to 10% of young females depending on the criteria used, and there is a 2:1 female to male preponderance of the disorder. The presentation in children can be more subtle than in congenital hypothyroidism and may include:

    • Slow growth or short stature
    • Increased sleep
    • Fatigue, lethargy, or inattention
    • Weight gain, usually not the cause of obesity though
    • Edema – especially facial
    • Slow hair or nail growth
    • Dry skin and/or sallow complexion
    • School performance, poor
    • Bradycardia
    • Puberty, precocious or late
    • Immature upper-to-lower body proportions
    • Constipation
    • Galactorrhea
    • Goiter
    • Cold intolerance
    • Heat intolerance, tremors, and weight loss can be common if active thyroiditis is occurring

    Acquired hypothyroidism can be a solitary problem or associated with other endocrinopathies and it can be associated with anemia and hypercholesterolemia. Although children can have neurological symptoms, acquired hypothyroidism generally is not associated with the long term neurological problems which can be seen in congenital hypothyroidism. An overview of congenital hypothyroidism can be found here. In fact some children may have their hypothyroidism resolve and a trial off medication may be warranted. This is usually tried after growth has finished.

    Learning Point
    TSH is the most sensitive screening test for hypothyroidism and for most patients it is the measure of efficacy of its treatment. However the T4 usually normalizes before the TSH, and thus T4 is often used in the initial adjustments to treatment.

    Levothyroxine a synthetic T4 that has a half-life of 6-7 days. Because of the half-life it takes about 3.5 weeks for serum T4 levels to reach a steady state, therefore repeat laboratory testing is usually done about 4 weeks after initial treatment and/or dosage adjustment. Some patients may require more frequent monitoring though. Laboratories are monitored monthly to every 3 months until a normalization of the T4 and TSH. Once this occurs and is stabilized, laboratories are usually monitored every 6 months. Levothyroxine is considered a relatively safe medication and side effects are usually due to iatrogenic or inadvertent overdosing of the medication.

    Questions for Further Discussion
    1. What are the causes of acquired hypothyroidism?
    2. What should be included in the differential diagnosis of acquired hypothyroidism?
    3. What initial laboratory testing is recommended for acquired hypothyroidism?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Thyroid Diseases

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Setian NS. Hypothyroidism in children: diagnosis and treatment. J Pediatr (Rio J). 2007 Nov;83(5 Suppl):S209-16.

    Lomenick JP, El-Sayyid M, Smith WJ. Effect of levo-thyroxine treatment on weight and body mass index in children with acquired hypothyroidism. J Pediatr. 2008 Jan;152(1):96-100.

    Custer JW, Rau RE. The Harriet Lane Handbook. 18th. Edit. Elsevier/Mosby Publications: Philadelphia, PA. 2009:881.

    Ferry RJ, Bauer AJ, Kemp. Pediatric Hypothyroidism. Medscape. Available from the Internet at http://emedicine.medscape.com/article/922777-overview (rev. 8/12/2010, cited 11/28/2011).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Major Diseases Involving Copper Metabolism?

    Patient Presentation
    A 2-year-old male was admitted after a planned gastric tube placement because of recurrent pneumonias and difficulty handling his secretions. He did well during and after the surgery but because of previous anesthesia problems he was monitored overnight. The past medical history showed that he was premature with hypoxic ischemic encephalopathy, developmental delay and seizures. He also had a not-fully defined copper metabolism problem.

    The pertinent physical exam showed a non-verbal child who responded to his parents and caretakers with a smile and some purposeful movements. The gastric tube was in place without bleeding. Neurological examination showed hypertonia with stiff heel cords. The diagnosis of a child with multiple medical problems, status-post gastric tube placement was made. The residents commented that they didn’t know much about copper problems other than they occurred with Menke’s kinky hair disease and Wilson’s disease. The staff pediatrician also agreed and they decided to look up more information and report back to the team the following day.

    Discussion
    Nutritional problems can occur in all parts of the world and in all socioeconomic strata. Caloric and/or protein inadequacy unfortunately plagues too many people because of inadequate supplies or availability. Supplemental food programs around the world attempt to provide appropriate nutrition, but can be stymied because of war, political instability, economic instability and many other social factors.

