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

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

A simple scoring system to predict early prognosis of patients undergoing loco-regional therapy for hepatocellular carcinoma

Abstract: Introduction: Hepatocellular carcinoma (HCC) is the sixth most common cancer and is the third leading cause of cancer-related deaths worldwide and its incidence is increasing. Aim of work: was to identify potential prognostic factors affecting survival in patients with unresectable HCC treated with local ablation. and proposing a new scoring system to predict early prognosis of those patients. Patients and methods: 150 consecutive patients with HCC who underwent RFA and/or TACE at National Liver Institute, Menoufiya University during 1 year were included in the study. Data of demographic, clinical, laboratory parameters and Triphasic spiral CT scan were collected. All patients were re-evaluated one month after intervention by laboratory testing and CT or MRI for detection of complications and detection of the effect of intervention Then all patients were followed up for 6 months for detection of mortality rate and prognostic factors related to survival. Results: 79.3% were males with mean age of 57.8 ± 9 year. Total bilirubin and serum creatinine significantly elevated one month after intervention (p&lt; 0.001). Serum albumin and AFP significantly decreased (p&lt; 0.001). Most of our patients were Child A and B. One month after intervention 49 (32.6%) remain Child (A) and 28 of them had no added points to their baseline child score, 76 (50.7%) patients had Child (B), Child (C) patients increased to 25 (16.7%). During 6 months follow up, upper GIT bleeding (due to bleeding esophageal varicies) occurred in 3 patients. Also, 3 patients developed infections and 12 patients developed hepatic decompensation. Development of complications was seen with (4.95 cm, tumor size with sensitivity of 78.9% and (p &lt; 0.01), AFP level of 184 ng/ml with sensitivity of 73.7% and (p &lt; 0.05), serum albumin level &lt; 2.35 g/dl with sensitivity of 73.7%, Child score &gt; 6.5 with sensitivity of 94.7%, MELD score &gt; 14.5 with a sensitivity of 78.9%. 14 patients died within 6 months of intervention (the mortality rate was 9.3%). The cause of death in most cases was progression of disease and/ or development of hepatic failure. The number of nodules significantly correlated with mortality (p &lt; 0.01). Tumor size above 5.9 cm, AFP &gt;330.5, serum albumin &lt;2.55 g/dl associated with increased mortality rate. Moreover, increased mortality was associated with Child score &gt;8.5 and MELD score &gt;13.5. Finally, we proposed a simple scoring system that could be used to predict outcome and stratify patients with unresectable HCC undergoing loco-regional therapy. Three factors; albumin &lt; 2.9 g/dl, AFP &gt; 330 and size of dominant tumor &gt; 5.3 cm were used in this score. A scoring system was derived by allocating one point for each factor that was elevated above the defined cut-off for AFP and tumor size or below the cut-off for the albumin; score 1=0 points, 2=1 point and score 3=&gt;1 point. The survival rate after six month from intervention for those with a score 1, 2 and 3 was 100%, 92.4% and 86.4% respectively. Conclusion: the new scoring system can be used easily to predict outcome in patients with HCC who are eligible to locoablative therapy. This scoring system needs to be validated on more patients. [Zaghla H, Gomaa AI, Elshimi E, Abdelaal EM, Elwaraki M, Gameel K and Badra G. A simple scoring system to predict early prognosis of patients undergoing loco-regional therapy for hepatocellular carcinoma. Life Sci

The success rate of radiofrequency catheter ablation in Wolff-Parkinson-White-Syndrome patients: A systematic review and meta-analysis

Introduction: radiofrequency catheter ablation (RFA) is the first-line therapy for symptomatic Wolff Parkinson White (WPW) patients according to the American Heart Association. We conducted this study to assess the success rate, recurrence rate, and rate of complications associated with the utilization of radiofrequency catheter ablation for managing patients with WPW. Method: We searched PubMed, Cochrane library, Web of Science and Scopus databases using all identified keywords and index terms through 4 January 2022. We included all studies conducted on WPW patients who were treated with ablation. We conducted the analysis using Open Meta Analyst and MedCalc version 19.1. Results: Among 2268 unique articles identified, only 11 articles met our inclusion criteria. The pooled effect estimates showed high success rate (94.1%[95%CI:92.3–95.9], p < 0.001)), low recurrence rate (6.2% [95%CI:4.5–7.8, p < 0.001]) and low rate of complications (1%[95%CI:0.4–1.5, p < 0.001]). Conclusion: RFA showed a high success rate, low recurrence rate and low rate of complications in WPW patients

