Septic (Infectious) Arthritis: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


 
Septic arthritis is also commonly referred as bacterial or infectious arthritis. Septic arthritis is an intensely painful infection in a joint. <ref name="mayo Clinic" />&nbsp;Bacteria, viruses and fungi may invade the joint through various routes which cause inflammation of the synovial membrane.<ref name="patho Book" /> &nbsp;With the onset of inflammation, cytokines and proteases are released, thus resulting in potential joint destruction. <ref name="ddx book" />&nbsp;The infection is located in the synovial or periarticular tissues and is most commonly bacterial. <ref name="Merck manual">http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html#v907387</ref>&nbsp;Bacteria or other foreign pathogens can infect either one joint or, if left untreated, can spread and cause further systemic damage. Septic arthritis may occur at any age but is more likely in children and older adults. The most commonly targeted joins in the body are the knee, hip, shoulder, ankle and wrists.&nbsp;<ref name="medscape">http://emedicine.medscape.com/article/236299-overview#aw2aab6b2b3aa</ref>  
 
Septic arthritis is also commonly referred as bacterial or infectious arthritis. Septic arthritis is an intensely painful infection in a joint. <ref name="mayo Clinic" />&nbsp;Bacteria, viruses and fungi may invade the joint through various routes which cause inflammation of the synovial membrane.<ref name="patho Book " /> &nbsp;With the onset of inflammation, cytokines and proteases are released, thus resulting in potential joint destruction. <ref name="ddx book " />&nbsp;The infection is located in the synovial or periarticular tissues and is most commonly bacterial. <ref name="Merck manual">http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html#v907387</ref>&nbsp;Bacteria or other foreign pathogens can infect either one joint or, if left untreated, can spread and cause further systemic damage. Septic arthritis may occur at any age but is more likely in children and older adults. The most commonly targeted joins in the body are the knee, hip, shoulder, ankle and wrists.&nbsp;<ref name="medscape">http://emedicine.medscape.com/article/236299-overview#aw2aab6b2b3aa</ref>


== Prevalence  ==
== Prevalence  ==
Line 19: Line 17:
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Typical presentation of septic arthritis in children and adults includes:
Typical presentation of septic arthritis in children and adults includes:  


*Acute, rapid onset of pain  
*Acute, rapid onset of pain  
Line 29: Line 27:
*Joint warmth  
*Joint warmth  
*Skin rash  
*Skin rash  
*Low grade fever
*Low grade fever  
*Lymphadenopathy&nbsp;
*Lymphadenopathy&nbsp;  
*The joints of the arms and legs are the most commonly affected in adults (especially the knees)  
*The joints of the arms and legs are the most commonly affected in adults (especially the knees)  
*The hip joint is most commonly affected in children
*The hip joint is most commonly affected in children


<ref name="patho Book " /><ref name="merck manual" /><ref name="Ddx book " />
<ref name="patho Book" /><ref name="merck manual" /><ref name="Ddx book" />  


<br>


Symptoms in Newborns/Infants


Symptoms in Newborns/Infants
*Cries when infected joint is moved
*Fever
*Unable to move the limb
*Irritability


*Cries when infected joint is moved
<ref name="pubmed">http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/</ref>
*Fever
*Unable to move the limb
*Irritability


<ref name="pubmed">http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/</ref>
<br>  


Note: A patient may be taking medications for other types of arthritis that may mask the original signs and symptoms of septic arthritis. Early diagnosis for proper treatment is critical.&nbsp;<ref name="Mayo Clinic" /><br>




Note: A patient may be taking medications for other types of arthritis that may mask the original signs and symptoms of septic arthritis. Early diagnosis for proper treatment is critical.&nbsp;<ref name="Mayo Clinic" /><br>
'''Prognosis:'''


