Image-free handheld robotic-assisted technology improved the accuracy of implant positioning compared to conventional instrumentation in patients undergoing simultaneous bilateral total knee arthroplasty, without additional benefits in improvement of clinical outcomes.

PURPOSE: The purpose of this study was to compare the clinical and radiological outcomes in patients who underwent simultaneous bilateral total knee arthroplasty (SB-TKA) using either robotic-assisted TKA (RA-TKA) or conventional TKA (C-TKA). METHODS: Included were the patients who underwent SB-TKA between January 2018 and January 2020 and had a minimum follow-up of 2 years. Of 151 patients included, 117 patients were operated using an image-free handheld robotic sculpting system (RA-TKA group) and 34 patients operated using conventional instrumentation (C-TKA group). The key outcomes noted were multiple patient-reported outcomes (PROs), adverse events, and radiological outcomes. Two investigators independently measured the radiological outcomes on pre- and post-operative radiographs in coronal plane (medial proximal tibial angle [MPTA] and anatomic lateral distal femoral angle [aLDFA]) and sagittal plane (posterior tibial slope [PTS] and posterior condylar offset [PCO]). The chi-square test was used to examine categorical variables. Student's t test was used to analyze the continuous variables. RESULTS: Patients in both groups were similar in baseline characteristics (gender, body mass index, incidence of comorbidities, and length of hospital stay) except that RA-TKA group patients younger (66.7 ± 8.9 vs 70.4 ± 10.5, P = 0.037) than C-TKA group. The operative time was longer in RA-TKA group as compared to C-TKA (189.3 ± 37.1 vs 175.0 ± 28.2, P = 0.040). The final PROs at each were similar between the two groups (P > 0.05). The values of PROs at final follow-up in RA-TKA compared to C-TKA were VAS pain (0.4 ± 0.9 vs 0.4 ± 0.5), KOOS-JR (89.3 ± 5.8 vs 87.1 ± 5.3), and physical (55.9 ± 2.8 vs 55.4 ± 3.2), mental (61.1 ± 4.4 vs 60.2 ± 4.7) component of VR-12 scores, and KSS satisfaction (37.5 ± 1.1 vs 37.1 ± 2.2) (all P > 0.50 or non-significant [n.s.]). While one patient in RA-TKA required revision of femoral component for peri-prosthetic fracture, none of the patient in conventional group were revised (0.85% vs 0%, P = n.s.). The proportion of patients with outliers in RA-TKA group was lower for aLDFA (2.6% vs 22.1%, P < 0.01) and PTS (0% vs 35%, P < 0.01). CONCLUSION: This comparative study in patients undergoing SB-TKA found reduction of outliers in femoral and tibial implant positioning with RA-TKA as compared to C-TKA. There were no differences in both groups for pain, function, and satisfaction at a minimum of 2 years of follow-up. LEVEL OF EVIDENCE: III Therapeutic Study.

Enteric Infections Circulating during Hajj Seasons, 2011-2013.

Hajj, the annual Muslim pilgrimage to Mecca, Saudi Arabia, is a unique mass gathering event that raises public health concerns in the host country and globally. Although gastroenteritis and diarrhea are common among Hajj pilgrims, the microbial etiologies of these infections are unknown. We collected 544 fecal samples from pilgrims with medically attended diarrheal illness from 40 countries during the 2011-2013 Hajj seasons and screened the samples for 16 pathogens commonly associated with diarrheal infections. Bacteria were the main agents detected, in 82.9% of the 228 positive samples, followed by viral (6.1%) and parasitic (5.3%) agents. Salmonella spp., Shigella/enteroinvasive Escherichia coli, and enterotoxigenic E. coli were the main pathogens associated with severe symptoms. We identified genes associated with resistance to third-generation cephalosporins ≈40% of Salmonella- and E. coli-positive samples. Hajj-associated foodborne infections pose a major public health risk through the emergence and transmission of antimicrobial drug-resistant bacteria.

Epidemiology of a Novel Recombinant Middle East Respiratory Syndrome Coronavirus in Humans in Saudi Arabia.

