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

Figur-Grund Segmentierung durch zeitliche Hinweise

Visual figure-ground segregation can rely on differences in luminance, texture, colour, motion, depth, and also on asynchronous changes in luminance and motion direction. However, since these displays were suspected to contain global motion and contrast artefacts, we created a new stimulus showing constantly 20 by 20 randomly oriented dipoles ( colons ) flipping (i.e. rotating instantaneously by 90 deg) with a defined frequency. All dipols flip synchronously within both areas, figure and ground but with a defined delay between them. Human subjects had to localize the targets in a 4-alternative forced-choice task.Given a high luminance contrast between dipols and monitor surround subjects could detect the target up to a threshold frequency of 23 Hz and down to a threshold delay of 14 ms. Replacing the luminance-defined dots by contrast-defined Mexican Hats led to comparable results. Although both tasks are contrast sensitive the segregation can still be detected when dots are isoluminant, whereas dichoptic presentation doesn´t allow for segregation at all.Visual Evoked Potentials and Functional Magnetic Resonance Imaging studies showed VEP components and fMRI locations previously identified with form-from-motion stimuli.In the last study we re-examined form from asynchronous motion-reversals using defined frequencies and delays, and demonstrate that segregation can rely on short intervals (15 ms) of opposing motion directions between figure and ground and on longer (40 ms) intervals of differing contrast cues (i.e. motion energy cues), but not on asynchronous motion reversals per se.In conclusion, we confirm that segregation can rely solely on local changes occuring temporally asynchronously in figure and ground. We propose a segregation mechanism consisting of a set of local (monocular) motion detectors at the front end and a second stage reading and globally comparing their output with a high temporal resolution

Temporal Figure-Ground Segregation

Visual figure-ground segregation can rely on differences in luminance, texture, colour, motion, depth, and also on asynchronous changes in luminance and motion direction. However, since these displays were suspected to contain global motion and contrast artefacts, we created a new stimulus showing constantly 20 by 20 randomly oriented dipoles ("colons") flipping (i.e. rotating instantaneously by 90 deg) with a defined frequency. All dipols flip synchronously within both areas, figure and ground but with a defined delay between them. Human subjects had to localize the targets in a 4-alternative forced-choice task.Given a high luminance contrast between dipols and monitor surround subjects could detect the target up to a threshold frequency of 23 Hz and down to a threshold delay of 14 ms. Replacing the luminance-defined dots by contrast-defined Mexican Hats led to comparable results. Although both tasks are contrast sensitive the segregation can still be detected when dots are isoluminant, whereas dichoptic presentation doesn´t allow for segregation at all.Visual Evoked Potentials and Functional Magnetic Resonance Imaging studies showed VEP components and fMRI locations previously identified with form-from-motion stimuli.In the last study we re-examined form from asynchronous motion-reversals using defined frequencies and delays, and demonstrate that segregation can rely on short intervals (15 ms) of opposing motion directions between figure and ground and on longer (40 ms) intervals of differing contrast cues (i.e. motion energy cues), but not on asynchronous motion reversals per se.In conclusion, we confirm that segregation can rely solely on local changes occuring temporally asynchronously in figure and ground. We propose a segregation mechanism consisting of a set of local (monocular) motion detectors at the front end and a second stage reading and globally comparing their output with a high temporal resolution

Coffee and Coronary Heart Disease, is there a relationship?

Context: Coffee has been shown to increase the risk factors associated with coronary heart disease (CHD), including serum cholesterol, insulin resistance, blood pressure, and plasma homocysteine; however studies examining the association between coffee consumption and CHD have been inconclusive. Objective: To determine if there is a relationship between coffee consumption and development of CHD among adults. Methods: A literature review of studies published between the years 2000 to 2015, using PubMed and Medline, with the titles containing the keywords “Coffee” AND “Coronary Heart Disease”, “Coffee” AND “Artery”, or “Coffee” AND “Coronary” was conducted. Review articles, editorials, and studies conducted on clinical subpopulations were excluded; the ten articles which remained were examined. Results: While the majority of case-control studies demonstrate a positive association between coffee consumption and CHD, most cohort studies have reported no such association. Conclusions: Inconclusive results may be explained by the acute detrimental effects of coffee on coronary events, rather than a long-term adverse effect of coffee consumption

Percutaneous iliosacral screw fixation in vertically unstable pelvic injuries, a refined conventional method.

Percutaneous ilio-sacral screw fixation is a well-established method for fixation of unstable posterior pelvic lesions. Due to unavailability of the navigation system in our institute and the limits of using CT-guided method, we tried to refine the conventional method. Between March 2011 and Nov. 2012, twenty patients with closed vertical pelvic injuries were admitted.  They were 17 males and three females with average age of 34 years (range from 27 to 55).  Percutaneous ilio-sacral screw was done in the supine position using a Schanz screw marking of a fixed entry point in the outer iliac table. Closed reduction was done in all cases with excellent reduction in 14 cases, good in two and fair in four cases. The mean duration of screw insertion was 17 minutes (ranged from 10 to 25). One case of injury of the superior gluteal vessels was present and one case with misplacement through ventral part of contra-lateral sacral ala. No neurological complications were detected.  Ilio-sacral screw fixation by this refined technique allows safe stabilization of vertical pelvic lesions with an acceptable complication rate.                         Keywords: Ilio-sacral; vertical shear; pelvic fracture

Celecoxib-induced cholestatic liver failure requiring orthotopic liver transplantation

Selective cyclooxygenase-2 (COX-2) inhibitors are widely used due to their efficacy and good safety profile. However, recent case reports have described varying degrees of liver injuries associated with the use of COX-2 inhibitors. We report the case of a patient who developed acute cholestatic hepatitis progressing to hepatic failure requiring liver transplantation, following a 3-d course of celecoxib for treatment of generalized muscle aches and pains. The clinical presentation, the laboratory data, as well as the liver histopathology were supportive of the putative diagnosis of drug induced liver injury

World Journal of Gastroenterology ISSN 1007-9327

doi:10.3748/wjg.15.393

Stress Reduction by Yoga versus Mindfulness Training in Adults Suffering from Distress: A Three-Armed Randomized Controlled Trial including Qualitative Interviews (RELAX Study)

Distress is a growing public health concern. In this three-armed randomized controlled trial, n = 102 adults with elevated stress levels and stress-related symptoms were randomly assigned to (1) &ldquo;integrative&rdquo; yoga classes which combined physical exercises, mindfulness training, and ethical/philosophical aspects of traditional yoga; to (2) Iyengar yoga classes which entailed primarily physical exercises; or to (3) mindfulness training without physical training. We hypothesized the synergistic effects of physical yoga exercises, mindfulness, and ethical/philosophical aspects. The primary outcome was the group difference on Cohen&rsquo;s Perceived Stress Scale (PSS) after 12 weeks. Secondary outcomes included burnout, quality of life, physical complaints, depression, anxiety, mindfulness, interoceptive awareness, self-regulation, spirituality, mysticism, and posttraumatic stress. All outcomes were evaluated at baseline (V0), after 12 weeks (V1), and after 24 weeks (V2). A subset of participants took part in qualitative interviews. A lasting and clinically relevant stress reduction was observed within all groups (PSS &Delta;V0&ndash;V1Integrative Yoga = &minus;6.69 &plusmn; 6.19; &Delta;V0&ndash;V1Iyengar Yoga = &minus;6.00 &plusmn; 7.37; &Delta;V0&ndash;V1Mindfulness = &minus;9.74 &plusmn; 7.80; all p &lt; 0.00). Effect sizes were also statistically large at the end of the follow-up period (Cohen&rsquo;s d Integrative Yoga = 1.41; d Iyengar Yoga = 1.37; d Mindfulness = 1.23). There were no significant group differences or evidence of relevant synergistic effects from combining mindfulness and physical yoga exercises. All three interventions were found to be equally effective methods of stress reduction. Their use in practice should be based on availability and patient preference

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