'''Prognosis:''' <br>The best outcome for individuals with septic arthritis is immediate treatment. Mortality ranges from 19-25% and permanent joint disability occurs in 25-50% of the cases.<ref name="Goodman and Fuller" /> &nbsp;Fifty percent of adults with septic arthritis have significant decreased range of motion or chronic pain after the infection.<ref name="goldenberg">Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med. Mar 1976;60(3):369-77.</ref> Poor outcome predictors in prognosis of septic arthritis include the following: Age older than 60, infection of the hip or shoulder joints, underlying rheumatoid arthritis, positive findings on synovial fluid cultures after 7 days of therapy, delay of 7 days or longer in beginning treatment.<ref name="Medscape" /><br><br>  
<br>Several factors influence how well the joint can fight the infection including other systemic issues occurring throughout the body. For example, patients with liver or kidney disease, or diseases that make the joint more susceptible to damage such as RA can all cause poorer outcomes.&nbsp;<ref name="Merck manual" /><ref name="science direct article">http://www.sciencedirect.com/science/article/pii/S0140673609615956</ref>.&nbsp;The best outcome for individuals with septic arthritis is immediate treatment. Fifty percent of adults with septic arthritis have significant decreased range of motion or chronic pain after the infection.[8] Poor outcome predictors in prognosis of septic arthritis include the following: Age older than 60, infection of the hip or shoulder joints, underlying rheumatoid arthritis, positive findings on synovial fluid cultures after 7 days of therapy, delay of 7 days or longer in beginning treatment.<ref name="medscape" />&nbsp;Depending on associated risk factors, infection type, and response to treatment, mortality rate from septic arthritis has varied between published studies. One systematic review stated that mortality rate was around 11% between the studies assessed.<ref name="science direct article" /><br><br><br>  


== Associated Co-morbidities<ref name="Goodman and Fuller" />  ==
== Associated Co-morbidities<ref name="Goodman and Fuller" />  ==
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• Systemic corticosteroid use<br>• Radiation therapy<br>• Preexisting arthritis<br>• Arthrocentesis: joint aspiration<br>• Human Immunodeficiency virus<br>• Diabetes Mellitus<br>• Alcohol or drug use<br>• Trauma<br>• Other infectious diseases<br>&nbsp;<br>  
• Systemic corticosteroid use<br>• Radiation therapy<br>• Preexisting arthritis<br>• Arthrocentesis: joint aspiration<br>• Human Immunodeficiency virus<br>• Diabetes Mellitus<br>• Alcohol or drug use<br>• Trauma<br>• Other infectious diseases<br>&nbsp;<br>  


== Medications&nbsp;<br>  ==
== Medical Management&nbsp;<br>  ==
 
The course of treatment for septic arthritis is case dependent. There is no conclusive evidence on the most effective way to begin<ref name="science direct article" />. However, it is a combination of antibiotics, joint fluid removal, infection drainage, and/or total joint surgery. The course of treatment also depends on the type of joint invasion (bacterial, STD bacterial, viral etc..). The first round antibiotics can be directed at the most likely pathogen, <ref name="Merck manual" />&nbsp;then the joint can be tested to see what further treatment may be necessary such as needle joint aspiration or drainage to release the fluid. Another option is to perform &nbsp;joint aspiration before a round of antibiotics is chosen. If the infection is severe enough following a round of antibiotics and aspiration for fluid removal, surgery or even replacement of the entire joint may be necessary. <ref name="Merck manual" /><br>
 
'''Antibiotic treatment:'''
 
Typically, the sexually transmitted related bacteria (gonococcal) is treated with antibiotics that other sexually transmitted infections are treated with. For example, doxycycline, ciproflaxin, and azythromyocin, amongst many others. The non-sexually transmitted bacterial infections can be treated with common antibiotics such as penecillin, vancomyocin, (etc), depending on the severity and resistance tendencies of the bacterial strain. <ref name="Merck manual" /><br>
 
 
 
'''Below is non-exhaustive list of antibiotics commonly used in the treatment of septic arthritis:'''&nbsp;<ref name="medscape" /><ref name="Mayo Clinic" />
 
Ceftriaxone (Rocephin)- Effective against gram-negative enteric rods<br>Ciprofloxacin (Cipro) - Treat N gonorrhoeae and gram-negative enteric rods.<br>Cefixime (Suprax) –Broad activity against gram-negative bacteria, by binding to one or more of the penicillin-binding proteins. Arrests bacterial cell wall synthesis and inhibits bacterial growth.<br>Oxacillin - Oxacillin is useful against methicillin-sensitive S aureus (MSSA).<br>Vancomycin (Vancocin) - An anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.<br>Linezolid (Zyvox) - An alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.<br><br>


Needle joint aspiration is often the initial choice of treatment. Floroscopy is used at the sacroiliac joint and hip due to the difficulty of performing needle aspiration. Following the results of the cultures, antibiotics are chosen.<ref name="Goodman and Fuller" />  
Management regarding antibiotic choice, dosage, route of administration, and duration of treatment is unknown in the treatment of septic arthritis. In addition, no evidence has shown if closed aspiration or open arthroscopy is better at removing materials from a joint that’s infected.&nbsp;<ref name="nih systematic review">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856038/pdf/440.pdf</ref><br><br>


