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

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

Performance of In-Band Full-Duplex for 5G Wireless Networks

In-band full duplex is a new duplexing scheme that allows radio nodes to transmit and receive, utilizing the same frequency and time resources. The implementation of in-band full duplex was not feasible in practice, due to the effect of self-interference. But then, advances in signal processing made it possible to reduce this effect. However, the system level performance of in-band full duplex has not been investigated thoroughly.Through computer simulations, we investigate the performance of in-band full duplex, for indoor 5G small cell wireless networks. We examine the performance of in-band full duplex in comparison to dynamic and static time division duplexing. Additionally, we analyze the performance of the duplexing schemes with two interference mitigation techniques, namely beamforming and interference cancellation.Our results indicate that for highly utilized wireless networks, in-band full duplex should be combined with beamforming and interference cancellation, in order to achieve a performance gain over traditional duplexing schemes. Only then, in-band full duplex is considered advantageous, at any network utilization, and any downlink to uplink traffic demand proportion. Our results also suggest that in order to achieve a performance gain with in-band full duplex in both links, the transmit power of the access points should be comparable to the transmit power of the mobile stations.Inomband hel duplex är en ny typ av duplexmetod som tillåter radionoder att sända och ta emot i samma frekvensoch tidsresurs. Att implementera inomband hel duplex har fram tills nu inte ansetts praktiskt genomförbart till följd av självstörningar. Framsteg inom signalbehandling har dock gjort det möjligt att begränsa denna självstörningseffekt. Emellertid har systemprestanda av inomband hel duplex inte undersökts tillräckligt noga i tidigare verk.Inomband hel duplex och dess prestanda för trådlösa 5G småcellsnätverk inomhus har studerats med hjälp av datasimuleringar och jämförts med dynamisk och statisk tidsdelning. Utöver detta har prestanda för de olika duplexmetoderna med avseende på två tekniker för störningsundertryckning, lobformning och störningseliminering, också undersökts.Våra resultat indikerar att för trådlösa nätverk med högt radioresursutnyttjande bör inomband hel duplex kombineras med lobformning och störningseliminering för att uppnå en prestandavinst jämfört med traditionella duplexmetoder. Bara då kan inomband hel duplex anses vara fördelaktig oberoende av radioresursutnyttjande och andelen upp- och nedlänkstrafik.Resultaten tyder också på att sändareffekten för radioaccesspunkterna bör vara jamförbar med den för mobilenheterna för att en prestandavinst med inomband hel duplex ska kunna uppnås.Wireless networks, In-band full duplex, Static-time division duplexing, Dynamic-time division duplexing, Interference mitigation techniques, small cell, 5G, mmWave bands, Beamforming, Interference cancellation

The Feasibility and Environmental Impact of Sustainable Public Transportation: A PV Supplied Electric Bus Network

Limited fuel resources and the huge negative impact on the environment from using fossil fuels have led to an urgency to utilize the most energy efficient solutions for public transportation. Environmentally sustainable solutions can deliver the same benefits of traditional systems, but without the negative impacts. The Bus Rapid Transit Project of Amman (Amman BRT) is used as a case study. Proposed measures include using electric buses instead of diesel ones, and installing elevated photovoltaic systems above buses parking and routes, in addition to using LED street lighting. The feasibility study of applying the proposed measures on the Amman BRT project showed that only 7.1 years is needed to payback the incremental investment throughout this transformation. Capital expenditure (CAPEX) is higher than the baseline buses, while operational expenditure (OPEX) is much lower, resulting in a 32% lower total cost of ownership (TCO). In addition, greenhouse gas (GHG) emissions are reduced by 27,203.68 metric ton of CO2 per year and 408,055.26 metric tons for the 15-year lifetime of the project

Characterization Circuit, Gate Driver and Fixture for Wide-Bandgap Power Semiconductor Device Testing

The world is currently experiencing major advancement in the electrification of both the industrial and commercial sectors. This is part of an effort to reduce reliance on combustible fuels, reduce emissions, integrate renewable energy systems and increase efficiency. Due to the complexity of modern circuits and systems, any circuit&rsquo;s design should start with proper simulation and device selection, to reduce overall cost and time of prototyping, both of which require accurate and thorough device characterization. Wide bandgap (WBG) power semiconductor devices offer superior characteristics over conventional devices, including faster switching speeds, higher breakdown voltage, lower losses, and higher operating temperature. These properties call for special test circuits and procedures for accurate characterization. In this work, custom characterization circuits and fixtures, suitable for WBG devices are designed, tested, and described. The circuits measure several of the main characteristics of voltage controlled WBG power switches. Different technology devices were tested and characterized

Development and implementation of interprofessional education activity among health professions students in Jordan: A pilot investigation

Implementing interprofessional education (IPE) in health professions curricula requires considerations of students’ attitudes and readiness. Interventional studies that assess students’ perceptions about IPE are needed. As IPE is an emerging concept in Jordan, our study aimed at exploring the attitudes of health profession students about IPE and collaborative practice before and after implementing an IPE activity. Students completed the validated Interprofessional Attitudes Scale (IPAS) before and after completing a 3-hour interprofessional activity. Students’ attitudes toward IPE were compared using the subscales and total IPAS scores. A total of 41 health profession students attending the professional health programs of Doctor of Pharmacy, Medicine, Nursing, Nutrition, or Pharmacy completed IPAS before and after conducting the interprofessional activity. Students reported positive attitudes toward IPE prior to the activity. Significant increases were observed in IPAS scores from pre- (median [interquartile range: IQR] score = 4.19 [0.61]) to post-activity (median [IQR] = 4.48 [0.65]), and in its subscales (teamwork, roles and responsibilities, diversity and ethics, and community-centeredness). Students’ experience with the IPE activity was positive and optimistic. The findings revealed for the first time the perception and readiness of health profession students toward IPE and collaborative practice in Jordan. This readiness can help draw a path for strategic integration of IPE in health profession curricula

A novel coated silver ketamine(I) electrode for potentiometric determination of ketamine hydrochloride in ampoules and urine samples

A new ketamine coated silver electrode (KCSE) based on ketamine hydrochloride with sodium tetraphenylborate (KT-TPB) as electroactive material has been described. The influence of membrane composition, type of solvent mediators, kind of electroactive materials and interfering ions on the sensor was investigated. The sensor displays Nernstian response of 55.8 ± 0.3 mV/decade over the concentration range of 2.5 × 10−6 to 1.0 × 10−2 M with limit of detection of 8.5 × 10−7 M. The coated wire electrode has short response time ∼8 s and it can be used in pH range of 2.6–6.4. The selective coefficients were determined in relation to several inorganic, organic ions, sugars and some common drug excipients. The KCSE electrode was successfully used for the determination of the ketamine content in ampoule and urine samples with satisfactory results. Statistical student’s t-test and F test showed insignificant systematic error between proposed and official methods

Chiari zero malformation with syringobulbia

Chiari zero malformation is a relatively new and rare subtype of Chiari malformations. Most of the patients present with signs and symptoms of Chiari malformation without actual cerebellar tissue herniation, with or without syringomyelia. Furthermore, Chiari zero cases can be associated with syringobulbia in rare instances. We present a case of a 39-year-old patient diagnosed with Chiari zero associated with syringomyelia and syringobulbia