Whole blood transcriptome in long-COVID patients reveals association with lung function and immune response.

BACKGROUND: Months after infection with severe acute respiratory syndrome coronavirus 2, at least 10% of patients still experience complaints. Long-COVID (coronavirus disease 2019) is a heterogeneous disease, and clustering efforts revealed multiple phenotypes on a clinical level. However, the molecular pathways underlying long-COVID phenotypes are still poorly understood. OBJECTIVES: We sought to cluster patients according to their blood transcriptomes and uncover the pathways underlying their disease. METHODS: Blood was collected from 77 patients with long-COVID from the Precision Medicine for more Oxygen (P4O2) COVID-19 study. Unsupervised hierarchical clustering was performed on the whole blood transcriptome. These clusters were analyzed for differences in clinical features, pulmonary function tests, and gene ontology term enrichment. RESULTS: Clustering revealed 2 distinct clusters on a transcriptome level. Compared with cluster 2 (n = 65), patients in cluster 1 (n = 12) showed a higher rate of preexisting cardiovascular disease (58% vs 22%), higher prevalence of gastrointestinal symptoms (58% vs 29%), shorter hospital duration during severe acute respiratory syndrome coronavirus 2 infection (median, 3 vs 8 days), lower FEV1/forced vital capacity (72% vs 81%), and lower diffusion capacity of the lung for carbon monoxide (68% vs 85% predicted). Gene ontology term enrichment analysis revealed upregulation of genes involved in the antiviral innate immune response in cluster 1, whereas genes involved with the adaptive immune response were upregulated in cluster 2. CONCLUSIONS: This study provides a start in uncovering the pathophysiological mechanisms underlying long-COVID. Further research is required to unravel why the immune response is different in these clusters, and to identify potential therapeutic targets to create an optimized treatment or monitoring strategy for the individual long-COVID patient.

Longer epidermal cells underlie a quantitative source of variation in wheat flag leaf size.

The wheat flag leaf is the main contributor of photosynthetic assimilates to developing grains. Understanding how canopy architecture strategies affect source strength and yield will aid improved crop design. We used an eight-founder population to investigate the genetic architecture of flag leaf area, length, width and angle in European wheat. For the strongest genetic locus identified, we subsequently created a near-isogenic line (NIL) pair for more detailed investigation across seven test environments. Genetic control of traits investigated was highly polygenic, with colocalisation of replicated quantitative trait loci (QTL) for one or more traits identifying 24 loci. For QTL QFll.niab-5A.1 (FLL5A), development of a NIL pair found the FLL5A+ allele commonly conferred a c. 7% increase in flag and second leaf length and a more erect leaf angle, resulting in higher flag and/or second leaf area. Increased FLL5A-mediated flag leaf length was associated with: (1) longer pavement cells and (2) larger stomata at lower density, with a trend for decreased maximum stomatal conductance (Gsmax ) per unit leaf area. For FLL5A, cell size rather than number predominantly determined leaf length. The observed trade-offs between leaf size and stomatal morphology highlight the need for future studies to consider these traits at the whole-leaf level.

Lichen planus esophagitis.

PURPOSE OF REVIEW: Dysphagia is one of the most common reasons for patients' visits to a gastroenterologist. Esophageal lichen planus (ELP) has historically been felt to be a rare disease, when in fact it is often misdiagnosed and unrecognized. Often first diagnosed as an unusual esophagitis, all gastroenterologists will see ELP in their practice, and need to be able to recognize this condition. RECENT FINDINGS: Although there is still a relative paucity of data on this condition, this article will update the typical presenting symptoms, endoscopic findings, and ways to differentiate ELP from other inflammatory mucosal diseases. There is still no standardized treatment algorithm, but we will also present the most recent treatment approaches. SUMMARY: It is critical that physicians maintain an increased awareness of ELP and have a high clinical suspicion in the appropriate patients. While management remains challenging, it is important to treat both the inflammatory and stricturing components of the disease. A multidisciplinary approach is also often required, utilizing dermatologists, gynecologists, and dentists who are familiar with managing patients with LP.

