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

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

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

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

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Comprehensive Review on Fault Ride-Through Requirements of Renewable Hybrid Microgrids

The world is interested in applying grid codes to increase the reliability of power systems through a micro-grid (MG). In a common practice, the MG comprises a wind farm, and/or photovoltaic (PV) arrays that are integrated with diesel generators and energy storage devices. Fault ride-through (FRT) capability is an important requirement of grid codes. FRT means that the MG is still connected to the grid during numerous disturbances such as faults. This is required to ensure that there is no loss of power generated due to grid faults. Reactive currents must be injected into the grid to increase the power system stability and restore voltage. To enhance FRT for doubly fed induction generator (DFIG) based WT installation, internal control modifications of rotor-side converters and grid-side converters are applied. The solutions that depend on these modifications are traditional and advanced control techniques. Advanced control techniques are needed due to the non-linear nature and less robustness of traditional ones. External hardware devices are also added to improve the FRT of DFIG which are classified into protection devices, reactive power injection devices, and energy storage devices. A comprehensive review of FRT enhancements of DFIG-based WTs, PV systems, and MGs using hardware and software methods is presented in this effort. A classification of FRT of PV systems is characterized plus various inverter control techniques are indicated. Several FRT methods for hybrid PV-WT are presented, with full comparisons. The overall operation and the schematic diagrams of the DFIG-WT with FRT methods are discussed and highlighted. Many Robust control methods for controlling grid connected AC, DC and hybrid AC/DC MGs in power systems are addressed. A total of 210 reported articles were review, including the most up-to-date papers published in the literature. This review may be used as the basis to improve system reliability for those interested in FRT methods. Various traditional and advanced control techniques to improve the FRT abilities are summarized and discussed, including protection devices, reactive power injection devices, and energy storage. In addition, the classifications of FRT hardware methods for DFIG are presented, including grid code requirements

Maximizing solar radiations of PV panels using artificial gorilla troops reinforced by experimental investigations

Abstract This article's main objective is to maximize solar radiations (SRs) through the use of the gorilla troop algorithm (GTA) for identifying the optimal tilt angle (OTA) for photovoltaic (PV) panels. This is done in conjunction with an experimental work that consists of three 100 W PV panels tilted at three different tilt angles (TAs). The 28°, 30°, and 50° are the three TAs. The experimental data are collected every day for 181-day and revealed that the TA of 28° is superior to those of 50° and 30°. The GTA calculated the OTA to be 28.445°, which agrees with the experimental results, which show a TA of 28°. The SR of the 28o TA is 59.3% greater than that of the 50° TA and 4.5% higher than that of the 30° TA. Recent methods are used to compare the GTA with the other nine metaheuristics (MHTs)—the genetic algorithm, particle swarm, harmony search, ant colony, cuckoo search, bee colony, fire fly, grey wolf, and coronavirus disease optimizers—in order to figure out the optimal OTA. The OTA is calculated by the majority of the nine MHTs to be 28.445°, which is the same as the GTA and confirms the experimental effort. In only 181-day, the by experimentation it may be documented SR difference between the TAs of 28° and 50° TA is 159.3%. Numerous performance metrics are used to demonstrate the GTA's viability, and it is contrasted with other recent optimizers that are in competition

Automated Settings of Overcurrent Relays Considering Transformer Phase Shift and Distributed Generators Using Gorilla Troops Optimizer

The relative protective devices are cascaded in a proper sequence with a proper min/max coordination time margin (CTM) to minimize the outage area of the network in case of fault condition. This manuscript addresses a new methodology based on the gorilla troops optimizer (GTO) to produce the best automated settings for overcurrent relays. In the GTO, the exploration and exploitation phases are realized using five methodologies. Three of them are used in the exploration phase and the other two in the exploitation phase. In the exploration phase, all gorillas are considered as candidate solutions and the best one is considered as the silverback gorilla. Then again, the exploitation phase comprises two steps: (i) the first one is the follow of silverback gorilla, and (ii) the second one is the competition for adult females. The latter mentioned offers an added advantage to the GTO framework to move forward steadily to global minima and to avoid trapping into local minima. Two test cases under numerous scenarios are demonstrated comprising an isolated real distribution network with distributed generations for the Agiba Petroleum company which is in the Western Desert of Egypt. The relay coordination problem is adapted as an optimization problem subject to a set of predefined constraints which is solved using the GTO including fixed and varied inverse IEC curves, in which the practical constraints including transformer phase shift and other scenarios for min/max fault conditions are dealt with. In due course, this current effort aims at proving the best strategy for achieving the smoothest coordination of overcurrent relays (OCRs), with the least obtained value of CTMs for the studied cases being established via the automated relay settings. At last, it can be pointed out that the GTO successfully dealt with this problem and was able to produce competitive answers compared to other competitors

Optimal Scheduling of Hybrid Sustainable Energy Microgrid: A Case Study for a Resort in Sokhna, Egypt

This paper is focused on analyzing, investigating, and designing a hybrid energy system based on sustainable or renewable resources, namely solar and wind energy, in addition to using a diesel generator and battery storage to supply a small resort in Suez, Egypt. The resort is located in Sokhna, which is on the Suez gulf and is about 50 km from the Suez governorate and 100 km from Cairo, Egypt. The Sokhna coast has plenty of high solar radiation and wind energy all year. At the same time, the Egyptian government is building many wind and photovoltaic projects there. Thus, it is expected that it will be very economic to use solar and wind energy in that area to supply the resort. The optimal combinations of energy resources to meet the load demand under various scenarios are considered. The optimal mix of sources is investigated with and without the presence of the grid. The cropped outcomes show that the hybrid energy system, which is also in the presence of the grid, is a very economical solution that provides the resort with an acceptable energy cost. The cost of energies (CoEs) is equal to 0.0441 and 0.0443 $/kWh for cases 2 and 4 (with grid), respectively. However, the CoEs are equal to 0.141 and 0.134$/kWh for cases 1 and 3 (without grid), respectively

Steady-State Modeling of Fuel Cells Based on Atom Search Optimizer

In simulation studies, the precision of fuel cell models has a vital role in the quality of results. Unfortunately, due to the shortage of manufacturer data given in the datasheets, several unknown parameters should be defined to establish the fuel cell model for further precise analysis. This research addresses a novel application of the atom search optimization (ASO) algorithm to generate these unknown parameters of the fuel cell model and in particular of the polymer exchange membrane (PEM) type. The objective of this study is to establish an accurate model of the PEM fuel cells, which will provide accurate results of modeling and simulation in a steady-state condition. Simulations and further demonstrations were performed under MATLAB/SIMULINK. The viability of the proposed models was appraised by comparing its simulation results with the experimental results of number of commercial PEM fuel cells. In the same context, the obtained numerical results by the proposed ASO-based method were compared to other challenging optimization methods-based results. Finally, parametric tests were made which indicated the robustness of the ASO results as well. It can be stated here that ASO performs well and has a good capability to extract the unknown parameters with lesser errors