<br> [http://www.cmaj.ca/content/176/11/1605.full.pdf+html?sid=6119ba81-df57-4f78-9118-4f8142ea4cb7]  
<br> [http://www.cmaj.ca/content/176/11/1605.full.pdf+html?sid=6119ba81-df57-4f78-9118-4f8142ea4cb7]  

Revision as of 21:16, 4 April 2017

Original Editors - Amy Bramble & Kayla Klope from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Amy Bramble, Kelli House, Kim Jackson, Lucinda hampton, Admin, Elaine Lonnemann, WikiSysop, 127.0.0.1, Jill Thompson, Wendy Walker, Lauren Lopez, Khloud Shreif and Nupur Smit Shah  

Definition/Description[edit | edit source]

Septic arthritis is also commonly referred as bacterial or infectious arthritis. Septic arthritis is an intensely painful infection in a joint. [1] Bacteria, viruses and fungi may invade the joint through various routes which cause inflammation of the synovial membrane.[2]  With the onset of inflammation, cytokines and proteases are released, thus resulting in potential joint destruction. [3] The infection is located in the synovial or periarticular tissues and is most commonly bacterial. [4] Bacteria or other foreign pathogens can infect either one joint or, if left untreated, can spread and cause further systemic damage. Septic arthritis may occur at any age but is more likely in children and older adults. The most commonly targeted joins in the body are the knee, hip, shoulder, ankle and wrists. [5]

Prevalence[edit | edit source]

In the United States, there are approximately 20,000 cases of septic arthritis reported each year. The most common strain is the staphyloccoccus aureus which is found in 60% of positive cultured joint aspirations. In non gonococcal strains, which includes staphylococcus, this incidence can increase to 28-38 cases per 100,000 in individuals also diagnosed with Rheumatoid Arthritis. [5]

Characteristics/Clinical Presentation[edit | edit source]

Typical presentation of septic arthritis in children and adults includes:

  • Acute, rapid onset of pain
  • Unable to move the joint through active and passive range of motion
  • Typically only one joint (can be bilateral or more than one joint depending on the type of infection)
  • Unable to bear any weight on the joint
  • Effusion 
  • Joint warmth
  • Skin rash
  • Low grade fever
  • Lymphadenopathy 
  • The joints of the arms and legs are the most commonly affected in adults (especially the knees)
  • The hip joint is most commonly affected in children

[2][6][7]


Symptoms in Newborns/Infants

  • Cries when infected joint is moved
  • Fever
  • Unable to move the limb
  • Irritability

[8]


Note: A patient may be taking medications for other types of arthritis that may mask the original signs and symptoms of septic arthritis. Early diagnosis for proper treatment is critical. [9]


Prognosis:


Several factors influence how well the joint can fight the infection including other systemic issues occurring throughout the body. For example, patients with liver or kidney disease, or diseases that make the joint more susceptible to damage such as RA can all cause poorer outcomes. [4][10]. The best outcome for individuals with septic arthritis is immediate treatment. Fifty percent of adults with septic arthritis have significant decreased range of motion or chronic pain after the infection.[8] Poor outcome predictors in prognosis of septic arthritis include the following: Age older than 60, infection of the hip or shoulder joints, underlying rheumatoid arthritis, positive findings on synovial fluid cultures after 7 days of therapy, delay of 7 days or longer in beginning treatment.[5] Depending on associated risk factors, infection type, and response to treatment, mortality rate from septic arthritis has varied between published studies. One systematic review stated that mortality rate was around 11% between the studies assessed.[10]


Associated Co-morbidities[11][edit | edit source]

• Systemic corticosteroid use
• Radiation therapy
• Preexisting arthritis
• Arthrocentesis: joint aspiration
• Human Immunodeficiency virus
• Diabetes Mellitus
• Alcohol or drug use
• Trauma
• Other infectious diseases
 

Medical Management 
[edit | edit source]

The course of treatment for septic arthritis is case dependent. There is no conclusive evidence on the most effective way to begin[10]. However, it is a combination of antibiotics, joint fluid removal, infection drainage, and/or total joint surgery. The course of treatment also depends on the type of joint invasion (bacterial, STD bacterial, viral etc..). The first round antibiotics can be directed at the most likely pathogen, [4] then the joint can be tested to see what further treatment may be necessary such as needle joint aspiration or drainage to release the fluid. Another option is to perform  joint aspiration before a round of antibiotics is chosen. If the infection is severe enough following a round of antibiotics and aspiration for fluid removal, surgery or even replacement of the entire joint may be necessary. [4]

