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

Case study discussion: The important partnership role of Disability Nurse Navigators in the context of abrupt system changes because of COVID-19 pandemic

Background: Rapidly implementing telehealth-facilitated healthcare services in a COVID-19 environment generates relational challenges for people with intellectual disability. Disability Nurse Navigators assume a critical intermediary role between the healthcare system and this population. Aim: To discuss the impact that rapid service change, in response to the COVID-19 pandemic, can have on people with disability and the work of Disability Nurse Navigators who support them. Methods: This clinical case discussion comprises two parts. First, a discussion on the impact that COVID-19 pandemic management has had on one person with an intellectual disability is framed using intersecting notions of cumulative complexity and Burden of Treatment Theory. Following, through a Latourian lens, the role of the Disability Nurse Navigator is explored. Findings: During COVID-19, telehealth has proved an important tool for healthcare continuity. Yet, for some people with some disabilities who live with additional and cumulative layers of health and social complexity, the healthcare workload that is transferred to them is exacerbated as they try to interact with disabling infrastructure. Discussion: The Disability Nurse Navigator recognises that people with disability are not independent of the technologies and structures that make up the healthcare system but that they are mutually constitutive. The Disability Nurse Navigator thus works to stabilise the relationships between changed service provision and the healthcare workload and capacity of people with disability. Conclusion: The work of the Disability Nurse Navigator ultimately mitigated the disruption and additional treatment burden that is transferred to people with disability because of unintended consequences arising from the rapid introduction of service change.</p

Advancing clinical facilitator capability to support graduate nurses: Outputs from social learning processes embedded in action research cycles

Aim: This study in the first instance, seeks to identify encounters that commonly occur between graduates, facilitators and others; and second, to explicate skills and behaviours needed by facilitators to effectively guide graduates to perform at expected standards. Background: In Australia, nursing graduates are expected to assimilate quickly and adapt to workplace practices within short timeframes. Clinical facilitators are provided to support transition to the workplace. However, providing support is only understood in broad terms. Design: Two consecutive action research cycles informed by extended Vygotskian learning concepts guided the study. The first cycle recorded and categorised critical encounters with graduates which were subsequently subjected to a thematic analysis to identify common circumstances where clinical facilitators are required to provide support to graduates. The second cycle articulated behaviours useful to clinical faciltators to foster graduate nurse learning, for optimal management of challenges experienced in routine daily practice. Method: Registered nurses involved in graduate clinical facilitation at a large (780 bed adult facility) and a medium (448 bed adult, paediatric, maternity) acute hospital participated in the study. This graduate facilitation team through situated learning and a series of joint activity designed an EXCEL spreadsheet on which they recorded their observations and experiences with faciltating graduates transition to practice. Results: From 1615 reported challenging interactions in the first cycle, saturation of emerging themes was reached with a random subset of 142. Six common areas of intensive needs for graduates were recorded, namely, resilience, technical support, emergent need, time management, advocate for graduate and catastrophe. The second cycle articulated processes for managing identified need areas in the form of flow charts. In practice, the flow charts provide a means for ‘scaffolding’ supervision and suggest conversations useful to facilitators to successfully support graduate nurses. Conclusion: This research has successfully explicated a largely ‘undefined’ area of nursing work, that is, making the invisible work of clinical facilitators ‘visible’ through the construction of flow charts. Specifically, advances have been made in articulating contextual, constructive support that nurses who facilitate the assimilation of graduates need to bring to interactions with graduates.</p

Understanding persistent breathlessness: impact on patients and optimal approaches to symptomatic reduction–an overview

Introduction: Persistent breathlessness (breathlessness persisting despite optimal treatment for the underlying condition and resulting in disability) is a prevalent syndrome associated with chronic and life-limiting conditions. Improving the clinical recognition and assessment of persistent breathlessness is essential to ensure people are provided with the best treatment for optimal symptom control. Areas covered: This overview focuses on the impact of persistent breathlessness on patients, carers and the health system. It highlights the importance of identifying persistent breathlessness in clinical consultations, suggests steps to recognize this syndrome and discusses the evidence for non-pharmacological and pharmacological treatments in this context. Future research directions are also suggested. Expert opinion: Persistent breathlessness is often invisible because 1) people may not engage with the health system and 2) both clinicians and patients are reluctant to discuss breathlessness in clinical consultations. Improving the recognition and assessment of this syndrome is critical to facilitate meaningful conversations between patients and clinicians and ensure patient-centered care. Non-pharmacological strategies are key to improving symptom management and health outcomes. Regular, low-dose, sustained-release morphine may help further reduce breathlessness in people who remain symptomatic despite disease-specific and non-pharmacological therapies

Invisibility of breathlessness in clinical consultations: a cross-sectional, national online survey

Breathlessness diminishes the physical, mental and social wellbeing of people living long-term with this disabling symptom [1]. Identifying its impacts on patients and their families helps to inform appropriate non-pharmacological and pharmacological management [2, 3]. A randomised controlled trial suggests that clinicians are less likely to identify or manage chronic breathlessness than chronic pain [4]. Previous population studies estimate 9.5% of adults experience breathlessness [5], with 1 in 100 individuals being seriously impacted daily [6]. We conducted a population study aimed at identifying the proportion of people with breathlessness who report this symptom in clinical consultations. If discussed, we explored whether patients or clinicians (physicians; nurses) initiated the conversation and, if not discussed, whether patients would welcome such discussions

Serum sodium and mortality in a national peritoneal dialysis cohort.

BackgroundSodium disarrays are common in peritoneal dialysis (PD) patients, and may be associated with adverse outcomes in this population. However, few studies of limited sample size have examined the association of serum sodium with mortality in PD patients, with inconsistent results. We hypothesized that both hypo- and hypernatremia are associated with higher death risk in a nationally representative cohort of US PD patients.MethodsWe sought to examine the association of serum sodium over time and mortality among 4687 adult incident PD patients from a large US dialysis organization who underwent one or more serum sodium measurements within the first 3 months of dialysis over January 2007 to December 2011. We examined the association of time-dependent and baseline sodium with all-cause mortality as a proxy of short- and long-term sodium-mortality associations, respectively. Hazard ratios were estimated using Cox models with three adjustment levels: minimally adjusted, case-mix adjusted, and case-mix + laboratory adjusted.ResultsIn time-dependent analyses, sodium levels &lt;140 mEq/L were associated with incrementally higher death risk in case-mix models (ref: 140 to &lt;142 mEq/L); following laboratory covariate adjustment, associations between lower sodium and higher mortality remained significant for levels &lt;136 mEq/L. In analyses using baseline values, sodium levels &lt;140 mEq/L were associated with higher mortality risk across all models (ref: 140 to &lt;142 mEq/L).ConclusionsIn PD patients, lower time-dependent and baseline sodium levels were independently associated with higher death risk. Further studies are needed to determine whether correction of dysnatremia improves longevity in this population