Modeling the importance of fish condition, overall health, and disease on the fecundity of White Perch in the Choptank River.

OBJECTIVE: Modeling of fecundity with allometric, nutritional, and environmental covariates has increased sensitivity of reproductive metrics in many fish species. In estuaries with heavy anthropogenic influence, resident species often experience sublethal health impacts because of increased stress, which can include increases in gonadal pathology, intersex, or potential reproductive failure. This study models the fecundity of the estuarine species White Perch Morone americana in response to health parameters identified as signals of habitat stress, including gross pathology presentation, nutritional condition, and disease presence. METHODS: Subpopulation fecundity in the Choptank River (Maryland) of the Chesapeake Bay was estimated using stereological fecundity sampling methods and modeled using information-theoretic approaches of model selection. Nutritional and health parameters identified through health assessment techniques, specific somatic indices, and disease presence were selected as covariates. RESULT: Nutrition demonstrated limited influence on model fit as compared to models with only conventional allometric variables such as weight and length. Of the health variables, gross pathology and somatic indices showed minimal influence on selection, but mycobacterial infection, a chronic condition in the Chesapeake Bay among temperate basses, showed measurable influence. Models with mycobacteriosis included were 40 times more likely the best fit when compared to models with only allometric parameters. CONCLUSION: Whether this has a region-wide influence on all subpopulations will require further research and sampling of the magnitude of mycobacteriosis infection.

Demystifying Esophageal Lichen Planus: A Comprehensive Review of a Rare Disease You Will See in Practice.

Lichen planus (LP) is a chronic inflammatory disorder that often affects the skin, hair, nails, and mucus membranes. Although esophageal involvement has traditionally been felt to be rare, recent reports suggest that it is often unrecognized or misdiagnosed. The diagnoses of esophageal lichen planus can be challenging and is suspected based on patients' endoscopic and histologic findings and in the context of their clinical history and physical examination. Physicians must have an index of suspicion, particularly in older white women and in those patients with an atypical esophagitis or stricturing disease, which do not respond to traditional treatment. Currently, there are limited data on esophageal lichen planus patients, and no formal management guidelines for this disease, which all gastroenterologists will see in practice. This article reviews the etiology and histopathology of LP and provides a comprehensive discussion of the clinical features, diagnosis, and management of esophageal disease from the gastroenterologist's perspective. Finally, we address the esophageal complications of LP.

Investigating the Relationship between Nitrate, Total Dissolved Nitrogen, and Phosphate with Abundance of Pathogenic Vibrios and Harmful Algal Blooms in Rehoboth Bay, Delaware.

