ACL microtrauma: healing through nutrition, modified sports training, and increased recovery time.

PURPOSE: Sports injuries among youth and adolescent athletes are a growing concern, particularly at the knee. Based on our current understanding of microtrauma and anterior cruciate ligament (ACL) healing characteristics, this clinical commentary describes a comprehensive plan to better manage ACL microtrauma and mitigate the likelihood of progression to a non-contact macrotraumatic ACL rupture. METHODS: Medical literature related to non-contact ACL injuries among youth and adolescent athletes, collagen and ACL extracellular matrix metabolism, ACL microtrauma and sudden failure, and concerns related to current sports training were reviewed and synthesized into a comprehensive intervention plan. RESULTS: With consideration for biopsychosocial model health factors, proper nutrition and modified sports training with increased recovery time, a comprehensive primary ACL injury prevention plan is described for the purpose of better managing ACL microtrauma, thereby reducing the incidence of non-contact macrotraumatic ACL rupture among youth and adolescent athletes. CONCLUSION: Preventing non-contact ACL injuries may require greater consideration for reducing accumulated ACL microtrauma. Proper nutrition including glycine-rich collagen peptides, or gelatin-vitamin C supplementation in combination with healthy sleep, and adjusted sports training periodization with increased recovery time may improve ACL extracellular matrix collagen deposition homeostasis, decreasing sudden non-contact ACL rupture incidence likelihood in youth and adolescent athletes. Successful implementation will require compliance from athletes, parents, coaches, the sports medicine healthcare team, and event organizers. Studies are needed to confirm the efficacy of these concepts. LEVEL OF EVIDENCE: V.

Distal thigh compression garment improves knee control and safety perceptions during single leg triple-hop for distance.

INTRODUCTION: Frontal plane knee control is essential to athletic knee injury prevention. AIM: To evaluate knee valgus frontal plane projection angle (FPPA), knee safety, and sports movement capability confidence during single leg triple hop for distance (SLTHD) under knee sleeve, distal thigh compression garment (DTCG), and no device (control) conditions. METHODS: A single-session, experimental study was performed using a within-subject design, and randomized device order. Two-dimensional FPPA measurements were collected during the final SLTHD landing of 18 healthy female college athletes for each condition. Sports movement capability and knee safety confidence were measured using 10-cm visual analog scale questions. One-way ANOVA assessed group differences, and Pearson correlations delineated FPPA, knee safety and sports movement capability confidence relationships (p < 0.05). RESULTS: The DTCG group had less valgus FPPA than the control group. The knee sleeve group had greater knee safety confidence than the control group. The DTCG (r = 0.48) had a moderate positive relationship between mean SLTHD and knee safety confidence. The DTCG group also had a moderate relationship between maximum SLTHD and knee safety confidence (r = 0.52). The DTCG and knee sleeve groups displayed moderate direct, and moderate inverse relationships between FPPA and sports movement capability confidence (r = 0.48 and r = -0.44, respectively). CONCLUSION: Reduced FPPA and relationships between maximum SLTHD magnitude and knee safety confidence, and between FPPA magnitude and sports movement capability confidence suggests that the DTCG may enhance pelvic deltoid kinesthetic acuity and dynamic knee stability through iliotibial tract compression. CLINICAL RELEVANCE: The DTCG was superior to the standard knee sleeve or control conditions for displaying characteristics that might better prevent knee injury, while still enabling effective sports movement capability.

The use of multiple indices of physiological activity to access viability in chlorine disinfected Escherichia coli O157:H7.

A suite of fluorescent intracellular stains and probes was used, in conjunction with viable plate counts, to assess the effect of chlorine disinfection on membrane potential (rhodamine 123; Rh123 and bis-(1,3-dibutylbarbituric acid) trimethine oxonol; DiBAC4(3)), membrane integrity (LIVE/DEAD BacLight kit), respiratory activity (5-cyano-2,3-ditolyl tetrazolium chloride; CTC) and substrate responsiveness (direct viable counts; DVC) in the commensal pathogen Escherichia coli O157:H7. After a 5 min exposure to the disinfectant, physiological indices were affected in the following order: viable plate counts > substrate responsiveness > membrane potential > respiratory activity > membrane integrity. In situ assessment of physiological activity by examining multiple targets, as demonstrated in this study, permits a more comprehensive determination of the site and extent of injury in bacterial cells following sublethal disinfection with chlorine. This approach to assessing altered bacterial physiology has application in various fields where detection of stressed bacteria is of interest.

Sensitive detection of Escherichia coli O157:H7 in food and water by immunomagnetic separation and solid-phase laser cytometry.

Rapid, direct methods are needed to assess active bacterial populations in water and foods. Our objective was to determine the efficiency of bacterial detection by immunomagnetic separation (IMS) and the compatibility of IMS with cyanoditolyl tetrazolium chloride (CTC) incubation to determine respiratory activity, using the pathogen Escherichia coli O157:H7. Counterstaining with a specific fluorescein-conjugated anti-O157 antibody (FAb) following CTC incubation was used to allow confirmation and visualization of bacteria by epifluorescence microscopy. Broth-grown E. coli O157:H7 was used to inoculate fresh ground beef (<17% fat), sterile 0.1% peptone, or water. Inoculated meat was diluted and homogenized in a stomacher and then incubated with paramagnetic beads coated with anti-O157 specific antibody. After IMS, cells with magnetic beads attached were stained with CTC and then an anti-O157 antibody-fluorescein isothiocyanate conjugate and filtered for microscopic enumeration or solid-phase laser cytometry. Enumeration by laser scanning permitted detection of ca. 10 CFU/g of ground beef or <10 CFU/ml of liquid sample. With inoculated meat, the regression results for log-transformed respiring FAb-positive counts of cells recovered on beads versus sorbitol-negative plate counts in the inoculum were as follows: intercept = 1.06, slope = 0.89, and r2 = 0. 95 (n = 13). The corresponding results for inoculated peptone were as follows: intercept = 0.67, slope = 0.88, and r2 = 0.98 (n = 24). Recovery of target bacteria on beads by the IMS-CTC-FAb method, compared with recovery by sorbitol MacConkey agar plating, yielded greater numbers (beef, 6.0 times; peptone, 3.0 times; water, 2.4 times). Thus, within 5 to 7 h, the IMS-CTC-FAb method detected greater numbers of E. coli O157 cells than were detected by plating. The results show that the IMS-CTC-FAb technique with enumeration by either fluorescence microscopy or solid-phase laser scanning cytometry gave results that compared favorably with plating following IMS.

Rapid direct methods for enumeration of specific, active bacteria in water and biofilms.

Conventional methods for detecting indicator and pathogenic bacteria in water may underestimate the actual population due to sublethal environmental injury, inability of the target bacteria to take up nutrients and other physiological factors which reduce bacterial culturability. Rapid and direct methods are needed to more accurately detect and enumerate active bacteria. Such a methodological advance would provide greater sensitivity in assessing the microbiological safety of water and food. The principle goal of this presentation is to describe novel approaches we have formulated for the rapid and simultaneous detection of bacteria plus the determination of their physiological activity in water and other environmental samples. The present version of our method involves the concentration of organisms by membrane filtration or immunomagnetic separation and combines an intracellular fluorochrome (CTC) for assessment of respiratory activity plus fluorescent-labelled antibody detection of specific bacteria. This approach has also been successfully used to demonstrate spatial and temporal heterogeneities of physiological activities in biofilms when coupled with cryosectioning. Candidate physiological stains include those capable of determining respiratory activity, membrane potential, membrane integrity, growth rate and cellular enzymatic activities. Results obtained thus far indicate that immunomagnetic separation can provide a high degree of sensitivity in the recovery of seeded target bacteria (Escherichia coli O157:H7) in water and hamburger. The captured and stained target bacteria are then enumerated by either conventional fluorescence microscopy or ChemScan(R), a new instrument that is very sensitive and rapid. The ChemScan(R) laser scanning instrument (Chemunex, Paris, France) provides the detection of individual fluorescently labelled bacterial cells using three emission channels in less than 5 min. A high degree of correlation has been demonstrated between results obtained with the ChemScan and traditional plate counts of mixed natural bacterial populations in water. The continuing evolution of these methods will be valuable in the rapid and accurate analysis of environmental samples.

Effects of starvation on physiological activity and chlorine disinfection resistance in Escherichia coli O157:H7.

Escherichia coli O157:H7 can persist for days to weeks in microcosms simulating natural conditions. In this study, we used a suite of fluorescent, in situ stains and probes to assess the influence of starvation on physiological activity based on membrane potential (rhodamine 123 assay), membrane integrity (LIVE/DEAD BacLight kit), respiratory activity (5-cyano-2,3-di-4-tolyl-tetrazolium chloride assay), intracellular esterase activity (ScanRDI assay), and 16S rRNA content. Growth-dependent assays were also used to assess substrate responsiveness (direct viable count [DVC] assay), ATP activity (MicroStar assay), and culturability (R2A agar assay). In addition, resistance to chlorine disinfection was assessed. After 14 days of starvation, the DVC values decreased, while the values in all other assays remained relatively constant and equivalent to each other. Chlorine resistance progressively increased through the starvation period. After 29 days of starvation, there was no significant difference in chlorine resistance between control cultures that had not been exposed to the disinfectant and cultures that had been exposed. This study demonstrates that E. coli O157:H7 adapts to starvation conditions by developing a chlorine resistance phenotype.

Rapid direct methods for enumeration of specific, active bacteria in water and biofilms.

Conventional methods for detecting indicator and pathogenic bacteria in water may underestimate the actual population due to sublethal environmental injury, inability of the target bacteria to take up nutrients and other physiological factors which reduce bacterial culturability. Rapid and direct methods are needed to more accurately detect and enumerate active bacteria. Such a methodological advance would provide greater sensitivity in assessing the microbiological safety of water and food. The principle goal of this presentation is to describe novel approaches we have formulated for the rapid and simultaneous detection of bacteria plus the determination of their physiological activity in water and other environmental samples. The present version of our method involves the concentration of organisms by membrane filtration or immunomagnetic separation and combines an intracellular fluorochrome (CTC) for assessment of respiratory activity plus fluorescent-labelled antibody detection of specific bacteria. This approach has also been successfully used to demonstrate spatial and temporal heterogeneities of physiological activities in biofilms when coupled with cryosectioning. Candidate physiological stains include those capable of determining respiratory activity, membrane potential, membrane integrity, growth rate and cellular enzymatic activities. Results obtained thus far indicate that immunomagnetic separation can provide a high degree of sensitivity in the recovery of seeded target bacteria (Escherichia coli O157:H7) in water and hamburger. The captured and stained target bacteria are then enumerated by either conventional fluorescence microscopy or ChemScan(R), a new instrument that is very sensitive and rapid. The ChemScan(R) laser scanning instrument (Chemunex, Paris, France) provides the detection of individual fluorescently labelled bacterial cells using three emission channels in less than 5 min. A high degree of correlation has been demonstrated between results obtained with the ChemScan and traditional plate counts of mixed natural bacterial populations in water. The continuing evolution of these methods will be valuable in the rapid and accurate analysis of environmental samples.

Comparative performance of Colisure.

Colisure presence-absence medium was compared with standard reference methods for detecting low numbers of total coliform bacteria and E. coli in drinking water when the bacteria were subjected to chlorine stress. When Colisure was compared with established reference methods to detect total coliforms in dilute, disinfected samples, Colisure yielded more positive results after 24, 28, and 48 h than lauryl tryptose broth (LTB) confirmed in bile green lactose broth after 48 h. Colisure also detected higher levels of chlorine-injured E. coli than LTB confirmed in EC medium with 4-methylumbelliferyl B-D-glucuronide (EC/MUG). The sensitivity and specificity of Colisure were also evaluated and were determined to be between 96 and 100 percent on nonchlorinated samples when positive and negative tests were verified.

Factors affecting the determination of respiratory activity on the basis of cyanoditolyl tetrazolium chloride reduction with membrane filtration.

Deficiencies in traditional bacterial enumeration techniques which rely on colony formation have led to the use of total direct counting methods, such as the acridine orange direct count technique for the enumeration of planktonic bacteria. As total direct counts provide no information on the viability or activity of the organisms, demonstration of respiratory activity with the fluorochrome cyanoditolyl tetrazolium chloride (CTC) has been employed. We have modified this technique by performing filtration prior to CTC incubation. Cells captured on a polycarbonate membrane were incubated on absorbent pads saturated with medium containing CTC. Following counterstaining with DAPI (4(prm1),6-diamidino-2-phenylindole) total and respiring cells were enumerated by epifluorescence microscopy. Factors affecting CTC reduction by Klebsiella pneumoniae, Salmonella typhimurium, and Escherichia coli K-12 were investigated. With K. pneumoniae, nutrient additions to the CTC medium did not increase the number of respiring cells detected. CTC reduction by all three organisms decreased in response to an increase of the pH of the CTC medium above pH 6.5. Increasing phosphate concentrations contributed to this inhibitory effect. CTC-membrane filter counts of K. pneumoniae, S. typhimurium, and E. coli K-12 and of bacteria in well water corresponded closely with plate counts (r = 0.987). The results show that careful attention should be given to the composition of CTC-containing media which are used to enumerate respiring bacteria. With an appropriate medium, reliable enumeration of respiring bacteria can be achieved within a few hours.

A rapid, direct method for enumerating respiring enterohemorrhagic Escherichia coli O157:H7 in water.

Simple, rapid methods for the detection and enumeration of specific bacteria in water and wastewater are needed. We have combined incubation using cyanoditolyl tetrazolium chloride (CTC) to detect respiratory activity with a modified fluorescent-antibody (FA) technique, for the enumeration of specific viable bacteria. Bacteria in suspensions were captured by filtration on nonfluorescent polycarbonate membranes that were then incubated on absorbent pads saturated with CTC medium. A specific antibody conjugated with fluorescein isothiocyanate was reacted with the cells on the membrane filter. The membrane filters were mounted for examination by epifluorescence microscopy with optical filters designed to permit concurrent visualization of fluorescent red-orange CTC-formazan crystals in respiring cells which were also stained with the specific FA. Experiments with Escherichia coli O157:H7 indicated that both respiratory activity and specific FA staining could be detected in logarithmic- or stationary-phase cultures, as well as in cells suspended in M9 medium or reverse-osmosis water. Following incubation without added nutrients in M9 medium or unsterile reverse-osmosis water, the E. coli O157:H7 populations increased, although lower proportions of the organisms reduced CTC. Numbers of CTC-positive, FA-positive cells compared with R2A agar plate counts gave a strong linear regression (R = 0.997). Differences in injury did not appear to affect CTC reduction. The procedure, which can be completed within 3 to 4 h, has also been performed successfully with Salmonella typhimurium and Klebsiella pneumoniae.

Physiological assessment of bacteria using fluorochromes.

NASA: This minireview focuses on the application of fluorogenic compounds in the detection of bacteria with particular emphasis on the assessment of physiological activity using epifluorescence microscopy. Microbiological applications of several related methods will also be reviewed.^ieng

Comparative performance of Colisure (TM) and accepted methods in the detection of chlorine-injured total coliforms and E.coli.

Studies were done to examine the comparability of Colisure (TM) and accepted reference methods to detect low numbers of total coliform bacteria and E.coli subjected to chlorine stress. Colisure (TM) is a medium designed to concurrently detect coliform bacteria and E.coli in drinking water by the specific action of beta-galactosidase (total coliforms) and beta-glucuronidase (E.coli). The methods used to compare the performance of various media followed a protocol established by the USEPA. Samples (31) of sewage from six different regions of the US were treated with sufficient concentrations of chlorine (1.2-2.5mg/l) to reduce viability 1-3 logs (39% average injury) and diluted with drinking water to achieve ca. 3 viable coliforms/100ml. The mean log reductions in viable bacteria, determined with various media following disinfection of the 31 samples were: mEndo = 1.87 (TC), Colisure (TM) = 1.55 (TC), mTec = 3.63 (E.coli) and Colisure (TM) = 2.01 (E.coli). When Colisure (TM) was compared with accepted methods to detect total coliforms in the dilute, disinfected samples, Colisure (TM) yielded results that were 1.6 times greater than LTB confirmed in BGLB at 28h. Colisure (TM) also detected 1.7 times greater levels of E.coli than LTB confirmed in EC/MUG at 28h. Sensitivity and specificity of Colisure (TM) were between 96 and 100% when positive and negative tests were verified. These findings indicate that Colisure (TM) is superior to certain accepted reference methods in the detection of chlorine-injured coliforms and E.coli under conditions that resemble contaminated drinking water.

Physiological aspects of disinfection resistance in Pseudomonas cepacia.

A Pseudomonas cepacia population was isolated which had reduced susceptibility to iodine and maintained resistance when subcultured several times in phosphate buffer. This population was also resistant to iodine after growth in a minimal medium containing glycerol but not glucose. Addition of cAMP to glucose-grown cells caused increased resistance to iodine. Iodine-resistant cultures also demonstrated reduced susceptibility to chlorination but not to heat or metals (Cu/Ag). The results indicate that halogen resistance can be expressed in varying degrees, dependent on the carbon source, and cAMP may promote this expression. Thus, a catabolite repression-like mechanism may cause resistant cultures grown in some media to become more sensitive to halogens.

Distribution of bacteria within operating laboratory water purification systems.

Experiments were conducted to measure communities of bacteria within operating ultrapure water treatment systems intended for laboratory use. Samples from various locations within Milli-Q Plus and Milli-Q UV Plus systems were analyzed for populations of planktonic bacteria at weekly intervals over 3 months of operation. Relatively high initial densities of planktonic bacteria (10(2) to 10(3) bacteria per ml) were seen within both units when they were challenged with source water of poor quality, although the product water continued to be acceptable with regard to bacterial numbers, resistivity, and endotoxin concentration. Under more normal operating conditions, significant differences were seen in planktonic populations throughout the systems with excellent product water quality. A great deal of variability was observed in biofilm populations analyzed from various system surfaces after 3 months of operation. The concentrations of planktonic bacteria and biofilm densities were much lower in the unit containing a UV lamp. These findings suggest that a range of microenvironmental conditions exist within purified water systems, leading to variable populations of bacteria. However, product water of excellent quality was obtained despite the bacterial communities.

A direct viable count method for the enumeration of attached bacteria and assessment of biofilm disinfection.

This report describes the adaptation of an in situ direct viable count (in situ DVC) method in biofilm disinfection studies. The results obtained with this technique were compared to two other enumeration methods, the plate count (PC) and conventional direct viable count (c-DVC). An environmental isolate (Klebsiella pneumoniae Kp1) was used to form biofilms on stainless steel coupons in a stirred batch reactor. The in situ DVC method was applied to directly assess the viability of bacteria in biofilms without disturbing the integrity of the interfacial community. As additional advantages, the results were observed after 4 h instead of the 24 h incubation time required for colony formation and total cell numbers that remained on the substratum were enumerated. Chlorine and monochloramine were used to determine the susceptibilities of attached and planktonic bacteria to disinfection treatment using this novel analytical approach. The planktonic cells in the reactor showed no significant change in susceptibility to disinfectants during the period of biofilm formation. In addition, the attached cells did not reveal any more resistance to disinfection than planktonic cells. The disinfection studies of young biofilms indicated that 0.25 mg/l free chlorine (at pH 7.2) and 1 mg/l monochloramine (at pH 9.0) have comparable disinfection efficiencies at 25 degrees C. Although being a weaker disinfectant, monochloramine was more effective in removing attached bacteria from the substratum than free chlorine. The in situ DVC method always showed at least one log higher viable cell densities than the PC method, suggesting that the in situ DVC method is more efficient in the enumeration of biofilm bacteria. The results also indicated that the in situ DVC method can provide more accurate information regarding the cell numbers and viability of bacteria within biofilms following disinfection.

Chlorine injury and the comparative performance of Colisure (TM), ColiLert (TM) and ColiQuik (TM) for the enumeration of coliform bacteria and E.coli in drinking water.

Several factors have stimulated interest in recently developed substrate specific media for the detection of coliform bacteria in water. This study compared the performance of Colisure (TM) (Millipore), ColiLert (TM) (Environetics) and ColiQuick (TM) (Hach) with accepted membrane filtration and MPN methodologies for the enumeration of total coliforms and E. coli in chlorinated water. The performance of all three media was compared, in MPN configuration, with LTB/MPN (confirmed) using a variety of drinking and source water samples, both with and without chlorination. The Cochran-Mantel-Haenszel test yielded statistical correlations between results obtained with each of the three new enzyme detection media and accepted reference methods for the detection of low numbers of total coliforms. Another series of tests compared the performance of Colisure with accepted methods (LTB/MPN confirmed with BGLB and EC-MUG) in the detection of total coliforms and E. coli in sewage-spiked samples simulating contaminated drinking water, using an USEPA/AWWA test protocol. The results demonstrated that Colisure detected these indicator bacteria with greater sensitivity than the accepted methods and that this difference increased between 24 and 28 hours of incubation. The results of this study collectively support the validity of the new enzyme detection method for the detection of low levels of coliform bacteria and E. coli in source water and contaminated drinking water.

Effects of culture conditions and biofilm formation on the iodine susceptibility of Legionella pneumophila.

The susceptibility of Legionella pneumophila to iodination was studied with cultures grown in well water, on rich agar media, and attached to stainless-steel surfaces. Legionella pneumophila grown in water cultures in association with other microorganisms were less sensitive to disinfection by chlorine and iodine than were agar-passaged cultures. Differences in sensitivity to disinfection between water-cultured and agar-grown legionellae were determined by comparing C x T values (concentration in milligrams per litre multiplied by time in minutes to achieve 99% decrease in viability) and CM x T values (concentration in molarity). Iodine (1500x) gave a greater difference in CM x T values than did chlorine (68x). Iodine was 50 times more effective than chlorine when used with agar-grown cultures but was only twice as effective when tested against water-grown Legionella cultures. C x T x S values (C x T multiplied by percent survivors), which take into consideration the percent surviving bacteria, were used to compare sensitivities in very resistant populations, such as those in biofilms. Water cultures of legionellae associated with stainless-steel surfaces were 135 times more resistant to iodination than were unattached legionellae, and they were 210,000 times more resistant than were agar-grown cultures. These results indicate that the conditions under which legionellae are grown can dramatically affect their susceptibility to some disinfectants and must be considered when evaluating the efficacy of a disinfecting agent.

Efficacy of copper and silver ions with iodine in the inactivation of Pseudomonas cepacia.

Alternatives to chlorination of water have been sought for reasons which include trihalomethane formation, possible bacterial regrowth, the high concentrations of chlorine required in certain circumstances, and the taste, odour and bodily irritation in chlorine-treated water. Electrolytically generated Cu and Ag ions at low levels, in addition to very low chlorine concentrations, have been suggested as an alternative to routine chlorination. We have examined the combination of Cu and Ag ions with low levels of iodine. Pseudomonas cepacia was grown either in rich medium or under nutrient restriction prior to disinfection. Survival of the organism and its ability to regrow after treatment as well as the effects of varying buffers, metal ion and iodine concentrations were determined. Low concentrations of metal ions (100 ppb Cu and 11 ppb Ag) and iodine (200 ppb) were more effective than either metal ions or iodine alone against Ps. cepacia grown on rich agar or in low nutrient buffer. After iodination, buffer-grown suspensions recovered to their original cell concentrations within 7 d. When Cu and Ag ions were used with or without iodine, regrowth was prevented. The results show that low concentrations of Cu and Ag in combination with iodine permit effective disinfection of bacteria after cultivation on either rich media or under nutrient restriction. These results, along with published data, suggest that the combination of these metals with halogenation may have applications in the disinfection of both recreational and potable water.

Population dynamics of pseudomonads after iodination.

The population dynamics of pseudomonads grown under rich or low nutrient conditions were examined following iodination. Iodinated and untreated controls of Pseudomonas aeruginosa or Pseudomonas cepacia were resuspended in phosphate buffer and incubated at room temperature. Viable populations of iodine-treated cultures increased faster in phosphate-buffered water than uniodinated controls. Thus, bacteria in iodinated water systems may recover or multiply during storage and distribution after disinfection and may pose a significant health risk.