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

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

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&lt;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&lt;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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Nuevos Miembros, Palabras del Académico José Félix Patiño Restrepo.

Con motivo de la posesión del Doctor Gustavo A. Quintero Hernández como Miembro Correspondiente de la Academia Nacional de Medicina de Colombia&#13; &#13; &#13; &#13; Agradezco a la Junta Directiva el privilegio de comentar el trabajo de ingreso a la Academia Nacional de Medicina de una persona por quien profeso profunda admiración y afecto, sentimientos que se derivan del hecho de haber trajinado juntos, ya por varios años, las lides de la atención quirúrgica, la docencia y la investigación.&#13; &#13; En este recinto, en pasadas ocasiones solemnes, he citado a Harvey Cushing, quien en su discurso ante los graduandos en el Jefferson Medical College de Filadelfia, el 5 de junio de 1926, se expresó así: «hay un viejo decir que plantea que el interés común no une a los hombres: más bien los separa; sólo hay una cosa que une en forma efectiva a la gente, y ésta es la devoción común».&#13; &#13; Devoción y consagración a la cirugía caracterizan la vida de Gustavo Adolfo Quintero Hernández, y por tales características congrega y conforma magníficos equipos de trabajo.&#13; &#13; Dueño de brillante inteligencia, investigador pertinaz, cirujano maestro, Gustavo Quintero tiene una extraordinaria capacidad ejecutiva. Es bien conocido un dictum: «si usted quiere que algo se haga, y que se haga bien, entréguelo a Gustavo Quintero».&#13; &#13; Siempre he creído que la personalidad del hombre es de dos clases: reactiva o proactiva. La cualidad de reactividad es innata y salta a la vista; se refiere a la capacidad actuar, de responder a las normas, a las órdenes, a las instrucciones o a las condiciones de su entorno. La cualidad de proactividad, casi en términos aristotélicos, se refiere más bien al hábito de una persona efectiva, que se adelanta a la rutina, a la demanda que le imponen las condiciones -y aun a modificar las condiciones.&#13; &#13; Proactividad en una persona significa ser responsable de su propia vida, refiriéndose al comportamiento, que es el resultado de su iniciativa y sus decisiones, no de las condiciones del entorno. El hombre proactivo tiene la habilidad de hacer que las cosas sucedan, de crear la diferencia entre el propósito y la ejecución. Su comportamiento y sus respuestas son el producto de sus propias decisiones conscientes y afirmativas. Todos conocemos personas que son reactivas, pero, desafortunadamente, muy pocas que son proactivas. Gustavo Quintero es la personificación de la proactividad.&#13; &#13; Por ello sus realizaciones son múltiples, y con una hoja de vida brillante ingresa hoy a la Academia Nacional de Medicina de Colombia. Su trabajo de ingreso, cuyo resumen acabamos de oír, es un erudito estudio sobre la Historia y Perspectiva de la Cirugía Biliar.&#13; &#13; Gustavo A. Quintero es egresado de la Facultad de Medicina del Colegio Mayor de Nuestra Señora del Rosario. Hizo su especialización en cirugía general en el benemérito Hospital San José. Luego de ejercer su práctica quirúrgica en forma exitosa con sede principal en la Clínica Palermo, donde ocupó el cargo de Jefe de Médicos, en 1985 viajó a Londres a continuar estudios avanzados de postgrado. En la Universidad de Londres obtuvo la maestría en microbiología médica, y luego se trasladó a Birmingham, en el Reino Unido, donde bajo la dirección del eminente cirujano Paul McMaster completó su formación en trasplante de órganos.&#13; &#13; En 1988 regresó a Bogotá, como Jefe del Servicio de Trasplantes de la Fundación Santa Fe de Bogotá.&#13; &#13; Es en la Fundación Santa Fe de Bogotá, donde Quintero ha desarrollado a plenitud su carrera como cirujano. Allí ha ocupado cargos de elevada responsabilidad, entre ellos el de Jefe de Microbiología Quirúrgica, Jefe Asociado del Departamento de Cirugía, Jefe de la Sección de Cirugía General y Jefe del Servicio de Cirugía Hepatobiliar. Además, ha sido Director de Palabras del Académico José Félix Patiño Restrepo con motivo de la posesión del Doctor Gustavo A. Quintero Hernández como Miembro Correspondiente de la Academia Nacional de Medicina de Colombia la Unidad de Apoyo a la Gestión, Director Médico Asociado y actualmente es el Director de la División de Educación. En esta última categoría ha jugado un papel de enorme valor en la estructuración de la nueva Facultad de Medicina de la Universidad de los Andes, proyecto en el cual, como en muchos otros, hemos tenido la oportunidad de trabajar hombro a hombro.&#13; &#13; Quintero es autor de más de 50 publicaciones, varias de ellas en revistas médicas internacionales, de capítulos en textos médicos y es editor o coeditor de tres libros de particular importancia: Trasplante de Órganos, Infección en Cirugía y Cirugía del Hígado y de las Vías Biliares.&#13; &#13; Cirujano talentoso y excepcionalmente hábil, Gustavo Quintero inició el programa de trasplante de hígado en la Fundación Santa Fe de Bogotá, el cual fue precedido por un activo trabajo de promoción en la sociedad y de reglamentación y estructuración legal. El 2 de junio, de 1989 realizó el primer trasplante de hígado en la historia de Bogotá, y poco tiempo después el trasplante en un niño de 6 meses de edad y 6 kg de peso, el primero en su clase en Latinoamérica.&#13; &#13; Son numerosas las contribuciones de Quintero a la cirugía biliar. Una de especial significación es el manejo quirúrgico de las estenosis biliares benignas con la técnica de hepático-yeyunostomía en Y de Roux con asa subcutánea, descrita por Hao-Hui Chen. Con laboriosidad y gran honestidad intelectual, Quintero rescató para este autor del Colegio Médico de Pekín el debido crédito. Su serie de 75 casos operados con excelente resultado es una de las mayores en América Latina y tal vez en el mundo..