Vibrio spp. and phytoplankton are naturally abundant in marine environments. Recent studies have suggested that the co-occurrence of phytoplankton and the pathogenic bacterium Vibrio parahaemolyticus is due to shared ecological factors, such as nutrient requirements. We compared these communities at two locations in the Delaware Inland Bays, representing a site with high anthropogenic inputs (Torquay Canal) and a less developed area (Sloan Cove). In 2017 to 2018, using light microscopy, we were able to identify the presence of many bloom-forming algal species, such as Karlodinium veneficum, Dinophysis acuminata, Heterosigma akashiwo, and Chattonella subsalsa. Dinoflagellate biomass was higher at Torquay Canal than that at Sloan Cove. D. acuminata and Chloromorum toxicum were found only at Torquay Canal and were not observed in Sloan Cove. Most probable number real-time PCR revealed V. parahaemolyticus and Vibrio vulnificus in environmental samples. The abundance of vibrios and their virulence genes varied between sites, with a significant association between total dissolved nitrogen (TDN), PO4-, total dissolved phosphorus (TDP), and pathogenic markers. A generalized linear model revealed that principal component 1 of environmental factors (temperature, dissolved oxygen, salinity, TDN, PO4-, TDP, NO3:NO2, NO2-, and NH4+) was the best at detecting total (tlh+) V. parahaemolyticus, suggesting that they are the prime drivers for the growth and distribution of pathogenic Vibrio spp. IMPORTANCE Vibrio-associated illnesses have been expanding globally over the past several decades (A. Newton, M. Kendall, D. J. Vugia, O. L. Henao, and B. E. Mahon, Clin Infect Dis 54:S391-S395, 2012, https://doi.org/10.1093/cid/cis243). Many studies have linked this expansion with an increase in global temperature (J. Martinez-Urtaza, B. C. John, J. Trinanes, and A. DePaola, Food Res Int 43:10, 2010, https://doi.org/10.1016/j.foodres.2010.04.001; L. Vezzulli, R. R. Colwell, and C. Pruzzo, Microb Ecol 65:817-825, 2013, https://doi.org/10.1007/s00248-012-0163-2; R. N. Paranjpye, W. B. Nilsson, M. Liermann, and E. D. Hilborn, FEMS Microbiol Ecol 91:fiv121, 2015, https://doi.org/10.1093/femsec/fiv121). Temperature and salinity are the two major factors affecting the distribution of Vibrio spp. (D. Ceccarelli and R. R. Colwell, Front Microbiol 5:256, 2014, https://doi.org/10.3389/fmicb.2014.00256). However, Vibrio sp. abundance can also be affected by nutrient load and marine plankton blooms (V. J. McKenzie and A. R. Townsend, EcoHealth 4:384-396, 2007; L. Vezzulli, C. Pruzzo, A. Huq, and R. R. Colwell, Environ Microbiol Rep 2:27-33, 2010, https://doi.org/10.1111/j.1758-2229.2009.00128.x; S. Liu, Z. Jiang, Y. Deng, Y. Wu, J. Zhang, et al. Microbiologyopen 7:e00600, 2018, https://doi.org/10.1002/mbo3.600). The expansion of Vibrio spp. in marine environments calls for a deeper understanding of the biotic and abiotic factors that play a role in their abundance. We observed that pathogenic Vibrio spp. were most abundant in areas that favor the proliferation of harmful algal bloom (HAB) species. These results can inform managers, researchers, and oyster growers on factors that can influence the growth and distribution of pathogenic Vibrio spp. in the Delaware Inland Bays.

Discordance between high-resolution manometry, esophagoscopy and contrast esophagogram in determining landmarks for per-oral endoscopic myotomy in spastic esophageal disorders: a word of caution.

BACKGROUND: Myotomy length for per-oral endoscopic myotomy (POEM) is standardized for type I and II achalasia. However, for type III achalasia, jackhammer esophagus, diffuse esophageal spasms and esophagogastric junction outflow obstruction, there is no standard. Determining myotomy length based on the high-pressure zone found during high-resolution manometry (HRM) and spastic length found during esophagography may be used to determine adequate myotomy length without excess muscle destruction. METHODS: The records of patients who have undergone POEM procedures at our institution had the following data gleaned: age, sex, esophageal spastic diagnosis, length of high-pressure zone and lower esophageal sphincter (LES) position by HRM, length of spastic esophagus by esophagography, position of the z-line by esophagoscopy and length of myotomy performed. Outcomes were assessed based on patient symptomatic improvement and need for re-intervention. RESULTS: 71 patients were evaluated for POEM, with 67 completing POEM. There was an average difference in LES position by HRM and z-line position by esophagoscopy of 3.9 ± 3.0 cm. There was an average difference in high-pressure zone by HRM and spastic length by esophagography of 4.9 ± 3.2 cm. Overall, with a median of 20 months follow-up, 74% achieved long-term symptomatic improvement, with 17 patients requiring re-intervention. CONCLUSIONS: Discordance among HRM, esophagography and esophagoscopy can be significant. Caution should be employed with using these methods to determine myotomy length in POEM.

Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of clinical improvement post treatment for achalasia.

Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and 2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and 16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%). AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87-0.99] and ASQ 0.97 (95% CI 0.92-0.99). The Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures, respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients' values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument and patients classified, as treatment successes may be spared routine physiologic testing in the long term.

Seasonal and Geographical Differences in Total and Pathogenic Vibrio parahaemolyticus and Vibrio vulnificus Levels in Seawater and Oysters from the Delaware and Chesapeake Bays Determined Using Several Methods.

Oyster and seawater samples were collected from five sites in the Chesapeake Bay, MD, and three sites in the Delaware Bay, DE, from May to October 2016 and 2017. Abundances and detection frequencies for total and pathogenic Vibrio parahaemolyticus and Vibrio vulnificus were compared using the standard most-probable-number-PCR (MPN-PCR) assay and a direct-plating (DP) method on CHROMagar Vibrio for total (tlh+ ) and pathogenic (tdh+ and trh+ ) V. parahaemolyticus genes and total (vvhA) and pathogenic (vcgC) V. vulnificus genes. The colony overlay procedure for peptidases (COPP) assay was evaluated for total Vibrionaceae DP had high false-negative rates (14 to 77%) for most PCR targets and was deemed unsatisfactory. Logistic regression models of the COPP assay showed high concordances with MPN-PCR for tdh+ and trh+V. parahaemolyticus and vvhA+V. vulnificus in oysters (85.7 to 90.9%) and seawater (81.1 to 92.7%) when seawater temperature and salinity were factored into the model, suggesting that the COPP assay could potentially serve as a more rapid method to detect vibrios in oysters and seawater. Differences in total Vibrionaceae and pathogenic Vibrio abundances between state sampling sites over different collection years were contrasted for oysters and seawater by MPN-PCR. Abundances of tdh+ and trh+V. parahaemolyticus were ∼8-fold higher in Delaware oysters than in Maryland oysters, whereas abundances of vcgC+V. vulnificus were nearly identical. For Delaware oysters, 93.5% were both tdh+ and trh+, compared to only 19.2% in Maryland. These results indicate that pathogenic V. parahaemolyticus was more prevalent in the Delaware Bay than in the Chesapeake Bay.IMPORTANCE While V. parahaemolyticus and V. vulnificus cause shellfish-associated morbidity and mortality among shellfish consumers, current regulatory assays for vibrios are complex, time-consuming, labor-intensive, and relatively expensive. In this study, the rapid, simple, and inexpensive COPP assay was identified as a possible alternative to MPN-PCR for shellfish monitoring. This paper shows differences in total Vibrionaceae and pathogenic vibrios found in seawater and oysters from the commercially important Delaware and Chesapeake Bays. Vibrio parahaemolyticus isolates from the Delaware Bay were more likely to contain commonly recognized pathogenicity genes than those from the Chesapeake Bay.

Heller Myotomy for Epiphrenic Diverticula Compared to Nondiverticula Esophageal Motility Disorders, A Single Institution Experience and Appraisal of Patient Characteristics, High-Resolution Manometry and Outcomes.

PURPOSE: The purpose of this study was to compare demographics, symptoms, prior interventions, operation, and outcomes of patients who underwent Heller myotomy for esophageal motility disorders and epiphrenic diverticulectomy with Heller myotomy. METHODS: We identified all patients who underwent Heller myotomy for esophageal motility disorders with and without esophageal diverticulectomy over an 80-month period. Primary data points included patient demographics, presenting symptoms, prior intervention, high-resolution manometry, surgery performed with rate of laparoscopic, conversion to open, and open procedures; postoperative complications, and symptom resolution. RESULTS: Over the study period, 308 Heller esophagomyotomy operations were performed on 301 patients. Of these, 277 cases were without epiphrenic diverticula and 31 included diverticula. One patient with an asymptomatic epiphrenic diverticulum did not undergo surgery was included, for a total of 32 diverticula patients. Six patients in the non-diverticula group and 1 in the diverticula group required a second operation for recurrent symptoms or residual diverticulum. The diverticula group was significantly older, had different manometry findings, required more open operations, and had longer length of stay. The diverticula group had a lower frequency of patients with prior interventions, but similar postoperative leaks, higher overall postoperative complications, and no difference in reported symptomatic improvement. CONCLUSIONS: Esophageal diverticula patients have a unique profile compare to patients with non-diverticula motility disorders. Operations are more complex, with increased complication rate and a longer length of stay. In spite of this, there is no statistically significant difference in symptomatic outcomes between the groups.

Vibrio parahaemolyticus in the Chesapeake Bay: Operational In Situ Prediction and Forecast Models Can Benefit from Inclusion of Lagged Water Quality Measurements.

Vibrio parahaemolyticus is a leading cause of seafood-borne gastroenteritis. Given its natural presence in brackish waters, there is a need to develop operational forecast models that can sufficiently predict the bacterium's spatial and temporal variation. This work attempted to develop V. parahaemolyticus prediction models using frequently measured time-indexed and -lagged water quality measures. Models were built using a large data set (n = 1,043) of surface water samples from 2007 to 2010 previously analyzed for V. parahaemolyticus in the Chesapeake Bay. Water quality variables were classified as time indexed, 1-month lag, and 2-month lag. Tobit regression models were used to account for V. parahaemolyticus measures below the limit of quantification and to simultaneously estimate the presence and abundance of the bacterium. Models were evaluated using cross-validation and metrics that quantify prediction bias and uncertainty. Presence classification models containing only one type of water quality parameter (e.g., temperature) performed poorly, while models with additional water quality parameters (i.e., salinity, clarity, and dissolved oxygen) performed well. Lagged variable models performed similarly to time-indexed models, and lagged variables occasionally contained a predictive power that was independent of or superior to that of time-indexed variables. Abundance estimation models were less effective, primarily due to a restricted number of samples with abundances above the limit of quantification. These findings indicate that an operational in situ prediction model is attainable but will require a variety of water quality measurements and that lagged measurements will be particularly useful for forecasting. Future work will expand variable selection for prediction models and extend the spatial-temporal extent of predictions by using geostatistical interpolation techniques.IMPORTANCEVibrio parahaemolyticus is one of the leading causes of seafood-borne illness in the United States and across the globe. Exposure often occurs from the consumption of raw shellfish. Despite public health concerns, there have been only sporadic efforts to develop environmental prediction and forecast models for the bacterium preharvest. This analysis used commonly sampled water quality measurements of temperature, salinity, dissolved oxygen, and clarity to develop models for V. parahaemolyticus in surface water. Predictors also included measurements taken months before water was tested for the bacterium. Results revealed that the use of multiple water quality measurements is necessary for satisfactory prediction performance, challenging current efforts to manage the risk of infection based upon water temperature alone. The results also highlight the potential advantage of including historical water quality measurements. This analysis shows promise and lays the groundwork for future operational prediction and forecast models.

Improving the Diagnostic Capability of the Modified Barium Swallow Study Through Standardization of an Esophageal Sweep Protocol.

The modified  barium swallow (MBS) study is a videofluoroscopic evaluation of oropharyngeal swallow function. Esophageal imaging is not routinely performed during an MBS, and few guidelines for implementation or interpretation exist. Aims of the current investigation were to (1) delineate the percentage of normal, oropharyngeal, esophageal, and mixed swallowing dysfunction, (2) develop operational definitions for rating our standardization cursory view of esophageal bolus flow, and (3) determine inter-rater reliability between speech pathology (SLP) and physician raters for categorizing esophageal abnormalities. A two-phase retrospective review of 358 patient charts and MBS studies was conducted. Esophageal bolus flow was operationally defined as (1) normal, (2) anatomic abnormality, (3) dysmotility and (4) combined. Descriptive statistics, a Chi square with alpha set at 0.05, and Kappa analysis were performed. Esophageal dysfunction was identified in 80 (26%) patients and included: anatomic abnormality (69%), dysmotility (17%), and combined abnormality (14%). Phase one reliability testing yielded fair agreement between SLP and MD raters k = 0.5. Following revision of definitions and consensus training, phase two reliability testing resulted in excellent agreement between the same raters k = 0.9. Multiphase or primary esophageal dysphagia was found in 26% of our sample using a standardized protocol rating esophageal bolus flow from the upper esophageal sphincter through the lower esophageal sphincter during the MBS. Improved agreement between SLP and MD raters after definition revision and training suggests these operational definitions are concise, objective and reliable. An expanded MBS study may lead to early identification of esophageal disorders, encourage multidisciplinary patient care, and improve patient health outcomes.