BACKGROUND: Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe respiratory illness in humans. Fundamental questions about circulating viruses and transmission routes remain. METHODS: We assessed routinely collected epidemiologic data for MERS-CoV cases reported in Saudi Arabia during 1 January-30 June 2015 and conducted a more detailed investigation of cases reported during February 2015. Available respiratory specimens were obtained for sequencing. RESULTS: During the study period, 216 MERS-CoV cases were reported. Full genome (n = 17) or spike gene sequences (n = 82) were obtained from 99 individuals. Most sequences (72 of 99 [73%]) formed a discrete, novel recombinant subclade (NRC-2015), which was detected in 6 regions and became predominant by June 2015. No clinical differences were noted between clades. Among 87 cases reported during February 2015, 13 had no recognized risks for secondary acquisition; 12 of these 13 also denied camel contact. Most viruses (8 of 9) from these 13 individuals belonged to NRC-2015. DISCUSSIONS: Our findings document the spread and eventual predominance of NRC-2015 in humans in Saudi Arabia during the first half of 2015. Our identification of cases without recognized risk factors but with similar virus sequences indicates the need for better understanding of risk factors for MERS-CoV transmission.

Viral Shedding and Antibody Response in 37 Patients With Middle East Respiratory Syndrome Coronavirus Infection.

BACKGROUND: The Middle East respiratory syndrome (MERS) coronavirus causes isolated cases and outbreaks of severe respiratory disease. Essential features of the natural history of disease are poorly understood. METHODS: We studied 37 adult patients infected with MERS coronavirus for viral load in the lower and upper respiratory tracts (LRT and URT, respectively), blood, stool, and urine. Antibodies and serum neutralizing activities were determined over the course of disease. RESULTS: One hundred ninety-nine LRT samples collected during the 3 weeks following diagnosis yielded virus RNA in 93% of tests. Average (maximum) viral loads were 5 × 10(6) (6 × 10(10)) copies/mL. Viral loads (positive detection frequencies) in 84 URT samples were 1.9 × 10(4) copies/mL (47.6%). Thirty-three percent of all 108 serum samples tested yielded viral RNA. Only 14.6% of stool and 2.4% of urine samples yielded viral RNA. All seroconversions occurred during the first 2 weeks after diagnosis, which corresponds to the second and third week after symptom onset. Immunoglobulin M detection provided no advantage in sensitivity over immunoglobulin G (IgG) detection. All surviving patients, but only slightly more than half of all fatal cases, produced IgG and neutralizing antibodies. The levels of IgG and neutralizing antibodies were weakly and inversely correlated with LRT viral loads. Presence of antibodies did not lead to the elimination of virus from LRT. CONCLUSIONS: The timing and intensity of respiratory viral shedding in patients with MERS closely matches that of those with severe acute respiratory syndrome. Blood viral RNA does not seem to be infectious. Extrapulmonary loci of virus replication seem possible. Neutralizing antibodies do not suffice to clear the infection.

Seroprevalence of Herpes Simplex Virus Type 1 and Type 2 and Coinfection With HIV and Syphilis: The First National Seroprevalence Survey in Saudi Arabia.

BACKGROUND: Herpes simplex virus (HSV) infection is one of the most common viral infections worldwide. Genital herpes is associated with other sexually transmitted infections (STIs) including HIV. Data on prevalence of HSV infections and other STIs in the Kingdom of Saudi Arabia are limited. METHODS: We conducted the first national seroprevalence survey to determine the prevalence and epidemiology of HSV infection among adult Saudis and coinfection with other STIs. Serology was used to detect HSV-1, HSV-2, HIV, and syphilis infections among 4985 participants recruited from across the Kingdom. RESULTS: The overall prevalence of HSV-1 and HSV-2 in the enrolled population was 88.8% and 1.26%, respectively. Although not significant for HSV-2, HSV infection was more prevalent among females, those working, and those who were married (married, divorced, or widowed), especially those married at a younger age. Prevalence of both viruses was statistically significantly higher among those with low education and increased with age. Prevalence of Treponema pallidum antibodies and HIV in the sampled population was very low (0.55% and 0.06%, respectively), as was their prevalence among HSV-2-positive participants (1.6% for both). The correlation between HSV-2 infection and other STIs was significant for HIV (P < 0.0001) but not for T. pallidum antibodies (P = 0.25). CONCLUSIONS: Herpes simplex virus type 1 infection is highly prevalent in Saudi Arabia and mostly acquired before adulthood. Herpes simplex virus type 2 prevalence is very low, acquired in adulthood, and increased with age. Monitoring the prevalence of HSV infection can help inform targeted strategies to prevent new infections, neonatal transmission, and the spread of other STIs in the Kingdom.

