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

Pedagogical memory and the space of the postcolonial classroom : reading Dangarembga's Nervous Conditions

This article addresses issues of the mnemonic space of the literature classroom by interrogating a classic text of African women’s writing, Tsitsi Dangaremnga’s Nervous Conditions (1988) for the ways it speaks about education in 1960s and 1970s late-colonial Rhodesia. The article suggests that the novel reviews and critiques a number of memorial strategies that were crucial to the colonial educational system, thereby facilitating a reflexive application of the novel’s concerns to the contexts in which it is often taught, that of today’s postcolonial classrooms. The article seeks to place Dangarembga’s novel in the context of its present moment, contemporary South Africa – that of the present critic’s site of practice, both pedagogical and scholarly, and that of many of this article’s readers. This present moment, in turn, is made up the many sites, successive and simultaneous, in which the novel’s work of memory is being re-activated in the minds of students as readers and writers. Via a dialogue between the textual past and the pedagogical present, one which is often subject to critical amnesia, the article seeks to inaugurate a debate on the nature of pedagogical memory in the space of the postcolonial university or high school literature classroom.http://www.informaworld.com/RSCRhb2013gv201

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Steady flow of Johnson-Segalman fluid through porous medium over an inclined plate

A mathematical model is presented for the thin-film flow of Johnson-Segalman fluid through porous medium down an inclined plate under steady-state flow. The developed model is based on modified Darcy's law for viscoelastic fluid. The nonlinear equation derived from the model is solved using the Adomian decomposition method to obtain an approximate analytical solution. The results of the proposed model are compared with the numerical solution that is obtained using Mathematica solver NDSolve. Graphically, it is shown that both solutions have almost the same behavior. Sensitivity analysis is conducted to highlight the importance of the inclination angle, ratio of viscosity, slip parameter, and Wissenberg number on the fluid velocity. The results reveal that the velocity is increased by raising the inclination angle or the Wissenberg number. Moreover, the velocity decreases by increasing the slip parameter or the ratio of viscosity

Radiation Oncology in the Land of the Pyramids: How Sudan Continues to Push the Frontiers of Cancer Care in Eastern Africa

When faced with illness, Sudanese patients have traditionally relied primarily on folklore healers. In the recent past, Sudan increased its health care spending and placed ever-greater importance on medical education. Although traditional remedies still play an important role, Sudanese patients increasingly consult conventional medicine. Not only infectious diseases but also a rising burden of noncommunicable conditions, including cancer, represent major health care challenges. Therefore, Sudan will need to make the best out of the limited resources available and further increase investment in health care to confront these trends successfully. Sudan was one of the first African countries to recognize the importance of radiation oncology in multidisciplinary cancer care and began investing in it in the 1960s. Today, there are 4 comprehensive cancer centers in the country, which offer radiation therapy and employ 10 radiation therapy machines for a population of about 45 million people. This proportion is an indication that Sudan still has an underfunded health care system with a lack of infrastructure and human resources. The present manuscript intends to provide a well-rounded overview of radiation oncology in Sudan today

Impacts of Dietary Supplementations of Orange Peel and Tomato Pomace Extracts as Natural Sources for Ascorbic Acid on Growth Performance, Carcass Characteristics, Plasma Biochemicals and Antioxidant Status of Growing Rabbits

The effect of dietary orange peel (OPE) and tomato pomace extract (TPE) supplementations on growth performance, plasma biochemicals, carcass characteristics and antioxidant status of growing male rabbits were investigated. A total of 96 rabbits (5 weeks old) were distributed into four groups. The first group received untreated pelleted diet (control). The second group was fed a diet containing ascorbic acid (AA; 1.0 g/kg diet), while the third and fourth groups consumed diets supplemented with 200 gm of OPE or (TPE, respectively. Our results indicated that OPE and TPE contained 59, 14.03 mg ascorbic acid/100 g DM, respectively. Growth performance, except feed conversion ratio, and carcass weight were improved by dietary supplementations. Dietary supplementations decreased kidneys, abdominal, back fats and ether extract of meat. Plasma protein and globulin levels were high in rabbits fed AA and TPE-supplemented diets. Low plasma total cholesterol and LDL-cholesterol concentrations were observed in rabbits fed the supplemented diets. Plasma AA was increased in rabbits fed AA and OPE-supplemented diets. Rabbits fed OPE and TPE-supplemented diets had great SOD activity. The best economic efficiency was recorded by rabbits fed the supplemented diets. Dietary supplementations of OPE and TPE could effectively improve growth performance, antioxidative status, modulate AA level in plasma and meat and lower plasma total cholesterol and LDL