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

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

Central Pain Mimicking Trigeminal Neuralgia as a Result of Lateral Medullary Ischemic Stroke

Background. Central pain mimicking trigeminal neuralgia (TN) as a result of lateral medullary infarction or Wallenberg syndrome has been rarely reported. Case Report. We discuss a patient who presented with a lateral medullary infarct and shortly after developed facial pain mimicking TN. We also elaborate on the anatomical pathway of the trigeminal nerve explaining facial pain as a result of a lateral medullary lesion. Discussion. Clinicians should be aware of this typical complication of lateral medullary infarct in order to attain proper management and work-up

Central Pain Mimicking Trigeminal Neuralgia as a Result of Lateral Medullary Ischemic Stroke

Background. Central pain mimicking trigeminal neuralgia (TN) as a result of lateral medullary infarction or Wallenberg syndrome has been rarely reported. Case Report. We discuss a patient who presented with a lateral medullary infarct and shortly after developed facial pain mimicking TN. We also elaborate on the anatomical pathway of the trigeminal nerve explaining facial pain as a result of a lateral medullary lesion. Discussion. Clinicians should be aware of this typical complication of lateral medullary infarct in order to attain proper management and work-up

Subdural Hematoma as a Consequence of Epidural Anesthesia.

Regional spinal and epidural anesthesia are used commonly in operative procedures. While the most frequent complication, postdural puncture headache (PDPH), is a clinically diagnosed positional headache that is usually self-limited, subdural hemorrhage (SDH) is a potentially fatal complication that cannot be missed. We report a case of an otherwise healthy female who presented with persistent positional headache and was ultimately found to have a large subdural hematoma with midline shift requiring surgical evacuation

Prevalence of Homelessness in the Emergency Department Setting

Background/Objective: To determine the prevalence of homelessness or at-risk for homelessness in the ED setting.Methods: Using a 5 question screening tool derived from teh US department of Housing and Urband Development (HUD), Health and Human Services (HHS) and the Beterans Administration (VA) definition for homelessness, we surveyed all patients meeting inclusion criteria on scheudled shifts in one of three EDs in Northeastern Pennsylvania  Two survey periods were selected to represent seasonal variations.Results: 4395 subjects were included in the analysis.  The mean age of participants was 50.8 (SD 20.5) and 2,557(58.2%) were women.  The mean age of those who screened positive for homelessness or at-risk for homelessness was 43.1 (SD16.6). Overall, 136 (3.1%) participants screened positive for at-risk for homelessness and 309 (7.0%) screened positive for homelessness.  103 (9.8%) subjects screened positive for homelessness or at-risk for homelessness on weekends and 312 (10.3%) on weekedays (p=-.64).  The proportion of those screening positive for homelessness or at-risk for homelessness varied by site: 145 (7.5%) at hte trauma cetner, 151 (9.1%) at the suburban site and 149 (18.7%) at the center city site, p&lt;0.001.  There was no statistical significance to the difference between the trauma center and the suburban site (p=.088), but there was statistical significance between both the suburban and the trauma cneter when compared to the center city site (both p&lt;0.0001).  The proportion of those screening positive for homelessness in the summer months (156,7.5%) was similar to those in the winter months (153, 6.6%), p=-.23, but it did favor summer months if those who were at-risk for homelessness were included (230, 11.1%, summer versus 215, 9.2% winter; p=0.045).Conclusions: In our study, the overall prevalence of homelessness or at-risk for homelessness was 10.1%. This prevalence did not seem to vary between weekdays and weekends.  Additionally summer months had a prevalence that was was concerning as winter months.  The prevalence does, however, seem to vary by institutional characteristics even in the same geographic region.  Understanding the patterns of prevalence of homelessness is a step toward considering possible interventions to assist this vulnerable populatio

Development of GBRT Model as a Novel and Robust Mathematical Model to Predict and Optimize the Solubility of Decitabine as an Anti-Cancer Drug

The efficient production of solid-dosage oral formulations using eco-friendly supercritical solvents is known as a breakthrough technology towards developing cost-effective therapeutic drugs. Drug solubility is a significant parameter which must be measured before designing the process. Decitabine belongs to the antimetabolite class of chemotherapy agents applied for the treatment of patients with myelodysplastic syndrome (MDS). In recent years, the prediction of drug solubility by applying mathematical models through artificial intelligence (AI) has become known as an interesting topic due to the high cost of experimental investigations. The purpose of this study is to develop various machine-learning-based models to estimate the optimum solubility of the anti-cancer drug decitabine, to evaluate the effects of pressure and temperature on it. To make models on a small dataset in this research, we used three ensemble methods, Random Forest (RFR), Extra Tree (ETR), and Gradient Boosted Regression Trees (GBRT). Different configurations were tested, and optimal hyper-parameters were found. Then, the final models were assessed using standard metrics. RFR, ETR, and GBRT had R2 scores of 0.925, 0.999, and 0.999, respectively. Furthermore, the MAPE metric error rates were 1.423 &times; 10&minus;1 7.573 &times; 10&minus;2, and 7.119 &times; 10&minus;2, respectively. According to these facts, GBRT was considered as the primary model in this paper. Using this method, the optimal amounts are calculated as: P = 380.88 bar, T = 333.01 K, Y = 0.001073