    The most common specific nutrient deficiencies are iron and Vitamin D deficiencies. Minerals important for essential nutrition include copper, iodine, selenium and zinc. A typical mixed diet usually provides enough minerals. In the United States, mineral deficiencies are usually uncommon unless there is an underlying disease process or abnormal food restrictions or diet. Vegan and other vegetarian diets can provide enough minerals but certain foods may need to be increased to ensure adequate intake.

    Copper is a cofactor in many enzymes include ceruloplasmin, cytochrome oxidase, superoxide dismutase, elastase, lysyl oxidase, dopamine-β-hyroxylase, tyrosinase, and ascorbic acid oxidase. With too much copper, there is the potential to induce reactive free radicals and cause cellular damage. Abnormalities of copper metabolism are caused by genetic mutations in copper-transporting ATPases.

    Copper is available in many foods including liver, shellfish, sunflower seeds, nuts, lentils and even chocolate. It is a component of breast milk (0.2 -0.4 mg/L) in small amounts but is very bioavailable. The World Health Organizations recommends 60 micrograms/kg/day for infants and up to 900 micrograms/day for adults. Increased amounts of copper are needed during growth phases, so it is not surprising that copper deficiency is associated with poor growth patterns or diseases that also cause growth problems. Preterm infants generally have low copper levels for the first 4-6 months of life.

    Copper is absorbed from the intestine into the blood and transported to the liver where is excreted in bile; a small amount is excreted in urine. Copper is processed mainly in the Golgi apparatus and cytoplasm of the hepatocytes.

    Learning Point
    Copper abnormalities occur in:

    • Menke’s kinky hair disease – an X-linked recessive disorder seen in 1/150,000 male births caused by the ATP7A gene which causes a copper deficiency. Problems include aberrant hair, connective tissue disorders, hypothermia, growth abnormalities, and cerebral and cerebellar degeneration including seizures, hypotonia, and developmental delay. Effects manifest usually between 2-4 months, and most children die by age 3 years. Treatment is copper-histadine injections.

    • Occipital horn syndrome – an X-linked recessive very rare syndrome caused by the ATP7A gene which causes a copper deficiency. Patients have connective tissue disorders and ataxia. Problems are similar to Menke’s kinky hair disease. No treatment is readily available.
    • Wilson’s disease – an autosomal recessive disorder seen in 1/30,000-50,000 live births caused by the ATP7B gene which causes copper excess and cellular toxicity. It causes hepatic disease, neurological and psychiatric abnormalities (dysarthria, dystonia, chorea/athetosis, and seizures), arthritis, cardiomyopathy, hematuria, Kayser-Fleischer rings, and pancreatitis. Treatment includes chelating agents and zinc.

    Copper abnormalities also can occur secondarily to patients dependent on total parental nutrition, short bowel syndrome and in burn patients. It can also be associated with problems gaining weight, hypochromic anemia during iron supplementation, neutropenia, and osteoporsis.

    Questions for Further Discussion
    1. What are Kayser Fleischer rings?
    2. What diseases are caused by zinc abnormalities?
    3. What diseases are caused by iodine abnormalities?
    4. What diseases are caused by selenium abnormalities?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Minerals and Wilson’s Disease.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Higdon J, Drake VJ, Turlund JR. Linus Pauling Institute
    Micronutrient Research for Optimum Health. Copper.
    Available from the Internet at http://lpi.oregonstate.edu/infocenter/minerals/copper/ (rev. 2007, cited 11/21/11).

    Suskind DL. Nutritional deficiencies during normal growth.
    Pediatr Clin North Am. 2009 Oct;56(5):1035-53.

    Shah MD, Shah SR. Nutrient deficiencies in the premature infant.
    Pediatr Clin North Am. 2009 Oct;56(5):1069-83.

    Kodama H, Fujisawa C, Bhadhprasit W.
    Pathology, clinical features and treatments of congenital copper metabolic disorders–focus on neurologic aspects.
    Brain Dev. 2011 Mar;33(3):243-51.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital