High pathogenic avian influenza A(H5) viruses of clade 2.3.4.4b in Europe-Why trends of virus evolution are more difficult to predict.

Since 2016, A(H5Nx) high pathogenic avian influenza (HPAI) virus of clade 2.3.4.4b has become one of the most serious global threats not only to wild and domestic birds, but also to public health. In recent years, important changes in the ecology, epidemiology, and evolution of this virus have been reported, with an unprecedented global diffusion and variety of affected birds and mammalian species. After the two consecutive and devastating epidemic waves in Europe in 2020-2021 and 2021-2022, with the second one recognized as one of the largest epidemics recorded so far, this clade has begun to circulate endemically in European wild bird populations. This study used the complete genomes of 1,956 European HPAI A(H5Nx) viruses to investigate the virus evolution during this varying epidemiological outline. We investigated the spatiotemporal patterns of A(H5Nx) virus diffusion to/from and within Europe during the 2020-2021 and 2021-2022 epidemic waves, providing evidence of ongoing changes in transmission dynamics and disease epidemiology. We demonstrated the high genetic diversity of the circulating viruses, which have undergone frequent reassortment events, providing for the first time a complete overview and a proposed nomenclature of the multiple genotypes circulating in Europe in 2020-2022. We described the emergence of a new genotype with gull adapted genes, which offered the virus the opportunity to occupy new ecological niches, driving the disease endemicity in the European wild bird population. The high propensity of the virus for reassortment, its jumps to a progressively wider number of host species, including mammals, and the rapid acquisition of adaptive mutations make the trend of virus evolution and spread difficult to predict in this unfailing evolving scenario.

Comparison of 2016-17 and Previous Epizootics of Highly Pathogenic Avian Influenza H5 Guangdong Lineage in Europe.

We analyzed the highly pathogenic avian influenza (HPAI) H5 epizootic of 2016-17 in Europe by epidemiologic and genetic characteristics and compared it with 2 previous epizootics caused by the same H5 Guangdong lineage. The 2016-17 epizootic was the largest in Europe by number of countries and farms affected and greatest diversity of wild birds infected. We observed significant differences among the 3 epizootics regarding region affected, epidemic curve, seasonality, and outbreak duration, making it difficult to predict future HPAI epizootics. However, we know that in 2005-06 and 2016-17 the initial peak of wild bird detections preceded the peak of poultry outbreaks within Europe. Phylogenetic analysis of 2016-17 viruses indicates 2 main pathways into Europe. Our findings highlight the need for global surveillance of viral changes to inform disease preparedness, detection, and control.

One-component revision in total hip arthroplasty: the fate of the retained component.

The purpose of the present study was to evaluate the long-term outcome of the unrevised part in one-component total hip arthroplasty revision (index operation). Forty-four patients (46 hips) with a mean age of 58years at the time of the index operation were included. At the final follow-up, 4 of the 19 (21%) unrevised acetabular components and 6 of the 27 (22%) unrevised femoral components were subsequently revised at a mean time of 14 and 11years from the index operation, and 22 and 24years from the primary operation, respectively. We concluded that revision of a stable component is not justifiable on the basis of its long duration in use or non-ideal position or possible loosening on radiographs.

The twenty-year survivorship of two CDH stems with different design features.

UNLABELLED: Previous studies have shown that anatomical abnormalities of the femur in dislocated hips require the application of special CDH prosthesis for the reconstruction of the proximal femur in total hip arthroplasty (THA). We have retrospectively examined the clinical records and radiographs of 50 patients (67 hips) with low and high dislocations treated with THA in our institution, between January 1987 and December 1994. For the reconstruction of the femur, the stainless steel Charnley CDH stem, with polished surface, monoblock and collarless, was used in 32 hips; the Harris CDH stem, made of CoCr, precoated at the proximal part, modular and with collar was used in 35 hips. At the time of the latest follow-up, 11 Charnley and 6 Harris CDH stems had been revised for aseptic loosening at an average of 14 years (range 6-20) and 13 years (range 2-19), respectively. The survival rate at 20 years, with failure for aseptic loosening as the end point, was 63% for the Charnley and 78% for the Harris CDH stems. These results provide a basis for evaluation of newer techniques and designs. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients.

BACKGROUND: Frailty is a phenotype characterized by complex and challenging medical problems and higher susceptibility to adverse health outcomes. It can be derived at by a multidimensional process known as comprehensive geriatric assessment (CGA), which assesses the functional reserves of the elderly. In this study we report for the first time on a prospective evaluation of the association between CGA and postoperative complications after elective laparoscopic cholecystectomy for biliary disease. METHODS: Fifty-seven patients older than 65 years who were to undergo elective laparoscopic cholecystectomy for uncomplicated biliary disease were prospectively examined. Preoperative CGA was performed and the patients were categorized as fit or frail. The main outcome of the study was the rate of any postoperative complication within 30 days of surgery. RESULTS: There were 29 women (50.9 %) and the median (interquartile range) age of the cohort was 73 (8.8) years. Thirty-two patients (56.1 %) were categorized as frail and 25 (43.9 %) as fit. The overall incidence of postoperative complications was 23.7 %, most of which were grade I and II (18.8 %). Frail patients, according to the CGA assessment, experienced a significantly higher incidence of postoperative complications compared to their fit counterparts (84.6 vs. 15.4 %, p = 0.023). Frail patients experienced a significantly higher frequency of prolonged (more than 2 days) postoperative hospital stay compared with their fit counterparts (p = 0.023). CONCLUSIONS: Preoperative CGA may predict postoperative complications and prolonged postoperative hospital stay of elderly patients who undergo elective laparoscopic cholecystectomy. Larger-scale studies independently assessing this association are warranted.

Total hip arthroplasty in patients with high dislocation: a concise follow-up, at a minimum of fifteen years, of previous reports.

We report the updated results at a minimum of fifteen years after eighty-four consecutive total hip arthroplasties performed in sixty-seven female patients with high dislocation of the hip. Sixty-four arthroplasties were performed in forty-nine patients, between 1976 and 1994, with Charnley low-friction acetabular and femoral components inserted with cement; nineteen arthroplasties were performed in seventeen patients, between 1990 and 1994, with the hybrid technique (acetabular component inserted without cement and femoral component inserted with cement); and one arthroplasty was done in 1991, with cementless acetabular and femoral components. All patients were followed prospectively on the basis of clinical assessment according to the Merle D'Aubigné and Postel scoring system, as modified by Charnley, and with radiographic analysis. At the time of the latest follow-up, twenty-six hips (41%) in the low-friction arthroplasty series, ten hips (53%) in the hybrid series, and the one hip with the cementless components had been revised for various reasons. The primary reason for revision in the low-friction arthroplasty group was aseptic loosening of the components (twenty-four hips), whereas the predominant reason for the revisions in the hybrid series and in the hip with cementless components was progressive polyethylene liner wear (six hips). After the minimal follow-up of fifteen years, twenty-five low-friction hip replacements and eight hybrid-type hip replacements had remained intact for an average of twenty-one years (range, seventeen to thirty-two years) and sixteen years (range, fifteen to nineteen years), respectively. These findings may be used in comparisons of results with newer techniques and designs.

Effect of cementless acetabular component orientation, position, and containment in total hip arthroplasty for congenital hip disease.

We evaluated the effect of the inclination angle, position, and containment of 53 cementless cups inserted in patients with congenital hip disease (CHD), after a minimum of 10 years of follow-up. The polyethylene wear rate was significantly greater when the cup was placed in more than 45° inclination (P=.045) or if the cup was placed lateral to the teardrop position by more than 25 mm (P=.001). Aseptic loosening of the femoral component was significantly greater when the cup was placed more than 25 mm superiorly to the teardrop (P=.049). Cup placement of more than 25 mm lateral to the teardrop affected significantly periacetabular osteolysis (P=.032). In CHD cases, it is preferable to avoid excessive vertical inclination, lateral, and superior placement of cementless cups in an attempt to obtain better containment.

Charnley low-friction arthroplasty in young patients with osteoarthritis: outcomes at a minimum of twenty-two years.

BACKGROUND: We previously reported the outcomes at a minimum of twelve years after eighty-four Charnley low-friction arthroplasties performed in patients with osteoarthritis who were less than fifty-six years old at the time of the surgery. We now update the results of that cohort at a minimum of twenty-two years postoperatively. METHODS: Eighty-four hips (in sixty-nine patients) with osteoarthritis, which was secondary to congenital hip disease in sixty-four (76%) of them, were followed prospectively with use of the Merle D'Aubigné and Postel scoring system as modified by Charnley and with serial radiographs. RESULTS: At the time of the latest follow-up, thirty-seven hips (44%) had failed. Twenty-eight acetabular and thirty femoral components, in a total of thirty-two hips, had been revised because of aseptic loosening; six of the loose femoral components were broken. Three hips were infected and were converted to a resection arthroplasty. A periprosthetic femoral fracture occurred in two additional hips, three and ten years postoperatively, and both were treated with internal fixation. Thirty-seven original acetabular components and thirty-six original femoral components were in place for an average of twenty-nine years. The probability of survival for both components, with failure for any reason as the end point, was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years. CONCLUSIONS: These long-term results can be used as a benchmark with which to compare outcomes of different designs when total hip arthroplasty is performed in young patients when the majority have congenital hip disease.

A comparison of the outcome of cemented all-polyethylene and cementless metal-backed acetabular sockets in primary total hip arthroplasty.

We compared, after a 10-year-minimum follow-up, the outcome of 50 cemented all-polyethylene Charnley acetabular sockets with that of 51 cementless metal-backed sockets in 2 comparable cohorts of young patients. Although the revision rate for the cemented and cementless group was 28% and 35%, respectively, the revision rate for aseptic loosening was 28% for the cemented and 12% for the cementless group. The mean polyethylene wear was 0.112 and 0.114 mm/y, respectively, for the 2 groups. Linear osteolysis was observed in 18 of 50 cemented sockets. Expansile osteolysis presented in 10 of 51 cementless sockets and only in one of the cemented sockets. In conclusion, cementless components had more durable fixation than cemented components. However, they presented more aggressive expansile osteolysis caused by the coexistence of polyethylene and metal debris.

Heparin-induced thrombocytopenia with pulmonary embolism and disseminated intravascular coagulation associated with low-molecular-weight heparin.

Heparin-induced thrombocytopenia (HIT) is a severe adverse effect of heparin therapy. Although most cases occur in patients receiving unfractionated heparin, HIT can arise in venous thrombosis prophylaxis with a low-molecular-weight heparin (LMWH). We report an uncommon case of HIT in a postoperative orthopedic patient associated with LMWH (nadroparin), complicated by deep venous thrombosis, pulmonary embolism, and disseminated intravascular coagulation, treated successfully with recombinant hirudin and immunoglobulin therapy.