Comentario del Académico Profesor José Félix Patiño Restrepo.

a la presentación del libro "La Medicina como Institución: Entre la Voracidad y el Suicidio" por la Académica Asociada Sonia Echeverri de Pimiento.&#13; &#13; &#13; Agradezco a la Academia el privilegio de presentar esta importante obra de la Académica Asociada Sonia de Pimiento, que es fruto de una profunda reflexión sobre la "Medicina como Institución", a lo cual le añade, en el título, un sugestivo e inquietante pronunciamiento: "Entre la Voracidad y el Suicidio".&#13; El señor Presidente ya ha hecho la descripción de la brillante hoja de vida profesional de la Académica Sonia de Pimiento. Me basta decir que es modelo, sin igual, de vocación, consagración y superación personal,&#13; cualidades que la han llevado a un gran reconocimiento internacional en el campo de la enfermería, y de la nutrición clínica en particular. Yo he tenido el privilegio de tenerla como colaboradora y colega ya por varios años.&#13; Ella tiene toda la autoridad para emitir un primer pronunciamiento al comienzo de su libro: "No es posible separar la medicina, el arte de curar, de la enfermería, el arte de cuidar". Y digo que tiene esa autoridad porque ella, en su diario actuar como Enfermera Jefe del&#13; Servicio de Soporte Metabólico y Nutricional de la Fundación Santa Fe de Bogotá, es ejemplo de lo que significa la colaboración óptima entre estas dos nobles profesiones. El libro que presenta esta noche es, ante&#13; todo, el resultado de sus estudios en bioética, que la llevaron a recibir la maestría, con tesis laureada, en la Universidad El Bosque.&#13; La Académica Echeverri de Pimiento plantea que en el devenir de las alteraciones cíclicas que sufren las sociedades, la medicina, como profesión liberal ha navegado entre el esplendor y la crisis, lo cual la ha&#13; llevado a la decadencia.&#13; Ciertamente hay decadencia de la medicina como profesión liberal en este país, donde la Ley 100 de diciembre de 1993 implantó la figura de un intermediario financiero al cual se le ha dado un gran empoderamiento y una posición dominante y crecientemente monopólica. El modelo de la "atención gerenciada" de la salud, tomado en buena parte del managed care de los Estados Unidos, en un mercado&#13; imperfecto y sin control, no podría dar sino ese resultado de crisis de la medicina, no sólo como profesión liberal, sino, lo más grave, como actividad intelectual de hondo compromiso social

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe