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

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

Lidar Observations in South America. Part I - Mesosphere and Stratosphere

South America covers a large area of the globe and plays a fundamental function in its climate change, geographical features, and natural resources. However, it still is a developing area, and natural resource management and energy production are far from a sustainable framework, impacting the air quality of the area and needs much improvement in monitoring. There are significant activities regarding laser remote sensing of the atmosphere at different levels for different purposes. Among these activities, we can mention the mesospheric probing of sodium measurements and stratospheric monitoring of ozone, and the study of wind and gravity waves. Some of these activities are long-lasting and count on the support from the Latin American Lidar Network (LALINET). We intend to pinpoint the most significant scientific achievements and show the potential of carrying out remote sensing activities in the continent and show its correlations with other earth science connections and synergies. In Part I of this chapter, we will present an overview and significant results of lidar observations in the mesosphere and stratosphere. Part II will be dedicated to tropospheric observations

Lidar Observations in South America. Part II - Troposphere

In Part II of this chapter, we intend to show the significant advances and results concerning aerosols’ tropospheric monitoring in South America. The tropospheric lidar monitoring is also supported by the Latin American Lidar Network (LALINET). It is concerned about aerosols originating from urban pollution, biomass burning, desert dust, sea spray, and other primary sources. Cloud studies and their impact on radiative transfer using tropospheric lidar measurements are also presented

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

11th September: relevance of the international judicial cooperation

Em um contexto cada vez mais complexo e internacionalizado, as ameaças também se propagam de forma difusa, aproveitando-se das novas possibilidades de ação que a globalização traz à tona, ameaças estas simbolizadas pelo atentado terrorista de 11 de setembro de 2001, contra o WTC e o Pentágono. Apenas a coordenação dos esforços dos Estados pode garantir a realização de um mundo dividido em unidades políticas soberanas. Pois se as fronteiras como expressão da soberania forem utilizadas como forma de evasão à lei, a própria legitimidade dos Estados estará comprometida na medida em que a legitimidade caminha de mãos dadas com a eficácia. Diante desses desafios, de um mundo cada vez mais interligado, destaca-se a importância da cooperação judiciária internacional como instrumento de política pública.In an increasingly complex and internationalized reality, the threats are fostering in a diffuse fashions, taking advantage of the new possibilities of action that the globalization creates; treats that could be symbolized by the terrorist attacks of September, 11th, 2001, against WTC and Pentagon. Only the coordination of the efforts of estates could guarantee a world divided in sovereign political unites. If the frontiers, as an expression of the notion of sovereignty, would be used to escape of the rule of law, the legitimacy of the states would be jeopardized; since legitimacy is the other face of efficacy. In the presence of these challenges, of an inter-linked world, turn up the importance of the international judicial co-operation, as an instrument of public policy

A audiência prévia de conciliação e mediação do artigo 334 do CPC/2015

- Divulgação dos SUMÁRIOS das obras recentemente incorporadas ao acervo da Biblioteca Ministro Oscar Saraiva do STJ. Em respeito à Lei de Direitos Autorais, não disponibilizamos a obra na íntegra.- Localização na estante: 347.925(81) S211

The prior hearing of conciliation and mediation of article 334 of the 2015 Code of Civil Procedure

O Código de Processo Civil de 2015 reforçou a importância da autocomposição e introduziu um novo paradigma no sistema processual, com a pretensão de retirar ênfase \"exagerada\" dada ao sistema adversarial fundado na heterocomposição. Tal mudança de mentalidade é visível na regra contida no art. 334 de referido diploma legal, pela qual se introduziu fase prévia de tentativa de autocomposição. Com tão pouco tempo de vigência, porém, diversas dúvidas pairam sobre a interpretação e a aplicação dessa regra, não só em razão do ineditismo de fase prévia de tentativa de autocomposição, mas também por guardar conflito com outra norma recentemente introduzida no sistema pátrio, o art. 27 da Lei da Mediação. O presente trabalho analisa tais conflitos normativos, bem como os principais aspectos acerca dessa nova fase processual: seu funcionamento, seus prazos, sua forma de realização, condutas permitidas e vedadas às partes. Tal análise, ao mesmo tempo em que se pauta por olhar acadêmico e doutrinário, coteja a prática forense, trazendo como exemplos as manifestações judiciais sobre questões controvertidas. A análise crítica da regra da obrigatoriedade da realização da fase prévia autocompositiva e a ausência de triagem dos processos que são direcionados são abordadas na perspectiva do desenvolvimento de sistema judicial équo.Brazil\'s 2015 Code of Civil Procedure stresses the importance of self-resolution of conflicts and introduces a new paradigm in our procedural system with aims to removing the \"excessive\" emphasis on the adversarial system, grounded in third-party mediation. Such mindset shift is clear in the rule contained in art. 334 of said legal device, which introduced a prior phase for an attempt at self-resolution. With so little time in force, however, many doubts still remain regarding the interpretation and applicability of this rule, not only due to the novelty of the prior phase for an attempt at self-resolution, but also because it conflicts with another rule recently introduced into our nation\'s system, art. 27 of the Mediation Act. This work analyzes such ruling conflicts, as well as the main aspects surrounding this new procedural phase: its functioning, periods, methods, and acts that the parties are allowed to and forbidden from taking. Such analysis, while performed from an academic and doctrine standpoint, involves the forensic practice, bringing as examples the statements of the courts on controversial matters. A critical analysis of the rule of required conduction of a prior selfresolution phase and the lack of some screening for the proceedings presented is performed from the standpoint of the development of an equitable justice system