Vibrio parahaemolyticus and Vibrio vulnificus Recovered from Oysters during an Oyster Relay Study.

Vibrio parahaemolyticus and Vibrio vulnificus are naturally occurring estuarine bacteria and are the leading causes of seafood-associated infections and mortality in the United States. Though multiple-antibiotic-resistant V. parahaemolyticus and V. vulnificus strains have been reported, resistance patterns in vibrios are not as well documented as those of other foodborne bacterial pathogens. Salinity relaying (SR) is a postharvest processing (PHP) treatment to reduce the abundances of these pathogens in shellfish harvested during the warmer months. The purpose of this study was to evaluate the antimicrobial susceptibility (AMS), pathogenicity, and genetic profiles of V. parahaemolyticus and V. vulnificus recovered from oysters during an oyster relay study. Isolates (V. parahaemolyticus [n = 296] and V. vulnificus [n = 94]) were recovered from oysters before and during the 21-day relaying study to detect virulence genes (tdh and trh) and genes correlated with virulence (vcgC) using multiplex quantitative PCR (qPCR). AMS to 20 different antibiotics was investigated using microbroth dilution, and pulsed-field gel electrophoresis (PFGE) was used to study the genetic profiles of the isolates. Twenty percent of V. vulnificus isolates were vcgC+, while 1 and 2% of V. parahaemolyticus were tdh+ and trh+, respectively. More than 77% of the V. vulnificus isolates and 30% of the V. parahaemolyticus isolates were resistant to at least one antimicrobial. Forty-eight percent of V. vulnificus and 8% of V. parahaemolyticus isolates were resistant to two or more antimicrobials. All isolates demonstrated a high genetic diversity, even among those isolated from the same site and having a similar AMS profile. No significant effects of the relaying process on AMS, virulence genes, or PFGE profiles of V. vulnificus and V. parahaemolyticus were observed.IMPORTANCE Analysis of the antibiotic resistance profiles of V. vulnificus and V. parahaemolyticus isolated from oysters during this study indicated that more than 48% of V. vulnificus isolates were resistant to two or more antimicrobials, including those recommended by the CDC for treating Vibrio infections. Also, the V. parahaemolyticus isolates showed high MICs for some of the Vibrio infection treatment antibiotics. Monitoring of AMS profiles of this bacterium is important to ensure optimal treatment of infections and improve food safety. Our study showed no significant differences in the AMS profiles of V. vulnificus (P = 0.26) and V. parahaemolyticus (P = 0.23) isolated from the oysters collected before versus after relaying. This suggests that the salinity of the relaying sites did not affect the AMS profiles of the Vibrio isolates, although it did reduce the numbers of these bacteria in oysters (S. Parveen et al., J Food Sci 82:484-491, 2017, https://doi.org/10.1111/1750-3841.13584).

Childhood Obesity is Associated With Osteochondritis Dissecans of the Knee, Ankle, and Elbow in Children and Adolescents.

BACKGROUND: Osteochondritis dissecans (OCD) is a joint disorder of the subchondral bone and articular cartilage whose association with obesity in children is not clearly known. The purpose of this study was to assess the magnitude of the association between childhood obesity and the occurrence of OCD of the knee, ankle, and elbow in children. METHODS: A retrospective chart review of an integrated health system was performed on OCD patients aged 2 to 19 from 2007 to 2011, with over 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. The body mass index (BMI) for each patient in the cohort was used to stratify patients into 5 weight classes (underweight, normal weight, overweight, moderately obese, and extremely obese) based on BMI-for-age. The associations between the 5 weight classes and OCD of the ankle, knee, and elbow were assessed using multiple logistic regression models to estimate odds ratios (OR) and 95% confidence intervals using multivariate analysis to adjust for patient demographic variables. RESULTS: In total, 269 patients fit the inclusion criteria. Mean BMI, both absolute and percentile, was significantly higher for patients with OCD of the knee, elbow, and ankle than patients without OCD. In the multivariate analysis, extremely obese patients were found to have an increased OR of OCD for all patients, with an 86% increased risk of any OCD compared with normal weight patients. In addition, assessment by different types of OCD revealed that extremely obese patients had an increased OR of OCD of the elbow and ankle individually, with a 3.1 times increased OCD elbow risk and 3.0 times increased risk of ankle OCD in extremely obese patients. Although extremely obese patients did not have a statistically significant increased risk of knee OCD, moderately obese patients did have a 1.8 times increased risk of knee OCD as compared with normal weight children. There were no significantly different risks of any type of OCD seen in overweight or underweight patients as compared with normal weight patients. CONCLUSIONS: In this population-based cohort study, extreme obesity is strongly associated with an increased risk of OCD overall and OCD of the elbow and ankle specifically. In addition, moderate obesity is associated with an increased risk of knee OCD. All types of OCD were also found to have a significantly greater average BMI when compared with patients without OCD. LEVEL OF EVIDENCE: Level IV-descriptive epidemiology study.