Abstract Number ‐ 52: Stem Cell Therapy for Ischemic Stroke: A Meta‐Analysis of 18 Studies including 724 Patients

Introduction The published clinical data assessing stem cell therapy for ischemic stroke (IS) are inconclusive. We conducted this comprehensive meta‐analysis to evaluate the efficacy and safety of stem cell therapy in the treatment of IS. Methods We searched electronic databases/search engines for studies comparing stem cell therapy to control in the treatment of IS from inception to June 2022. References were screened manually for eligibility. The relevant baseline data along with outcomes measured by modified Rankin scale (mRS), National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI) and death were extracted and analyzed. Results We included 18 studies (12 randomized controlled trials (RCTs) and six non‐RCTs) comprising a total of 724 patients including 365 in the stem cells and 359 in the control group. Pooled results considering the last follow‐up point across 12 studies showed that stem cells significantly decreased mRS scores in relation to control (MD = ‐0.265, 95% CI [‐0.403 to ‐0.1269], P‐value = 0.00017). There was no publication bias (P = 0.4). The univariate meta‐regression demonstrated that route of administration, stem cell type, stroke type, and study design did not significantly contribute to the heterogeneity of the stem cells effect estimate (P >0.05). Additional analyses showed no significant differences in mRS scores between stem cells and control after seven days to three months (n = seven studies; MD = ‐0.039, 95% CI [‐0.22 to 0.15], P‐value = 0.681) and six to twelve months (n = ten studies; MD = ‐0.13, 95% CI [‐0.37 to 0.089], P‐value = 0.234). However, stem cells significantly decreased mRS scores in relation to control after two to four years (n = four studies; MD = ‐0.28, 95% CI [‐0.49 to ‐0.068], P‐value = 0.0096). Similarly, pooled results considering the last follow‐up point across nine studies showed that stem cells marginally decreased NIHSS scores in relation to control (MD = ‐1.185, 95% CI [‐2.37 to 0.00], P‐value = 0.05) with no publication bias (P = 0.5). Moreover, pooled results from 11 studies showed that stem cells significantly increased BI in relation to control (MD = 5.36, 95% CI [2.51 to 8.21], P‐value = 0.0002) with no publication bias (P = 0.675). Pooled results from 17 studies showed that stem cells treatment was significantly associated with lower risk of death in relation to control group (RR = 0.565, 95% CI [0.345 to 0.927], P‐value = 0.024). Conclusions Stem cell therapy for the treatment of IS seems to be associated with improved functional outcomes and reduced mortality. Notably, the demonstration of the functional outcome benefit appears to be more evident on longer follow‐up times (>2 years). Additional prospective studies are needed and should consider longer follow‐up periods

Titrated oral misoprostol versus static regimen of oral misoprostol for induction of labour: a systematic review and meta-analysis

We aimed to conduct a systematic review and meta-analysis to compare the efficacy and safety of titrated oral misoprostol versus static oral misoprostol for labour induction. We searched for the available randomised clinical trials (RCTs) in the Cochrane Library, PubMed, ISI web of science, Scopus, and ClinicalTrials.gov. We included RCTs compared titrated oral misoprostol versus static regimen of oral misoprostol during labour induction. Our main outcomes were vaginal and caesarean delivery rates, uterine tachysystole, misoprostol side effects, and neonatal adverse events. Three RCTs met our inclusion criteria with a total number of 360 patients. The vaginal delivery rate did not significantly differ between both groups (p = 0.49). Titrated oral misoprostol was associated with significant increase in the caesarean delivery rate compared to static oral misoprostol (p = 0.04). Moreover, titrated oral misoprostol led to significant increase in the uterine tachysystole and misoprostol side effects (p = 0.01 & p = 0.003, respectively). There were no differences among both groups regarding different neonatal adverse events. In conclusion, titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. Thus, static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. Impact Statement What is already known on this subject? Different studies have evaluated titrated oral misoprostol administration for induction of labour and proved their efficacy in comparison with other induction methods. However, there is controversy among the published studies between titrated oral misoprostol and static oral misoprostol during induction of labour. A recent study concluded that hourly titrated misoprostol and static oral misoprostol are equally safe and effective when utilised for induction of labour with no fear of any adverse events. However, another study recommended static oral misoprostol administration for labour induction as it was linked to a lower caesarean section incidence, fewer drug side effects, and decline in complication rates in comparison with titrated oral misoprostol. What the results of this study add? Titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. What the implications are of these findings for clinical practice and/or further research? Static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. More future trials are required to confirm our findings

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially