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

ICAR: endoscopic skull‐base surgery

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Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

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

The effect of type of carbohydrate (starch vs. nonstarch polysaccharides) on nutrients digestibility, energy retention and maintenance requirements in Nile tilapia

For Nile tilapia, the energetic value of non-starch polysaccharides (NSP) was compared to starch. It was assessed if carbohydrate type (NSP vs. starch) affected the energetic utilization for growth (KgDE) and the energy requirements for maintenance (DEm). Eighteen groups of fish were assigned in 2 × 3 factorial design: two diets, with either a high NSP or high starch content; and three feeding levels (low, medium or satiation). The NSP diet contained 70% of the starch diet supplemented with 30% dried distillers grains with solubles. Nutrients digestibility, nitrogen and energy balances were measured. All nutrients digestibility decreased with increasing feeding level (P < 0.001). Diet type (NSP vs. starch) affected the digestibility of all nutrients except for dry matter and fat. NSP of both diets were digested and the NSP digestibility ranged between 23% and 73%. Averaged over feeding levels, 5% and 17% of the total digestible energy originated from NSP at the starch and NSP diet, respectively. Although the digestible energy intake was similar, the contrast in type of carbohydrates between the diets resulted in lower energy retention with the NSP rich diet (P < 0.05). Despite this impact on energy retention, both DEm and kgDE were not significantly influence by diet. However, DEm was numerically higher (96 vs. 110 kJ kg-0.8 BW d-1) and kgDE was numerically lower (65% vs. 58%) at the NSP diet compared to the starch diet. In conclusion, NSP are digested by Nile tilapia. Digested NSP are less well utilized for growth, which is reflected by a lower energy retention in fish and is due to the slightly higher DEm in combination with a slightly lower kgDE. Statement of relevance: Scarcity of fishmeal and -oil combined with the fast growing aquaculture sector, result in diversification of feed ingredients in fish-feeds. Plant ingredients as protein source become more important, which also increases the dietary carbohydrate content including non-starch polysaccharides (NSP). This paper provides information on the nutritional value of NSP in tilapia. This will eventually lead to improved fish-feed formulations

Energy efficiency of digestible protein, fat and carbohydrate utilisation for growth in rainbow trout and Nile tilapia

Currently, energy evaluation of fish feeds is performed on a digestible energy basis. In contrast to net energy (NE) evaluation systems, digestible energy evaluation systems do not differentiate between the different types of digested nutrients regarding their potential for growth. The aim was to develop an NE evaluation for fish by estimating the energy efficiency of digestible nutrients (protein, fat and carbohydrates) and to assess whether these efficiencies differed between Nile tilapia and rainbow trout. Two data sets were constructed. The tilapia and rainbow data set contained, respectively, eight and nine experiments in which the digestibility of protein, fat and energy and the complete energy balances for twenty-three and forty-five diets was measured. The digestible protein (dCP), digestible fat (dFat) and digestible carbohydrate intakes (dCarb) were calculated. By multiple regression analysis, retained energy (RE) was related to dCP, dFat and dCarb. In tilapia, all digestible nutrients were linearly related to RE (P2 for trout (NE in kJ/(kg0·8×d); dCP, dFat and dCarb in g/(kg0·8×d)). In tilapia, the energetic efficiency of dCP, dFat and dCarb was 49, 91 and 66 %, respectively, showing large similarity with pigs. Tilapia and trout had similar energy efficiencies of dCP (49 v. 57 %) and dFat (91 v. 84 %), but differed regarding dCarb.</p

Effects of feed ingredients on nutrient digestibility, nitrogen/energy balance and morphology changes in the intestine of Nile tilapia (Oreochromis niloticus)

The present study assessed the effect of different feed ingredients on nutrient apparent digestibility coefficients (ADC), nitrogen/energy balance and morphology changes in the intestine of Nile tilapia; using a control diet and six test diets, in which the following six ingredients were included at 30%: hydrolysed feather meal (HFM), soybean meal (SBM), rice bran (RB), rapeseed meal (RM), sunflower meal (SFM) and dried distillers grains with solubles (DDGS). The proximal, middle and distal intestine was processed for quantitative histology counting the number of goblet cells (GC), and measuring the thickness of lamina propria (LP) and submucosa (SM). The study showed that the ADC of protein in raw materials were highest in SBM (92.2%), followed by SFM (90.2%), DDGS (89.2%), RM (87.8%), HFM (86.9%) and RB (84.0%). The nutrient ADCs had no correlation with intestinal morphology changes. Only the SBM diet caused noticeable changes in intestinal morphology such as an increase the thickness of SM and LP and the number of GC. The diet composition, however, altered the protein efficiency and the maintenance energy requirement. Protein retention efficiency was the lowest in fish fed HFM and the highest in RB. The highest maintenance energy requirements were observed in HFM and SBM treatments.</p