David Grant USAF Medical Center

Bats are hosts to a variety of viruses capable of zoonotic transmissions. Because of increased contact between bats, humans, and other animal species, the possibility exists for further cross-species transmissions and ensuing disease outbreaks. We describe here full and partial viral genomes identified using metagenomics in the guano of bats from California and Texas. A total of 34% and 58% of 390,000 sequence reads from bat guano in California and Texas, respectively, were related to eukaryotic viruses, and the largest proportion of those infect insects, reflecting the diet of these insectivorous bats, including members of the viral families Dicistroviridae, Iflaviridae, Tetraviridae, and Nodaviridae and the subfamily Densovirinae. The second largest proportion of virus-related sequences infects plants and fungi, likely reflecting the diet of ingested insects, including members of the viral families Luteoviridae, Secoviridae, Tymoviridae, and Partitiviridae and the genus Sobemovirus. Bat guano viruses related to those infecting mammals comprised the third largest group, including members of the viral families Parvoviridae, Circoviridae, Picornaviridae, Adenoviridae, Poxviridae, Astroviridae, and Coronaviridae. No close relative of known human viral pathogens was identified in these bat populations. Phylogenetic analysis was used to clarify the relationship to known viral taxa of novel sequences detected in bat guano samples, showing that some guano viral sequences fall outside existing taxonomic groups. This initial characterization of the bat guano virome, the first metagenomic analysis of viruses in wild mammals using second-generation sequencing, therefore showed the presence of previously unidentified viral species, genera, and possibly families. Viral metagenomics is a useful tool for genetically characterizing viruses present in animals with the known capability of direct or indirect viral zoonosis to humans.

An unidentified agent was cultured in primary monkey cells at the Los Angeles County Public Health Department from each of five stool specimens submitted from an outbreak of gastroenteritis. Electron microscopy and an adenovirus-specific monoclonal antibody confirmed this agent to be an adenovirus. Since viral titers were too low, complete serotyping was not possible. Using the DNase-sequence-independent viral nucleic acid amplification method, we identified several nucleotide sequences with a high homology to human adenovirus 41 (HAdV-41) and simian adenovirus 1 (SAdV-1). However, using anti-SAdV-1 sera, it was determined that this virus was serologically different than SAdV-1. Genomic sequencing and phylogenetic analysis confirmed that this new adenovirus was so divergent from the known human adenoviruses that it was not only a new type but also represented a new species (human adenovirus G). In a retrospective clinical study, this new virus was detected by PCR in one additional patient from a separate gastroenteritis outbreak. This study suggests that HAdV-52 may be one of many agents causing gastroenteritis of unknown etiology.

The relationship between impingement of the roof of the intercondylar notch on a reconstructed anterior cruciate ligament, and the subsequent stability and range of extension of the joint, was analyzed in forty-seven knees. The extent of the impingement was determined by analysis of the relationship of the tibial tunnel to the intersection of the line of slope of the intercondylar roof with the plane of the subchondral bone of the articular surface of the tibial plateau. These lines were drawn on a lateral roentgenogram that was made with the knee in maximum extension, two years after the operation. In all four knees in which the entire articular opening of the tibial tunnel was anterior to the slope of the intercondylar roof, there was severe impingement on the graft, and all four grafts failed. In the fourteen knees in which a portion of the articular opening of the tibial tunnel was anterior to the slope of the intercondylar roof, there was moderate impingement on the graft, and four grafts failed (an unacceptable rate of failure). There was no impingement in the knees in which the entire articular opening of the tibial tunnel was posterior to the slope of the intercondylar roof, and these knees were associated with the lowest rate of failure of the grafts (three of twenty-nine). Knees that had an impinged graft and regained a complete range of extension became unstable.