Environmental Determinants of Vibrio parahaemolyticus in the Chesapeake Bay.

Vibrio parahaemolyticus naturally occurs in brackish and marine waters and is one of the leading causes of seafood-borne illness. Previous work studying the ecology of V. parahaemolyticus has often been limited in geographic extent and lacked a full range of environmental measures. This study used a unique large data set of surface water samples in the Chesapeake Bay (n = 1,385) collected from 148 monitoring stations from 2007 to 2010. Water was analyzed for more than 20 environmental parameters, with additional meteorological and surrounding land use data. The V. parahaemolyticus-specific genetic markers thermolabile hemolysin (tlh), thermostable direct hemolysin (tdh), and tdh-related hemolysin (trh) were assayed using quantitative PCR (qPCR), and interval-censored regression models with nonlinear effects were estimated to account for limits of detection and quantitation. tlh was detected in 19.6% of water samples; tdh or trh markers were not detected. The results confirmed previously reported positive associations for V. parahaemolyticus abundance with temperature and turbidity and negative associations with high salinity (>10 to 23‰). Furthermore, the salinity relationship was determined to be a function of both low temperature and turbidity, with an increase of either nullifying the high salinity effect. Associations with dissolved oxygen and phosphate also appeared stronger when samples were taken near human developments. A renewed focus on the V. parahaemolyticus ecological paradigm is warranted to protect public health.IMPORTANCE Vibrio parahaemolyticus is one of the leading causes of seafood-borne illness in the United States and across the globe. Exposure is often through consuming raw or undercooked shellfish. Given the natural presence of the bacterium in the marine environment, an improved understanding of its environmental determinants is necessary for future preventative measures. This analysis of environmental Vibrio parahaemolyticus is one of only a few that utilize a large data set measured over a wide geographic and temporal range. The analysis also includes a large number of environmental parameters for Vibrio modeling, many of which have previously only been tested sporadically, and some of which have not been considered before. The results of the analysis revealed previously unknown relationships between salinity, turbidity, and temperature that provide significant insight into the abundance and persistence of V. parahaemolyticus bacterium in the environment. This information will be essential for developing environmental forecast models for the bacterium.

The Anterolateral Ligament of the Knee: An Inconsistent Finding in Pediatric Cadaveric Specimens.

BACKGROUND: The anterolateral ligament (ALL) of the knee has been identified as a structure that limits internal rotation, and thus, affects the pivot shift mechanism. It has previously been reported in a high percentage of adult subjects. The purpose of the current study was to evaluate whether the ALL could be identified on pediatric cadaveric knee specimens and compare these findings to previously published reports. METHODS: Eight skeletally immature cadaver knee specimens were examined through gross dissection: ages 3 months, 4 months, 1 year, 2 years, 3 years, 3 years, 8 years, and 10 years. There were 3 male and 5 female (7 right, 1 left) specimens. The presence or absence of the ALL was documented in each specimen, through dissection, intermittent internal and external rotation of the tibia, and anterior translation of the tibia, to produce tension of the lateral collateral tissues and joint capsule. These dissections were performed by a group of fellowship-trained orthopaedic surgeons. RESULTS: The iliotibial band, entire lateral joint capsule, lateral collateral ligament, and popliteus were readily identified in each specimen. In 7 specimens, a distinct ALL structure was not identified during dissection. The ALL was identified in 1 of 8 specimens (1-year-old female, right knee). The ALL was further delineated under applied internal rotational stress. CONCLUSIONS: Previous research has suggested that this ligament is present in the majority of adult specimens. This finding was not reproduced in the current study of pediatric cadaveric specimens, where only one of 8 specimens had an identifiable ALL. This suggests that this ligament may develop later in life, after physiological loads are applied to the joint capsule. Further research in both adult and pediatric knees needs to be conducted to further elucidate the development of this ligament, and the role of this structure in knee stability. CLINICAL RELEVANCE: The ALL is a knee ligament that has been described in adults. However, it is unclear whether this structure is present or fully developed in younger populations. The current study sought to identify the ALL in pediatric cadaver knee specimens, identifying this structure in only one of 8 specimens. The findings of this study suggest that the ALL may be an inconsistent structure in the pediatric population.

Incarceration of the intermeniscal ligament in tibial eminence injury: a block to closed reduction identified using MRI.

Tibial eminence fractures are a relatively uncommon injury, but most frequently occur in children and adolescents with open physes. Entrapment of the intermeniscal ligament or the meniscus itself can occur in the setting of a tibial eminence fracture and when present, poses a significant obstacle to successful closed or surgical reduction. Identification of these entrapped structures on preoperative imaging may be helpful to the physicians caring for these patients and assist with preoperative planning. We present a case of a 13-year-old male who sustained a tibial eminence fracture while playing football. Review by the orthopedic surgeon identified entrapment of the intermeniscal ligament. Subsequently, a closed reduction attempt under anesthesia prior to surgery was unsuccessful and arthroscopy was needed to remove the entrapped intermeniscal ligament and reduce the tibial eminence fracture. Pre-operative knowledge of entrapped soft tissue structures under the fracture plane, particularly the meniscus and intermeniscal ligament, provides the surgeon with valuable insight as to how to best counsel patients on the success of treatment options, how to best prepare for operative treatment, and can guide the surgeon during open reduction to maximize treatment success.

Volumetric Damage to the Femoral Physis During Double-Bundle Posterior Cruciate Ligament Reconstruction: A Magnetic Resonance Imaging Computer Modeling Study.

PURPOSE: The purpose of this study was to use computer models to evaluate the volume of femoral physeal disruption in double-bundle posterior cruciate ligament (PCL) reconstruction in patients with open physes. METHODS: Ten skeletally immature patients (6 girls and 4 boys) were selected for this study. The magnetic resonance imaging scans of each patient were converted into a 3-dimensional model using computer-aided design/computer-aided manufacturing software. The software allowed the users to differentiate the epiphyseal, physeal, and metaphyseal tissues. This allowed for quantification of volume removed of each tissue type. Furthermore, we used the 3-dimensional models to simulate an anatomic double-bundle technique using 6-, 7-, 8-, and 9-mm-diameter tunnels. The software method reflects an inside-out drilling technique. RESULTS: For drill holes of all diameters, the posteromedial tunnels exited the knee inferior to the physis, thus avoiding physeal damage. In contrast, all the anterolateral tunnels perforated the physis. The results for the percent of total physis removed are as follows: 6-mm tunnel, 1.79% ± 0.99%; 7-mm tunnel, 2.23% ± 1.19%; 8-mm tunnel, 3.00% ± 1.54%; and 9-mm tunnel, 3.84% ± 1.73%. CONCLUSIONS: This computer modeling simulation of double-bundle PCL reconstruction in skeletally immature knees found that the posteromedial tunnel avoided disruption of the distal femoral physis. In contrast, the anterolateral tunnel did disrupt the physis with all drill hole sizes (6 to 9 mm), but all had a less than 4% volume of total physis removed. CLINICAL RELEVANCE: A clear understanding of the drill hole position may reduce the volume of physeal injury during double-bundle PCL reconstruction. This study shows that physeal disruption of less than the experimental 7% threshold that has been shown to cause physeal arrest may not cause arrest, but this is still speculative.