Antibiotic treatment:

Typically, the sexually transmitted related bacteria (gonococcal) is treated with antibiotics that other sexually transmitted infections are treated with. For example, doxycycline, ciproflaxin, and azythromyocin, amongst many others. The non-sexually transmitted bacterial infections can be treated with common antibiotics such as penecillin, vancomyocin, (etc), depending on the severity and resistance tendencies of the bacterial strain. [4]


Below is non-exhaustive list of antibiotics commonly used in the treatment of septic arthritis: [5][9]

Ceftriaxone (Rocephin)- Effective against gram-negative enteric rods
Ciprofloxacin (Cipro) - Treat N gonorrhoeae and gram-negative enteric rods.
Cefixime (Suprax) –Broad activity against gram-negative bacteria, by binding to one or more of the penicillin-binding proteins. Arrests bacterial cell wall synthesis and inhibits bacterial growth.
Oxacillin - Oxacillin is useful against methicillin-sensitive S aureus (MSSA).
Vancomycin (Vancocin) - An anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.
Linezolid (Zyvox) - An alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.

Management regarding antibiotic choice, dosage, route of administration, and duration of treatment is unknown in the treatment of septic arthritis. In addition, no evidence has shown if closed aspiration or open arthroscopy is better at removing materials from a joint that’s infected. [12]


[1]

Septic Arthritis.png

www.cmaj.ca/content/176/11/1605.full.pdf+html

Common Antibiotic Used:[13]

  • Ceftriaxone (Rocephin)- Effective against gram-negative enteric rods
  • Ciprofloxacin (Cipro) - Treat N gonorrhoeae and gram-negative enteric rods.
  • Cefixime (Suprax) –Broad activity against gram-negative bacteria, by binding to one or more of the penicillin-binding proteins. Arrests bacterial cell wall synthesis and inhibits bacterial growth.
  • Oxacillin - Oxacillin is useful against methicillin-sensitive S aureus (MSSA).
  • Vancomycin (Vancocin) - An anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.
  • Linezolid (Zyvox) - An alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.

Diagnostic Tests/Lab Tests/Lab Values[14][edit | edit source]

  • Arthrocentesis with synovial fluid examination and culture
  • Increased White blood cell count
  • Increased Erythrocyte sedimentation rate (ESR)
  • Increased Temperature
  • Increased C-Reactive Protein (CRP)
  • Imaging studies are used to rule out other conditions

 Algorithm septic arthritis.png[15]

www.vumc.nl/afdelingen-themas/41463/27797/2089686/2090082/1608664/8.pdf

Etiology/Causes[edit | edit source]

Septic arthritis is caused by invasion of bacteria, viruses, or fungi into the synovial membrane of a joint. This occurs most commonly by direct inoculation, penetrating wound, or direct extension.  [16]The most common mechanism of infection is via hematogenous. [11]

www.merckmanuals.com/media/professional/pdf/Table_039-2.pdf

The most important risk factors to consider include age (children and older adults are at greatest risk), diabetes mellitus, IV drug use, indwelling catheters, immunocompromised condition, rheumatoid arthritis, osteoarthritis, alcohol abuse, or a recent history of joint damage.  [16]An additional risk factor is recent ACL reconstruction with a contaminated bone-tendon-bone allograft.[16]  This is not a common occurrence secondary to advances in medicine.

Risk Factors for Acquiring Septic Arthritis 
Age (Neonates, children, older adult)
Alcoholism
Anemia
Arthrocentesis or joint surgery
Bacteremia
Cancer
Diabetes
Hemodialysis
Hemophilia
History of previous joint infection
Immunodeficiency 
Immunosuppressive therapy 
IV drug use
Joint Replacement 
RA
Risk for sexually tramitted disease
Sickle cell disease 
Skin infection 
SLE
Any other chronic illness not listed

Systemic Involvement[edit | edit source]

Septic arthritis presents with a multitude of signs and symptoms affecting visceral systems. Joint symptoms may present in conjunction with a skin rash, low-grade fever, chills, and lymphadenopathy.  [16]Bilateral joint involvement is common in the fingers, knees, shoulders, and ankles. The classic signs of infection may be present including increased temperature, swelling, redness, and loss of function.  [11] Acute symptoms of an arthritic joint in the presence of fever should alert the health care provider of potential septic arthritis and should be treated as a medical emergency.