Metagenomics and a panmicrobial microarray were used to examine eight live-attenuated viral vaccines. Viral nucleic acids in trivalent oral poliovirus (OPV), rubella, measles, yellow fever, varicella-zoster, multivalent measles/mumps/rubella, and two rotavirus live vaccines were partially purified, randomly amplified, and pyrosequenced. Over half a million sequence reads were generated covering from 20 to 99% of the attenuated viral genomes at depths reaching up to 8,000 reads per nucleotides. Mutations and minority variants, relative to vaccine strains, not known to affect attenuation were detected in OPV, mumps virus, and varicella-zoster virus. The anticipated detection of endogenous retroviral sequences from the producer avian and primate cells was confirmed. Avian leukosis virus (ALV), previously shown to be noninfectious for humans, was present as RNA in viral particles, while simian retrovirus (SRV) was present as genetically defective DNA. Rotarix, an orally administered rotavirus vaccine, contained porcine circovirus-1 (PCV1), a highly prevalent nonpathogenic pig virus, which has not been shown to be infectious in humans. Hybridization of vaccine nucleic acids to a panmicrobial microarray confirmed the presence of endogenous retroviral and PCV1 nucleic acids. Deep sequencing and microarrays can therefore detect attenuated virus sequence changes, minority variants, and adventitious viruses and help maintain the current safety record of live-attenuated viral vaccines.

This study compared the stiffness (K), yield load (YL), and slippage (SL) of six tibial fixation methods. These properties were determined from load-to-failure and cyclic tests of double-looped tendon grafts fixed to both animal and young human tissue. Tandem washers (K = 259 N/mm, YL = 1159 N, SL = 0.5 mm) and the Washerloc (K = 248 N/mm, YL = 905 N, SL = 2.0 mm) were the two best fixations. At 500 N of load, which is the estimated daily tension of an anterior cruciate ligament graft during intensive rehabilitation, slippage was significantly greater in either of the other two methods for sutures tied to a post (4.9 mm), double staples (3.3 mm), and a 20-mm spiked metal washer (3.5 mm). Interference screw fixation performed well in animal tissue (YL = 776 N), but was significantly worse in young human tissue (YL = 350 N), with 57% of the fixations failing before 500 N of load. Animal tissue should not be used to estimate the performance of interference screw fixation in human tissue. Because 57% of the interference screw fixations using human tissue failed at loads below 500 N, their ability to provide adequate fixation during intensive rehabilitation should be questioned. However, both the Washerloc and tandem washers and screws provide fixation structural properties in young human tibia that should be appropriate for intensive rehabilitation.

Fifty-six anterior cruciate ligament (ACL) reconstructions had a magnetic resonance scan of the ACL graft six months after operation. The impingement-free grafts (n = 26) had a low magnetic resonance signal from origin to insertion. Impinged grafts (n = 30) had an increased magnetic resonance signal confined to the distal two thirds of the graft. The location of the tibial tunnel (TT) was determined from a lateral roentgenogram. Positioning the center of the TT 12-23 mm from the anterior edge of the tibia consistently produced graft impingement and flexion contractures. Roof impingement was avoided and hyperextension was regained when the TT was centered more posteriorly within a 6-mm impingement-free zone (22-28 mm from the anterior edge of the tibia). Stability and knee extension were significantly better when the center of the TT was 2-3 mm posterior to the center of the normal ACL insertion.

Lipomatous tumors range from benign lipomas to high-grade liposarcomas. Liposarcomas are classified into five histologic subtypes: well-differentiated, dedifferentiated, myxoid, round cell, and pleomorphic, which differ in outcomes and patterns of recurrence. Surgical resection is the mainstay of curative treatment; however, large, high grade liposarcomas may benefit from multimodality treatment with chemotherapy and radiation. A histologic-subtype specific nomogram provides accurate survival predictions. Prospective randomized clinical trials will continue to improve our care of patients with liposarcoma.

Cerebral vascular malformations have traditionally been divided into four categories: arteriovenous, venous, cavernous, and capillary telangiectases. A controversy exists about separating the latter two lesions into separate entities. Critics claim the distinction is arbitrary but have been unable to present convincing evidence linking the two types of lesions. We have reviewed the histories of 20 patients with cavernous malformations and have analyzed the clinical, radiographic, and surgical-autopsy data associated with these lesions. In some patients, multiple lesions, including cavernous malformations, capillary telangiectases, and transitional forms between the two, were identified. Based on this analysis, we conclude that capillary telangiectasia and cavernous malformations represent two pathological extremes within the same vascular malformation category and propose grouping them as a single cerebral entity called cerebral capillary malformations.

