Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Incorporating Contextual Knowledge Into Human-Robot Collaborative Task Execution

An essential measure of autonomy in service robots designed to assist humans is adaptivity to the various contexts of human-oriented tasks. These robots may have to frequently execute the same action, but subject to subtle variations in task parameters that determine optimal behaviour. Such actions are traditionally executed by robots using pre-determined, generic motions, but a better approach could utilize robot arm maneuverability to learn and execute different trajectories that work best in each context. In this project, we explore a robot skill acquisition procedure that allows incorporating contextual knowledge, adjusting executions according to context, and improvement through experience, as a step towards more adaptive service robots. We propose an apprenticeship learning approach to achieving context-aware action generalisation on the task of robot-to-human object hand-over. The procedure combines learning from demonstration, with which a robot learns to imitate a demonstrator’s execution of the task, and a reinforcement learning strategy, which enables subsequent experiential learning of contextualized policies, guided by information about context that is integrated into the learning process. By extending the initial, static hand-over policy to a contextually adaptive one, the robot derives and executes variants of the demonstrated action that most appropriately suit the current context. We use dynamic movement primitives (DMPs) as compact motion representations, and a model-based Contextual Relative Entropy Policy Search (C-REPS) algorithm for learning policies that can specify hand-over position, trajectory shape, and execution speed, conditioned on context variables. Policies are learned using simulated task executions, before transferring them to the robot and evaluating emergent behaviours. We demonstrate the algorithm’s ability to learn context-dependent hand-over positions, and new trajectories, guided by suitable reward functions, and show that the current DMP implementation limits learning context-dependent execution speeds. We additionally conduct a user study involving participants assuming different postures and receiving an object from the robot, which executes hand-overs by either exclusively imitating a demonstrated motion, or selecting hand-over positions based on learned contextual policies and adapting its motion accordingly. The results confirm the hypothesized improvements in the robot’s perceived behaviour when it is context-aware and adaptive, and provide useful insights that can inform future developments

A Neuromorphic Approach to Obstacle Avoidance in Robot Manipulation

Neuromorphic computing aims to mimic the computational principles of the brain in silico and has motivated research into event-based vision and spiking neural networks (SNNs). Event cameras (ECs) capture local, independent changes in brightness, and offer superior power consumption, response latencies, and dynamic ranges compared to frame-based cameras. SNNs replicate neuronal dynamics observed in biological neurons and propagate information in sparse sequences of ”spikes”. Apart from biological fidelity, SNNs have demonstrated potential as an alternative to conventional artificial neural networks (ANNs), such as in reducing energy expenditure and inference time in visual classification. Although potentially beneficial for robotics, the novel event-driven and spike-based paradigms remain scarcely explored outside the domain of aerial robots. To investigate the utility of brain-inspired sensing and data processing in a robotics application, we developed a neuromorphic approach to real-time, online obstacle avoidance on a manipulator with an onboard camera. Our approach adapts high-level trajectory plans with reactive maneuvers by processing emulated event data in a convolutional SNN, decoding neural activations into avoidance motions, and adjusting plans in a dynamic motion primitive formulation. We conducted simulated and real experiments with a Kinova Gen3 arm performing simple reaching tasks involving static and dynamic obstacles. Our implementation was systematically tuned, validated, and tested in sets of distinct task scenarios, and compared to a non-adaptive baseline through formalized quantitative metrics and qualitative criteria. The neuromorphic implementation facilitated reliable avoidance of imminent collisions in most scenarios, with 84% and 92% median success rates in simulated and real experiments, where the baseline consistently failed. Adapted trajectories were qualitatively similar to baseline trajectories, indicating low impacts on safety, predictability and smoothness criteria. Among notable properties of the SNN were the correlation of processing time with the magnitude of perceived motions (captured in events) and robustness to different event emulation methods. Preliminary tests with a DAVIS346 EC showed similar performance, validating our experimental event emulation method. These results motivate future efforts to incorporate SNN learning, utilize neuromorphic processors, and target other robot tasks to further explore this approach