Medical Management (current best evidence)[edit | edit source]

Antibiotic Treatment- Septic arthritis is best treated immediately with antibiotics. There is no one antibiotic better than another; rather it is based on the organism involved. Antibiotics will need to be chosen based on the culture.[17] 


Joint Drainage and Surgical options- Removal of infected joint material is imperative in improving a patient’s status. One systematic review found “the results suggested that needle aspiration appeared, in general, to be preferable to surgical treatment as an initial mode of treatment of joint sepsis, although the results did not reach statistical significance (and there was a trend towards higher mortality in the needle aspiration group)".[17]


Management regarding antibiotic choice, dosage, route of administration, and duration of treatment is unknown in the treatment of septic arthritis. In addition, no evidence has shown if closed aspiration or open arthroscopy is better at removing materials from a joint that’s infected.[17]



[18]

Physical Therapy Management (current best evidence)[13][edit | edit source]

It is important to first immobilize the joint. This will control the patient’s pain because it is often too painful to bear weight. Gentle mobilization of the infected joint can begin if the patient is responding well following 5 days of gentle treatment. Patients will usually respond better to aggressive PT to allow maximum post infection functioning. PT needs to consists of allowing the joint to be in its functional position and positioning the joint to allow passive range of motion activities.

Differential Diagnosis[edit | edit source]

Septic arthritis presents as many associated arthropathies, these must be ruled out in order for a definitive diagnosis to be made. With the immediacy of joint destruction with septic arthritis, the differential diagnosis must be performed with urgency to initiate proper treatment immediately. Conditions that must be considered include: rheumatoid arthritis, osteoarthritis, HIV infection, Lyme disease, and gout. Patients with these diagnoses often have a poor prognosis secondary to delays in the proper diagnosis of septic arthritis. Clinicians often attribute the signs and symptoms to the preexisting conditions. Other conditions that must be ruled out include: infective endocarditis, reactive arthritis, and viral arthritis.[19] 

Case Reports/ Case Studies[edit | edit source]

  • Septic arthritis of the hip:

www.ncbi.nlm.nih.gov/pmc/articles/PMC2485040/

  • Pneumococcal polyarticular septic arthritis after a single infusion of infliximab in a rheumatoid arthritis patient:

www.jmedicalcasereports.com/content/6/1/81

  • Cervical facet joint septic arthritis:  

ukpmc.ac.uk/articles/PMC2958294/

Resources
[edit | edit source]

Mayo Clinic  www.mayoclinic.com/health/bone-and-joint-infections/DS00545

Medscape emedicine.medscape.com/article/236299-overview

Merck Manual

 www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html

PubMed www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/

Recent Related Research (from Pubmed)
[edit | edit source]

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References[edit | edit source]

see adding references tutorial.

  1. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named mayo Clinic
  2. ↑ 2.0 2.1 Cite error: Invalid <ref> tag; no text was provided for refs named patho Book
  3. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named ddx book
  4. ↑ 4.0 4.1 4.2 4.3 4.4 http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html#v907387
  5. ↑ 5.0 5.1 5.2 5.3 http://emedicine.medscape.com/article/236299-overview#aw2aab6b2b3aa
  6. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named merck manual
  7. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Ddx book
  8. ↑ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/
  9. ↑ 9.0 9.1 Cite error: Invalid <ref> tag; no text was provided for refs named Mayo Clinic
  10. ↑ 10.0 10.1 10.2 http://www.sciencedirect.com/science/article/pii/S0140673609615956
  11. ↑ 11.0 11.1 11.2 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009.
  12. ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856038/pdf/440.pdf
  13. ↑ 13.0 13.1 Cite error: Invalid <ref> tag; no text was provided for refs named Medscape
  14. ↑ Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg. 2011 July; 93(11): 1556-61.
  15. ↑ Goldenberg DL. Septic arthritis. The Lancet. 1998 [cited 2012 March 22]; 351: 197-202. Available from VUMC with Full Text: http://www.vumc.nl/afdelingen-themas/41463/27797/2089686/2090082/1608664/8.pdf
  16. ↑ 16.0 16.1 16.2 16.3 Goodman CC, Snyder TEK. Differential diagnosis for physical therapists: screening for referral. 4th ed. St. Louis: Saunders Elsevier; 2007.
  17. ↑ 17.0 17.1 17.2 Matthews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007 [cited 2012 March 2]; 66: 440-45. Available from NCBI with Full Text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856038/pdf/440.pdf
  18. ↑ YouTube. Septic arthritis of the knee arthroscopic debridement. Available at: http://www.youtube.com/watch?v=0AOv06XWCps. (Accessed 2012 April 3).
  19. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named goldenberg
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