Prevalence of MERS-CoV nasal carriage and compliance with the Saudi health recommendations among pilgrims attending the 2013 Hajj.

BACKGROUND: Annually, Saudi Arabia is the host of the Hajj mass gathering. We aimed to determine the Middle East respiratory syndrome coronavirus (MERS-CoV) nasal carriage rate among pilgrims performing the 2013 Hajj and to describe the compliance with the Saudi Ministry of Health vaccine recommendations. METHOD: Nasopharyngeal samples were collected from 5235 adult pilgrims from 22 countries and screened for MERS-CoV using reverse transcriptase-polymerase chain reaction. Information regarding the participants' age, gender, country of origin, medical conditions, and vaccination history were obtained. RESULTS: The mean age of the screened population was 51.8 years (range, 18-93 years) with a male/female ratio of 1.17:1. MERS-CoV was not detected in any of the samples tested (3210 pre-Hajj and 2025 post-Hajj screening). According to the vaccination documents, all participants had received meningococcal vaccination and the majority of those from at-risk countries were vaccinated against yellow fever and polio. Only 22% of the pilgrims (17.5% of those ≥65 years and 36.3% of diabetics) had flu vaccination, and 4.4% had pneumococcal vaccination. CONCLUSION: There was no evidence of MERS-CoV nasal carriage among Hajj pilgrims. While rates of compulsory vaccinations uptake were high, uptake of pneumococcal and flu seasonal vaccinations were low, including among the high-risk population.

Hajj abattoirs in Makkah: risk of zoonotic infections among occupational workers.

At completion of Hajj, the Islamic pilgrimage to Makkah, pilgrims give thanks for the blessing, and acceptance, of Hajj, marking the end of the pilgrimage by sacrificing an animal and distributing the sacrificial meat to the poor. With over two million Muslims making Hajj, each Hajj, more than 1.2 million heads of cattle: sheep, goats and camels are slaughtered. Over 16 000 abattoir workers work around the clock to sacrifice and process the cattle in keeping with Islamic law and public health guidelines. Because of their proximity to high densities of cattle and cattle meat, Makkah's abattoir workers are at risk of zoonosis. This was a longitudinal study aimed at determining the risk of some zoonotic diseases among male permanent abattoir workers during Hajj. Specifically, seroprevalence of antigens for Brucella, Crimean-Congo haemorrhagic fever (CCHF), Alkhurma haemorrhagic fever (AHF) and Rift Valley Fever (RVF) were determined, among the study participants. An enrolment questionnaire, and a follow-up questionnaire, with provision of 10 mL blood for testing 2 days before intense Hajj animal exposure, up to 20 days after intense animal exposure and between 30 and 42 days after Hajj butchering exposures. While working with livestock, study participants were interrogated on hand hygiene and personal protection. Eighty male permanent abattoir workers participated in the study. Majority, 96.25% (n = 77) declared washing their hands with soap and water, most 98.75% (n = 79) never used eye protection, few occupational workers dressed in personal protective clothing or footwear. All workers tested negative for CCHF and RVF, one was positive for AHF and six for Brucella. The risk of some zoonotic infections like Brucella and AHF is low among permanent occupational workers in the slaughtering house in Makkah during Hajj 2013. No serological evidence for CCHF and RVF viruses, even though workers showed low compliance with use of personnel protective equipment.

Neisseria meningitidis nasopharyngeal carriage during the Hajj: A cohort study evaluating the need for ciprofloxacin prophylaxis.

BACKGROUND: The annual Muslim pilgrimage has the potential of increase risk for acquisition of Neisseria meningitidis. Here, we evaluate the Hajj impact on the prevalence of N. meningitidis carriage in a paired and non-paired cohort of pilgrims. Secondary objectives were to calculate the compliance with recommended vaccination. METHODS: This is a prospective paired (arriving and departing), non-paired arriving and non-paired departing cohort study with the collection of nasopharyngeal samples at the start and the end of the Hajj. RESULTS: The study included unpaired arriving pilgrims at King Abdul Aziz International Airport (N=1055), unpaired departing cohort (N=373), and a paired cohort (N=628) who were tested on arrival and departure. Meningococcal vaccination was received by all pilgrims, 98.2% received quadrivalent polysaccharide vaccine (ACWY), and 1.8% received meningococcal quadrivalent conjugate vaccine (MCV4). Only 1.61% and 23.03% received pneumococcal and influenza vaccines, respectively. Of the 1055 arriving unpaired pilgrim, 36 (3.4%) tested positive for nasopharyngeal carriage of N. meningitidis, and 24 (66.7%) of these were serogroup B, the remainder were non-groupable. Haemophilus influenza was detected among 45 (4.3%), and 11 (1%) carriers were positive for both N. meningitidis and H. influenzae. Out of 373 in the unpaired departing cohort, 6 (1.61%) tested positive for N. meningitidis, and 34 (9.1%) were positive for H. influenzae. Of the 628 paired cohort pilgrims, 36 (5.7%) pilgrims were positive for N. meningitidis at arrival and 16 (2.5%) pilgrims were positive after the hajj. CONCLUSION: This the largest study of the epidemiology of N. meningitidis among pilgrims. The study showed a significant difference in the carriage between pilgrims from high endemicity and other pilgrims with a predominance of serogroup B. The continued use of ciprofloxacin as prophylactic antibiotics should be reconsidered as well as the consideration to add serogroup B as a required vaccination.

A cohort study of the impact and acquisition of naspharyngeal carriage of Streptococcus pneumoniae during the Hajj.

BACKGROUND: The annual Muslim pilgrimage attracts over two million pilgrims who gather in a limited time and space. The pilgrimage carries the potential risk of increase risk of the acquisition of Streptococcus pneumonia. In this cohort study, we evaluate the effect of the Hajj on the prevalence of pneumococcal serotype nasopharyngeal carriage in the Hajj pilgrim population. The secondary objective is to evaluate the effects of the mass gathering on carriage of invasive pneumococcal serotypes. METHODS: This is a prospective cohort study with two data collection periods: at the beginning and at the end of the Hajj. Nasopharyngeal samples were taken via a standardized swabbing method. RESULTS: A total of 1175 pilgrims were enrolled at the beginning of the study and 1155 (98.3%) were included at the second part of the study. The pre-Hajj samples were obtained at a mean of 0 days and the post-Hajj sampling occurred at a mean of 15 days after arrival to Saudi Arabia. The overall carriage rate of Streptococcus pneumoniae in the pre- and post-Hajj was 1.8% and 7.1% (P = 0.0016). The potential coverage of the 7-valent pneumococcal conjugate vaccine (PCV7), PCV10 and PCV13 were 15.5%, 19.1%; and 35.5%, respectively. The coverage for the 23-valent pneumococcal polysaccharide vaccine (PPV23) was 40%. CONCLUSION: Although there was an increase in the acquisition of S. pneumoniae, its magnitude is low which does not support public health recommendations for general pneumococcal vaccination of pilgrims except those at risk.

Increase in Middle East Respiratory Syndrome-Coronavirus Cases in Saudi Arabia Linked to Hospital Outbreak With Continued Circulation of Recombinant Virus, July 1-August 31, 2015.

During July-August 2015, the number of cases of Middle East respiratory syndrome (MERS) reported from Saudi Arabia increased dramatically. We reviewed the 143 confirmed cases from this period and classified each based upon likely transmission source. We found that the surge in cases resulted predominantly (90%) from secondary transmission largely attributable to an outbreak at a single healthcare facility in Riyadh. Genome sequencing of MERS coronavirus from 6 cases demonstrated continued circulation of the recently described recombinant virus. A single unique frameshift deletion in open reading frame 5 was detected in the viral sequence from 1 case.

Molecular characterization of carbapenemase production among gram-negative bacteria in saudi arabia.

We characterized the molecular basis of carbapenemase production in carbapenem-resistant Gram-negative bacteria isolated from hospitalized patients from Saudi Arabia in the year 2012. Isolates were collected from across the Kingdom and phenotypically tested for carbapenemase production. Polymerase chain reaction detection of carbapenemase genes was also performed. Our results indicate that in Saudi Arabia, OXA-48 and NDM-1 are the dominant carbapenemases among Enterobacteriaceae with low prevalence of VIM. The latter is the most prevalent metallo-beta-lactamase in Pseudomonas aeruginosa, whereas oxacillinases, OXA-23 in particular, are the dominant carbapenemases in Acinetobacter baumannii. No KPC or IMP genes were detected. Our study is the first report of OXA-48, NDM-1, and VIM-4 enzymes in Enterobacter from the Kingdom. Also it is the first report of OXA-72 and NDM-1 in A. baumannii in Saudi Arabia, and the coexistence of blaOXA-23 and blaNDM-1 genes in this species in the country. Awareness of the role of international travel in the spread of carbapenem-resistant determinants in the Kingdom, as well as effective infection control interventions in hospitals and strict antimicrobial stewardship in healthcare facilities and the community are keys to combat the rise of carbapenemase producers in the Kingdom.

Etiology of severe community-acquired pneumonia during the 2013 Hajj-part of the MERS-CoV surveillance program.

BACKGROUND: Pneumonia is the leading cause of hospital admission during the annual Islamic pilgrimage (Hajj). The etiology of severe pneumonia is complex and includes the newly emerged Middle East respiratory syndrome coronavirus (MERS-CoV). Since 2012, the Saudi Ministry of Health (MoH) has required screening for MERS-CoV for all cases of severe pneumonia requiring hospitalization. We aimed to screen Hajj pilgrims admitted to healthcare facilities in 2013 with severe community-acquired pneumonia (CAP) for MERS-CoV and to determine other etiologies. METHODS: Sputum samples were collected from all pilgrims admitted to 15 healthcare facilities in the cities of Makkah and Medina, Saudi Arabia, who were diagnosed with severe CAP on admission, presenting with bilateral pneumonia. The medical records were reviewed to collect information on age, gender, nationality, and patient outcome. Samples were screened for MERS-CoV by PCR, and a respiratory multiplex array was used to detect up to 22 other viral and bacterial respiratory pathogens. RESULTS: Thirty-eight patients met the inclusion criteria; they were predominantly elderly (mean age 58.6 years, range 25-83 years) and male (68.4%), and all were from developing countries. Fourteen of the 38 patients died (36.8%). MERS-CoV was not detected in any of the samples. Other respiratory pathogens were detected in 26 (68.4%) samples. Of these, bacterial pathogens were detected in 84.6% (22/26) and viruses in 80.7% (21/26). Twenty-one (80.7%) samples were positive for more than one respiratory pathogen and 17 (65.3%) were positive for both bacteria and viruses. The most common respiratory virus was human rhinovirus, detected in 57.7% of the positive samples, followed by influenza A virus (23.1%) and human coronaviruses (19.2%). Haemophilus influenzae and Streptococcus pneumoniae were the predominant bacteria, detected in 57.7% and 53.8%, respectively, of the positive samples, followed by Moraxella catarrhalis (36.4%). CONCLUSIONS: MERS-CoV was not the cause of severe CAP in any of the hospitalized pilgrims investigated. However we identified a variety of other respiratory pathogens in the sputum of this small number of patients. This indicates that the etiology of severe CAP in Hajj is complex with implications regarding its management.

Eradicating leprosy in Saudi Arabia: outcome of a ten-year surveillance (2003­2012).

BACKGROUND: The Kingdom of Saudi Arabia (KSA) has a sentinel surveillance system on leprosy for effective monitoring of the disease. METHODS: A retrospective epidemiological analysis of all cases of leprosy captured by the surveillance system between 2003 and 2012 was conducted. RESULTS: Over the 10-year period, there were 242 reported cases of leprosy in KSA, 67% of which were in those aged between 15 and 44 years of age. Males accounted for over 77% of all cases and non-Saudi nationals, dominated by Indians, and represented 57.4% of the total cases. Just over half of the cases were paucibacillary leprosy, and 9% were grade 2 disability. Makkah region accounted for nearly 42% of all cases. Annual trends showed an overall decline in the yearly cases and prevalence of the disease from 41 cases (0.018 per 10,000 population) in 2003 to 15 cases (0.005 per 10,000 population) in 2012. CONCLUSION: KSA needs to strengthen the leprosy surveillance systems, as well as health care and community education about the disease which will help effective monitoring, early detection and treatment of the disease. Moreover, the role or migrants in the importation of the disease needs to be addressed to achieve and maintain eradication.

Meningococcal serogroup A, C, W, and Y serum bactericidal antibody profiles in Hajj pilgrims.

BACKGROUND: The religious seasons of Hajj and Umra in the Kingdom of Saudi Arabia (KSA) have historically been associated with epidemics of meningococcal disease. Due to the effective preventive measures taken in recent years, including vaccination, no meningococcal outbreaks have been reported during Hajj or were Hajj-associated. However, little is known about the immunological profile of pilgrims. The aim of this study was to assess the immunological profile of pilgrims on arrival in KSA against the four meningococcal serogroups, A, C, W, and Y, contained within the quadrivalent vaccine. METHODS: Following consent, socio-demographic factors and health-related information was collected from pilgrims arriving at King Abdul Aziz International Airport and a blood sample taken. Antibodies were quantified by serum bactericidal antibody assay using baby rabbit complement (rSBA) against the four meningococcal serogroups, A, C, W, and Y. RESULTS: Serum samples were collected from 796 pilgrims; rSBA results were obtained for all four serogroups for 741 of these samples. A total of 48 (6.5%) Hajjis had previously attended Hajj, ranging from 1 to 14 times (median 2 times); 98.2% had received meningococcal quadrivalent vaccine in the last 3 years. Of the 13 who had not, all originated from Bangladesh, with four reporting no previous meningococcal vaccination and nine reporting having received the vaccination more than 3 years ago. For serogroup A, only one pilgrim from Indonesia had an rSBA titre <8. For serogroups C, W, and Y, the percentages of pilgrims with rSBA titres <8 were 9.9%, 17.4%, and 9.4%, respectively. Of note was the high prevalence of non-complement-mediated lysis in pilgrims originating from Nigeria (28/47; 59.6%) and Afghanistan (21/47; 44.7%), but not the other countries. This may be a reflection of the type and pattern of antibiotic usage among these communities. CONCLUSION: The vast majority of pilgrims are vaccinated and protected against meningococcal serogroups A, C, W, and Y.

Environmental sampling for respiratory pathogens in Jeddah airport during the 2013 Hajj season.

BACKGROUND: Respiratory tract infections (RTIs) are common during the Hajj season and are caused by a variety of organisms, which can be transmitted via the air or contaminated surfaces. We conducted a study aimed at sampling the environment in the King Abdul Aziz International (KAAI) Airport, Pilgrims City, Jeddah, during Hajj season to detect respiratory pathogens. METHODS: Active air sampling was conducted using air biosamplers, and swabs were used to sample frequently touched surfaces. A respiratory multiplex array was used to detect bacterial and viral respiratory pathogens. RESULTS: Of the 58 environmental samples, 8 were positive for at least 1 pathogen. One air sample (1 of 18 samples, 5.5%) tested positive for influenza B virus. Of the 40 surface samples, 7 (17.5%) were positive for pathogens. These were human adenovirus (3 out of 7, 42.8%), human coronavirus OC43/HKU1 (3 out of 7, 42.8%), Haemophilus influenzae (1 out of 7, 14.2%), and Moraxella catarrhalis (1 out of 7, 14.2%). Chair handles were the most commonly contaminated surfaces. The handles of 1 chair were cocontaminated with coronavirus OC43/HKU1 and H influenzae. CONCLUSION: Respiratory pathogens were detected in the air and on surfaces in the KAAI Airport in Pilgrims City. Larger-scale studies based on our study are warranted to determine the role of the environment in transmission of respiratory pathogens during mass gathering events (eg, Hajj) such that public health preventative measures might be better targeted.