Context-Aware Task Execution Using Apprenticeship Learning

An essential measure of autonomy in assistive service robots is adaptivity to the various contexts of human-oriented tasks, which are subject to subtle variations in task parameters that determine optimal behaviour. In this work, we propose an apprenticeship learning approach to achieving context-aware action generalization on the task of robot-to-human object hand-over. The procedure combines learning from demonstration and reinforcement learning: a robot first imitates a demonstrator’s execution of the task and then learns contextualized variants of the demonstrated action through experience. We use dynamic movement primitives as compact motion representations, and a model-based C-REPS algorithm for learning policies that can specify hand-over position, conditioned on context variables. Policies are learned using simulated task executions, before transferring them to the robot and evaluating emergent behaviours. We additionally conduct a user study involving participants assuming different postures and receiving an object from a robot, which executes hand-overs by either imitating a demonstrated motion, or adapting its motion to hand-over positions suggested by the learned policy. The results confirm the hypothesized improvements in the robot’s perceived behaviour when it is context-aware and adaptive, and provide useful insights that can inform future developments

The effect of social media on spouse relations on Jordan society

Social media has an effect in practically all aspects of human interactions. The present study focuses on the impact of social media on married couples. The research proposes hypothesis for the positive as well as the negative aspects that social media usage might have on spouse relationships. The approach for the study is based on exploratory and descriptive social research methodology, using both qualitative and quantitative methods to collect and analyze data. A survey questionnaire was designed and tested for the purpose of the study. The result of the research highlights the potential benefits of social media for married couples when used to strengthen the relationship, by increasing their daily interaction, keeping them communicated while prolong absences, or finding solutions to common shared problems. On the other hand, the negative effect of social media for spouses’ relationships relies on the perceived decrease of quality and quantity time spend together, the feeling of wasting couples time, and the potential threat that this might cause to the relation.&nbsp; Finally, variables such as age, income level and number of years within the relation, influence how social media usage will affect the spouse relationship

On the Diagnosability of Actions Performed by Contemporary Robotic Systems

When a robotic agent experiences a failure while acting in the world, it should be possible to discover why that failure has occurred, namely to diagnose the failure. In this paper, we argue that the diagnosability of robot actions, at least in a classical sense, is a feature that cannot be taken for granted since it strongly depends on the underlying action representation. We specifically define criteria that determine the diagnosability of robot actions. The diagnosability question is then analysed in the context of a handle manipulation action, such that we discuss two different representations of the action – a composite policy with a learned success model for the action parameters, and a neural network-based monolithic policy – both of which exist on different sides of the diagnosability spectrum. Through this comparison, we conclude that composite actions are more suited to explicit diagnosis, but representations with less prior knowledge are more flexible. This suggests that model learning may provide balance between flexibility and diagnosability; however, data-driven diagnosis methods also need to be enhanced in order to deal with the complexity of modern robots

Intrabronchial valves for persistent pulmonary air leaks in children

Background: Surgery to address parenchymal lung disease in children is rare. One of the complications of the surgery is a persistent air leak (PAL). Intrabronchial valves (IBV), which received FDA approval for treating PAL in recent years, limit or exclude the inflow of air towards the pleura and allow air and secretions to flow towards central airways. The valves have been effective in adults with PAL but little has been published on their use in children. Methods: Retrospective chart review was performed after IRB approval on patients treated with IBV after surgical excision of lung parenchyma. A literature review was then performed. Results: 2 pediatric patients are presented. Patient 1, a 10 year old girl underwent excision of a lung mass that developed persistent air leak. Traditional conservative methods did not seal the air leak for 23 days but an IBV sealed the leak in 24 h. Patient 2, a 6 year old boy underwent a pneumonectomy with post-operative bronhical leak. The bronchus was repaired but a leak persisted for 36 days. An IBV sealed the leak immediately. Conclusion: Intrabronchial valves can be used for the management of persistent pulmonary air leaks. We propose a tentative algorithm for using the devices in children with PAL. Keywords: Endobronchial valve, Intrabronchial valve, PAL, Persistent air leak, Pediatri