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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

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

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&nbsp;years; 78.2% included were male with a median age of 37&nbsp;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

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 &lt; 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

Improving Fatigue Performance of GFRP Composite Using Carbon Nanotubes

Glass fiber reinforced polymers (GFRP) have become a preferable material for reinforcing or strengthening reinforced concrete structures due to their corrosion resistance, high strength to weight ratio, and relatively low cost compared with carbon fiber reinforced polymers (CFRP). However, the limited fatigue life of GFRP hinders their use in infrastructure applications. For instance, the low fatigue life of GFRP caused design codes to impose stringent stress limits on GFRP that rendered their use non-economic under significant cyclic loads in bridges. In this paper, we demonstrate that the fatigue life of GFRP can be significantly improved by an order of magnitude by incorporating Multi-Wall Carbon Nanotubes (MWCNTs) during GFRP fabrication. GFRP coupons were fabricated and tested under static tension and cyclic tension with mean fatigue stress equal to 40% of the GFRP tensile strength. Microstructural investigations using scanning electron microscopy (SEM) and Fourier Transform Infrared (FTIR) spectroscopy were used for further investigation of the effect of MWCNTs on the GFRP composite. The experimental results show the 0.5 wt% and the 1.0 wt% MWCNTs were able to improve the fatigue life of GFRP by 1143% and 986%, respectively, compared with neat GFRP

Flexural Behavior of a Novel Textile-Reinforced Polymer Concrete

Textile reinforced concrete (TRC) has gained attention from the construction industry due to its light weight, high tensile strength, design flexibility, corrosion resistance, and remarkably long service life. Some structural applications that utilize TRC components include precast panels, structural repair, waterproofing elements, and façades. TRC is produced by incorporating textile fabrics into thin cementitious concrete panels. Premature debonding between the textile fabric and concrete due to improper cementitious matrix impregnation of the fibers was identified as a failure-governing mechanism. To overcome this performance limitation, in this study, a novel type of TRC is proposed by replacing the cement binder with a polymer resin to produce textile reinforced polymer concrete (TRPC). The new TRPC is created using a fine-graded aggregate, methyl methacrylate polymer resin, and basalt fiber textile fabric. Four different specimen configurations were manufactured by embedding 0, 1, 2, and 3 textile layers in concrete. Flexural performance was analyzed and compared with reference TRC specimens with similar compressive strength and reinforcement configurations. Furthermore, the crack pattern intensity was determined using an image processing technique to quantify the ductility of TRPC compared with conventional TRC. The new TRPC improved the moment capacity compared with TRC by 51%, 58%, 59%, and 158%, the deflection at peak load by 858%, 857%, 3264%, and 3803%, and the toughness by 1909%, 3844%, 2781%, and 4355% for 0, 1, 2, and 3 textile layers, respectively. TRPC showed significantly improved flexural capacity, superior ductility, and substantial plasticity compared with TRC

Invasion of the Land of Samurai: Potential Spread of Old-World Screwworm to Japan under Climate Change

Temperatures have fluctuated dramatically throughout our planet&rsquo;s long history, and in recent decades, global warming has become a more visible indicator of climate change. Climate change has several effects on different economic sectors, especially the livestock industry. The Old-world screwworm (OWS), Chrysomya bezziana (Villeneuve, 1914), is one of the most destructive insect pests which is invading new regions as a result of climate change. The economic loss in livestock business due to invasion of OWS was previously assessed by FAO in Iraq to be USD 8,555,000. Other areas at risk of invasion with OWS in the future include Japan. Therefore, maximum entropy implemented in MaxEnt was used to model predictive risk maps of OWS invasion to Japan based on two representative concentration pathways (RCPs), 2.6 and 8.5, for 2050 and 2070. The Area Under Curve (AUC) indicates high model performance, with a value equal to 0.89 (&plusmn;0.001). In addition, the True Skill Statistics (TSS) value was equal to 0.7. The resulting models indicate the unsuitability of the northern territory of Japan for invasion by OWS. The main island&rsquo;s southern costs show high and very high invasion suitability, respectively, and both Kyushu and Okinawa are at high risk of invasion with OWS. The predicted risk maps can be considered a warning sign for the Japanese quarantine authority to hasten a control program in order to protect the livestock industry from this devastating pest

Invasion of the Land of Samurai: Potential Spread of Old-World Screwworm to Japan under Climate Change

Temperatures have fluctuated dramatically throughout our planet’s long history, and in recent decades, global warming has become a more visible indicator of climate change. Climate change has several effects on different economic sectors, especially the livestock industry. The Old-world screwworm (OWS), Chrysomya bezziana (Villeneuve, 1914), is one of the most destructive insect pests which is invading new regions as a result of climate change. The economic loss in livestock business due to invasion of OWS was previously assessed by FAO in Iraq to be USD 8,555,000. Other areas at risk of invasion with OWS in the future include Japan. Therefore, maximum entropy implemented in MaxEnt was used to model predictive risk maps of OWS invasion to Japan based on two representative concentration pathways (RCPs), 2.6 and 8.5, for 2050 and 2070. The Area Under Curve (AUC) indicates high model performance, with a value equal to 0.89 (±0.001). In addition, the True Skill Statistics (TSS) value was equal to 0.7. The resulting models indicate the unsuitability of the northern territory of Japan for invasion by OWS. The main island’s southern costs show high and very high invasion suitability, respectively, and both Kyushu and Okinawa are at high risk of invasion with OWS. The predicted risk maps can be considered a warning sign for the Japanese quarantine authority to hasten a control program in order to protect the livestock industry from this devastating pest