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

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Development of a new performance criteria for higher wire-electrical discharge machining performance considering the ecological and economical aspects / Ibrahem Maher Abdelrahem Soltan

Wire electrical discharge machining (WEDM) is a manufacturing process whereby a desired shape is obtained using electrical discharges (sparks). WEDM involves high cutting rates and superior quality to improve machining performance in manufacturing hard materials. The machining performance of computer-controlled WEDM is directly dependent on spark energy (pulse on time, peak current, and gap voltage), pulse frequency (pulse off time and pulse on time), and wire electrode parameters (material, wire speed, and wire tension). In the field of wire electrical discharge machining, it is necessary to develop suitable WEDM technology to facilitate the production of high quality workpiece surfaces at high cutting rates. Surface roughness and white layer thickness are the most important factors in evaluating WEDM surface quality. In order to ensure good surface quality, the surface roughness must be low and the white layer must be as thin as possible, homogeneous, crack-free, and well-bonded to the substrate material. In this study, the effect of cutting parameters is investigated on the machining performance parameters including cutting speed, surface roughness, wire rupture, and white layer thickness. The adaptive Neuro-Fuzzy Inference System (ANFIS) along with the Taguchi method is applied to determine the effects of the significant parameters on WEDM performance. Moreover, a new performance index is proposed to identify the effects of spark energy and pulse frequency simultaneously on machining performance and to identify the wire rupture limit. However, the performance index cannot be used to identify the most feasible wire electrode from ecological (energy and wire consumption) and economic (machining costs) perspectives. Therefore, a new performance criterion (production economic index) is developed to select the most feasible wire electrode considering the economic and ecological aspects along with the performance index to achieve superior machining performance at the lowest cost. This can be done by dividing the performance index by the total machining cost ((Es×DF)/Ct). In addition, a new coated-wire electrode iv design with higher strength for less wire rupture and high machining performance in WEDM is proposed. The results obtained represent a technological knowledge base for the selection of optimal machining conditions along with suitable types of wire electrodes for WEDM in terms of ecological and economic aspects. By applying the proposed performance criterion (Es×DF/Ct), it appears that using lower spark and higher pulse cycle settings with a brass wire electrode can decrease the surface roughness and white layer thickness, and facilitate more economical cutting speed. This could lead to faster cutting with good surface finish and less wire rupture

Surface Roughness Prediction in End-Milling Process

<p><b>Surface roughness prediction for the end-milling process, which is one of the major cutting processes, is a very important economical consideration in order to increase machine operation and decrease production cost in an automated manufacturing environment. </b></p> <p><b>In this study; prediction of surface roughness (Ra) for Brass (60/40) material based on cutting parameters: cutting speed, feed rate, and depth of cut; was studied.  </b></p> <p><b> </b></p> <p><b>Adaptive neuro-fuzzy inference system (ANFIS) was used to predict the surface roughness in the end milling process. Surface roughness was used as dependant variable while cutting speed of range (750 - 1750rpm), feed rate of range (50 - 250mm/min) and depth of cut of range (0.3 - 0.7mm) were used as predictor variables. Normal and feed forces were used as predictor variables to verify the ANFIS model. Different membership functions were adopted during the training process of ANFIS.</b></p> <p><b> </b></p> <p><b>Surface roughness was measured in an off line manner using stylus based profile-meter (surtronic 3+). The normal and feed forces were measured in an on-line manner using two components dynamometer.</b></p> <p><b> </b></p> <p><b>The effects of cutting parameters on the normal force, feed force and surface roughness were discussed.  Experimental test data were used to examine the ANFIS model by defining the reliability and percentage error of the model. Experimental results demonstrate the effectiveness of the proposed model. While the predicted surface roughness was compared with measured data; the mean square error has been found equal to 8.5 % hence the achieved accuracy is equal to 91.5 %.</b></p> <p><b> </b></p> <p><b>Although this work focuses on prediction of surface roughness for end-milling operation, the concepts introduced are general; ie., prediction of surface roughness using ANFIS can be applied to many other cutting and machining processes.</b></p

Wire Rupture Optimization in Wire Electrical Discharge Machining using Taguchi Approach

Wire electrical discharge machining (WEDM) is one of the most important nontraditional machining process that is well-known for cutting difficult to machine materials. The wire electrode along with machining parameters control the WEDM process. This research work focuses on optimizing WEDM parameters using Taguchi technique to minimize wire rupture. Experiments have been done using the L18 orthogonal array. Each experiment is repeated three times to ensure accurate readings of the wire rupture. The statistical methods of signal to noise ratio (S/N ratio) is applied to study effects of peak current, pulse width, charging time, wire speed, and wire tension on wire rupture. As a results, the peak current, pulse width, and wire tension have the most significant effect on wire rupture followed by charging time and wire speed. The developed analysis can be used in the metal cutting field to identify the optimum machining parameters for less wire rupture

Wire Rupture Optimization in Wire Electrical Discharge Machining using Taguchi Approach

Wire electrical discharge machining (WEDM) is one of the most important nontraditional machining process that is well-known for cutting difficult to machine materials. The wire electrode along with machining parameters control the WEDM process. This research work focuses on optimizing WEDM parameters using Taguchi technique to minimize wire rupture. Experiments have been done using the L18 orthogonal array. Each experiment is repeated three times to ensure accurate readings of the wire rupture. The statistical methods of signal to noise ratio (S/N ratio) is applied to study effects of peak current, pulse width, charging time, wire speed, and wire tension on wire rupture. As a results, the peak current, pulse width, and wire tension have the most significant effect on wire rupture followed by charging time and wire speed. The developed analysis can be used in the metal cutting field to identify the optimum machining parameters for less wire rupture

Review of improvements in wire electrode properties for longer working time and utilization in wire EDM machining

<div>Wire electrical discharge machining (WEDM) is an important technology, which demands high-speed cutting and high-precision machining to realize productivity and improved accuracy for manufacturing hard materials. WEDM has experienced explosive growth and complexity of equipment as well as rising demand for the basic process tool (the wire electrode). Greater taper angles, thicker workpieces, automatic wire threading, and long periods of unattended operationmake the selection of the idealwire a much more critical basis for achieving successful operation. This paper focuses on the evolution of EDM wire electrode technologies from using copper to the widely employed brass wire electrodes and from brass wire electrodes to the latest coated wire electrodes. Wire electrodes have been developed to help user demand and needs through maximum productivity and quantity by choosing the best wire. In the final part of the paper, the possible trends for future WEDM electrode research are discussed.</div