In 2005, a human adenovirus strain (formerly known as HAdV-D22/H8 but renamed here HAdV-D53) was isolated from an outbreak of epidemic keratoconjunctititis (EKC), a disease that is usually caused by HAdV-D8, -D19, or -D37, not HAdV-D22. To date, a complete change of tropism compared to the prototype has never been observed, although apparent recombinant strains of other viruses from species Human adenovirus D (HAdV-D) have been described. The complete genome of HAdV-D53 was sequenced to elucidate recombination events that lead to the emergence of a viable and highly virulent virus with a modified tropism. Bioinformatic and phylogenetic analyses of this genome demonstrate that this adenovirus is a recombinant of HAdV-D8 (including the fiber gene encoding the primary cellular receptor binding site), HAdV-D22, (the epsilon determinant of the hexon gene), HAdV-D37 (including the penton base gene encoding the secondary cellular receptor binding site), and at least one unknown or unsequenced HAdV-D strain. Bootscanning analysis of the complete genomic sequence of this novel adenovirus, which we have re-named HAdV-D53, indicated at least five recombination events between the aforementioned adenoviruses. Intrahexon recombination sites perfectly framed the epsilon neutralization determinant that was almost identical to the HAdV-D22 prototype. Additional bootscan analysis of all HAdV-D hexon genes revealed recombinations in identical locations in several other adenoviruses. In addition, HAdV-D53 but not HAdV-D22 induced corneal inflammation in a mouse model. Serological analysis confirmed previous results and demonstrated that HAdV-D53 has a neutralization profile representative of the epsilon determinant of its hexon (HAdV-D22) and the fiber (HAdV-D8) proteins. Our recombinant hexon sequence is almost identical to the hexon sequences of the HAdV-D strain causing EKC outbreaks in Japan, suggesting that HAdV-D53 is pandemic as an emerging EKC agent. This documents the first genomic, bioinformatic, and biological descriptions of the molecular evolution events engendering an emerging pathogenic adenovirus.

Forty-one patients in whom operative reconstruction of a torn anterior cruciate ligament had been performed by one surgeon with use of a double-looped semitendinosus and gracilis hamstring graft were studied to determine (1) if a brace-free rehabilitation program compromised the early stability of the knee; (2) if the stability of the knee deteriorated between four months, when the patient returned to unrestricted activities, and two years; and (3) if the function of the treated knee was completely restored by four months after the operation. The graft was placed arthroscopically, without impingement by the intercondylar roof, and was fixed within the tibial tunnel to conserve the length of the graft. The stability and function of thirty-seven of the knees were assessed at four months as part of a larger prospective study. Four patients chose not to return for the four-month evaluation. The patients returned to unrestricted sports and work activities after the four-month evaluation. At two years, all forty-one patients were evaluated. At four months, after completion of the brace-free rehabilitation program, thirty-three (82 per cent) of the thirty-seven patients had an absent pivot shift and a normal Lachman test. Twenty-eight (88 per cent) of thirty-four knees had less than three millimeters of difference in laxity compared with the contralateral knee, as determined by testing at the maximum manual force with use of a KT-1000 arthrometer. Stability remained unchanged at two years, justifying the early return to vigorous activities at four months. The girth of the thigh, the extension of the knee, and the Lysholm and Gillquist score were the same at four months as at two years, verifying the success of the brace-free intensive rehabilitation program in the restoration of early function to the treated knee. However, some continued improvement was observed in the performance of the one-leg-hop for distance test between four months and two years.

OBJECTIVE: This study examined the association of weight concerns with potential risk factors for the development of eating disorders. METHOD: A self-report survey was given to 103 elementary (Grades 4 and 5) and 420 middle (Grades 6-8) school students in Arizona and California. Of these, 78 elementary and 333 middle school students provided complete data and were used in the analyses. RESULTS: In a multivariate stepwise regression analysis, the importance that peers put on weight and eating was most strongly related to weight concerns in the elementary school girls, accounting for 34% of the variance after adjusting for site differences. Trying to look like girls/women on TV and in magazines as well as body mass index (BMI) entered the final model that accounted for 57% of the variance in weight concerns. In middle school, the importance that peers place on weight and eating was also the strongest predictor accounting for 33% of the variance followed by confidence, BMI, trying to look like girls/women on TV and in magazines, and being teased about weight. Together these variables accounted for 55% of the variance. DISCUSSION: Prevention programs aimed at reducing weight concerns need to address these factors.

Novel human adenoviruses (HAdVs) arise from genome recombination. Analysis of HAdV type 55 from an outbreak in China shows a hexon recombination between HAdV-B11 and HAdV-B14, resulting in a genome that is 97.4% HAdV-B14. Sporadic appearances as a re-emergent pathogen and misidentification as "HAdV-B11a" are due to this partial hexon.

Although most persons with parvovirus B19 infection are asymptomatic or have mild, nonspecific, cold-like symptoms, several clinical conditions have been linked to the virus. Parvovirus B19 usually infects children and causes the classic "slapped-cheek" rash of erythema infectiosum (fifth disease). The virus is highly infectious and spreads mainly through respiratory droplets. By the time the rash appears, the virus is no longer infectious. The virus also may cause acute or persistent arthropathy and papular, purpuric eruptions on the hands and feet ("gloves and socks" syndrome) in adults. Parvovirus B19 infection can trigger an acute cessation of red blood cell production, causing transient aplastic crisis, chronic red cell aplasia, hydrops fetalis, or congenital anemia. This is even more likely in patients with illnesses that have already shortened the lifespan of erythrocytes (e.g., iron deficiency anemia, human immunodeficiency virus, sickle cell disease, thalassemia, spherocytosis). A clinical diagnosis can be made without laboratory confirmation if erythema infectiosum is present. If laboratory confirmation is needed, serum immunoglobulin M testing is recommended for immunocompetent patients; viral DNA testing is recommended for patients in aplastic crisis and for those who are immunocompromised. Treatment is usually supportive, although some patients may require transfusions or intravenous immune globulin therapy. Most patients recover completely.

Reconstruction of a form anterior cruciate ligament (ACL) cannot be successful without a properly placed tibial tunnel. Preventable complications such as anterior knee pain, effusions, extension loss, and recurrent instability can occur when the tibial tunnel is improperly placed and the roof and notchplasty are insufficient. This article reviews the principles for anatomic placement of the tibial tunnel so that complications associated with impingement of the ACL graft on the intercondylar roof can be prevented. Five factors that contribute to roof impingement are discussed, including differences in the size and shape of the ACL and the graft, variability in knee extension and roof angle between patients, inability to view the contact between the intercondylar roof and the graft, accentuation of roof impingement from anterior tibial translation caused by quadriceps contraction, and the use of tibial guides that rely on soft-tissue landmarks. A surgical technique is presented which consistently places the tibial tunnel in the pathway of the normal ACL (i.e., anatomic placement) and avoids roof impingement. The indications and need for roof- and wallplasty are discussed.

We evaluated three methods for fixing a medial meniscal autograft to determine which method restored tibial contact mechanics closest to normal. The contact mechanics (maximum pressure, mean pressure, contact area, and location of the center of maximum pressure) of the medial tibial articular surface were determined using pressure-sensitive film while knee specimens were loaded in compression to 1000 N at 0 degree, 15 degrees, 30 degrees, and 45 degrees of flexion. Pressure was measured for the intact knee, the knee after meniscectomy, and the knee with the original meniscus removed and reimplanted as an autograft using three different fixation methods. The contact mechanics of the autograft reinserted with bone plug fixation were closest to normal; however, the maximum pressure was significantly greater than in the intact knee. Adding peripheral sutures neither improved nor worsened the contact mechanics. Fixation with sutures only did not restore normal contact mechanics. We concluded that medial meniscal transplantation requires anatomic fixation of bone plugs attached to the anterior and posterior horns to restore contact mechanics closest to normal. Fixation of the meniscal horns with sutures alone cannot be recommended.

Vertebral compression fractures (VCFs) are the most common complication of osteoporosis, affecting more than 700,000 Americans annually. Fracture risk increases with age, with four in 10 white women older than 50 years experiencing a hip, spine, or vertebral fracture in their lifetime. VCFs can lead to chronic pain, disfigurement, height loss, impaired activities of daily living, increased risk of pressure sores, pneumonia, and psychological distress. Patients with an acute VCF may report abrupt onset of back pain with position changes, coughing, sneezing, or lifting. Physical examination findings are often normal, but can demonstrate kyphosis and midline spine tenderness. More than two-thirds of patients are asymptomatic and diagnosed incidentally on plain radiography. Acute VCFs may be treated with analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, narcotics, and calcitonin. Physicians must be mindful of medication adverse effects in older patients. Other conservative therapeutic options include limited bed rest, bracing, physical therapy, nerve root blocks, and epidural injections. Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, is controversial, but can be considered in patients with inadequate pain relief with nonsurgical care or when persistent pain substantially affects quality of life. Family physicians can help prevent vertebral fractures through management of risk factors and the treatment of osteoporosis.

This study was designed to analyze how anterior tibial tunnel placement can result in graft impingement by the intercondylar roof. The relationship of the ACL to the intercondylar roof was studied using magnetic resonance scans. An attempt was made to predict the amount of bone that may need to be removed from the intercondylar roof to prevent impingement on a 10 mm thick ACL graft. Magnetic resonance scans of 19 normal ACLs were analyzed. The amount of bone removal required to correct roof impingement was determined for a graft placed either eccentrically or centrally within the ACL insertion, and within the bulk of the normal ACL fibers. An eccentric tibial tunnel placement required approximately 5 to 6 mm and a central placement required 2 to 3 mm of bone removal from the intercondylar roof to prevent impingement. Placing the graft within the bulk of the ACL fibers, just 3 mm posterior to the center of the ACL insertion, required little bone resection to prevent impingement. To prevent ACL graft impingement, roofplasties need to be performed in both acute and chronic ACL reconstructions if the presently accepted locations for positioning the tibial tunnel are used. A more anteriorly placed tibial tunnel requires more bone removal to prevent roof impingement than a more posteriorly positioned tibial tunnel.

Fever of unknown origin (FUO) is a serious problem in the United States. An unidentified agent was cultured from the stool of an infant who presented with FUO. This virus showed growth in HFDK cells and suckling mice. Using DNase sequence-independent single-primer amplification, we identified several nucleotide sequences with a high homology to Theiler's murine encephalomyelitis virus. Nearly full-length viral genome sequencing and phylogenetic analysis demonstrate that this virus is a member of the Cardiovirus genus of the Picornaviridae family.

Abnormally enlarged visceral arteries in the abdomen and pelvis must be recognized radiologically because early treatment can improve the quality of life and prevent life-threatening complications. These lesions, typically classified as aneurysms and pseudoaneurysms, are being detected more frequently with increased utilization of imaging and have various causes (eg, atherosclerosis, trauma, infection) and complications that may be identified radiologically. Ultrasonography, computed tomography, and magnetic resonance imaging often enable detection of visceral vascular lesions, but angiography is important for further diagnosis and treatment. Endovascular treatment is often the first-line therapy. Endovascular intervention or open surgical repair is necessary for all visceral pseudoaneurysms and is likely indicated for visceral aneurysms 2 cm or more in diameter. Endovascular exclusion of flow can be achieved with coils, stents, and injectable liquids. Techniques include embolization ("sandwich" or "sac-packing" technique), exclusion of flow with luminal stents, and stent-assisted coil embolization. Management often depends on the location and technical feasibility of endovascular repair. Embolization is usually preferred for aneurysms or pseudoaneurysms within solid organs, and the sandwich technique is often used when collateral flow is present. Covered stent placement may be preferred to preserve the parent artery when main visceral vessels are being treated. It is usually tailored to lesion location, and a cure can often be effected while preserving end-organ arterial flow. Posttreatment follow-up is usually based on treatment location, modality accuracy, and potential consequences of treatment failure. Follow-up imaging may help identify vessel recanalization, unintended thrombosis of an artery or end organ, or sequelae of nontarget embolization. Retreatment is usually warranted if the clinical risks for which embolization was performed are still present.

We conducted a prospective trial at a military medical center to determine which treatment for first-time ankle sprains, early mobilization or immobilization, is more effective. Eighty-two patients with a lateral ankle sprain were randomly selected for one of two treatment groups. The Early Mobilization Group received an elastic wrap for 2 days followed by functional bracing for 8 days. Two days after injury, this group began weight-bearing and an ankle rehabilitation program. Patients in the Immobilization Group were placed in a nonweight-bearing plaster splint for 10 days followed by weight-bearing and the same rehabilitation program. Patients in the Early Mobilization Group had less pain at 3 weeks (57% versus 87%, P = 0.02); otherwise, there were no significant differences between groups in the frequency of residual symptoms. Only one patient in each group had residual symptoms 1 year after injury. Three patients (8%) in each group resprained their ankles. Ten days after injury, patients in the Early Mobilization Group were more likely to be back to full work (54% versus 13%, P < 0.001). We conclude that in first-time lateral ankle sprains, although both immobilization and early mobilization prevent late residual symptoms and ankle instability, early mobilization allows earlier return to work and may be more comfortable for patients.