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

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

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 macrophage polarization on gold nanoparticle-assisted plasmonic photothermal therapy

Tumor associated macrophages (TAM) are key pathogenic factors in neoplastic diseases. They are known to have plasticity and can polarize into two opposing phenotypes, including the tumoricidal M1 and the protumoral M2 phenotypes with high prevalence of M2-phentoypes in patients with poor prognosis. Strategies for targeting M2-TAM may consequently increase the efficacy of therapeutic strategies for cancer treatment. Gold nanorod-assisted plasmonic photothermal therapy (PPTT) has emerged as a promising treatment for cancer but the effects of macrophage polarization parameters in the performance of this new treatment modality is still unknown. Herein, human monocytic THP-1 cells were polarized into two opposite phenotypic macrophages (M1-TAM and M2-TAM) and their response to PPTT was examined. M2-TAM exhibits a three-fold increase in AuNP uptake compared to M1-TAM. Laser irradiation results in selective killing of pro-tumoral M2-TAM after treatment with AuNPs with limited effects on anti-tumoral M1-TAM. A positive correlation between the expression of CD206 marker and the AuNP uptake may indicate the role of CD206 in facilitating AuNP uptake. Our findings also suggest that the differences in AuNP avidity and uptake between the M1-TAM and M2-TAM phenotypes may be the rationale behind the effectiveness of PPTT in the treatment of solid tumors.Funding Agencies|Binational Fulbright Commission in Egypt [99869795N]; Swedish Research Council (VR)Swedish Research Council [2017-04475]; Swedish Foundation for Strategic Research (SFF)Swedish Foundation for Strategic Research [FFL15-0026]; Knut and Alice Wallenberg FoundationKnut &amp; Alice Wallenberg Foundation [KAW 2016.0231]; Swedish Cancer Foundation [CAN 2017/430]; Swedish Government Strategic Research Area in Materials Science on Functional Materials at Linkoping University [2009-00971]</p

Optimal Allocation of Multiple Types of Distributed Generations in Radial Distribution Systems Using a Hybrid Technique

In recent years, the integration of distributed generators (DGs) in radial distribution systems (RDS) has received considerable attention in power system research. The major purpose of DG integration is to decrease the power losses and improve the voltage profiles that directly lead to improving the overall efficiency of the power system. Therefore, this paper proposes a hybrid optimization technique based on analytical and metaheuristic algorithms for optimal DG allocation in RDS. In the proposed technique, the loss sensitivity factor (LSF) is utilized to reduce the search space of the DG locations, while the analytical technique is used to calculate initial DG sizes based on a mathematical formulation. Then, a metaheuristic sine cosine algorithm (SCA) is applied to identify the optimal DG allocation based on the LSF and analytical techniques instead of using random initialization. To prove the superiority and high performance of the proposed hybrid technique, two standard RDSs, IEEE 33-bus and 69-bus, are considered. Additionally, a comparison between the proposed techniques, standard SCA, and other existing optimization techniques is carried out. The main findings confirmed the enhancement in the convergence of the proposed technique compared with the standard SCA and the ability to allocate multiple DGs in RDS

Developing a Hybrid Approach Based on Analytical and Metaheuristic Optimization Algorithms for the Optimization of Renewable DG Allocation Considering Various Types of Loads

The optimal location of renewable distributed generations (DGs) into a radial distribution system (RDS) has attracted major concerns from power system researchers in the present years. The main target of DG integration is to improve the overall system performance by minimizing power losses and improving the voltage profile. Hence, this paper proposed a hybrid approach between an analytical and metaheuristic optimization technique for the optimal allocation of DG in RDS, considering different types of load. A simple analytical technique was developed in order to determine the sizes of different and multiple DGs, and a new efficient metaheuristic technique known as the Salp Swarm Algorithm (SSA) was suggested in order to choose the best buses in the system, proportionate to the sizes determined by the analytical technique, in order to obtain the minimum losses and the best voltage profile. To verify the power of the proposed hybrid technique on the incorporation of the DGs in RDS, it was applied to different types of static loads; constant power (CP), constant impedance (CZ), and constant current (CI). The performance of the proposed algorithm was validated using two standards RDSs—IEEE 33-bus and IEEE 69-bus systems—and was compared with other optimization techniques

Can pregnancy aggravate the criticality of COVID-19 infection in obese asthmatic peripartum woman? A peripartum COVID-19 mortality case report

As coronavirus disease 2019 (COVID-19) sweeps all over the world, Information about COVID-19 is evolving rapidly and interim guidance by multiple organisations is constantly being updated and expanded. Early with discovery of COVID 19, it was reported that pregnancy did affect the progress of the disease severity. Recently, Centres for Disease Control and Prevention (CDC) reported that pregnancy is a risk factors for COVID-19 severity. The current case report is presenting a peripartum COVID-19 positive mortality case

High prevalence of Coxiella burnetii infection in humans and livestock in Assiut, Egypt: A serological and molecular survey

Background and Aim: Q fever is considered a neglected zoonotic disease and is caused by Coxiella burnetii. Very little information is available on C. burnetii infections in cattle, sheep, and goat populations in Egypt. The aim of this study was to identify the seroprevalence of C. burnetii in humans and livestock and to test for the presence of C. burnetii DNA in sera from seropositive animals and humans. Materials and Methods: Blood samples were collected from 160 apparently healthy farm animals and 120 patients from three hospitals of the Assiut Governorate throughout 2017/2018. These populations were tested for antibodies against C. burnetii phase II antigen by immunofluorescence assay [IFA]) and enzyme-linked immunosorbent assay (ELISA). Seropositive samples were subjected to real-time quantitative polymerase chain reaction (RT-qPCR). Results: The results of the IFA revealed C. burnetii seroprevalence rates of 45.3%, 56.0%, 45.7%, and 53.3% in cattle, sheep, goats, and humans, respectively. In humans, the seroprevalence rates were 52.1%, 30.4%, 37.5%, 74.1%, and 62.5% in patients with fever of unknown origin, influenza, kidney dialysis, hepatitis C virus, and hepatitis B virus, respectively. Likewise, by ELISA, the seroprevalence in bovine was 50.7%; sheep, 60.0%; goats, 51.4%; and humans, 55.0% (54.3%, 30.4%, 37.5%, 77.8%, and 62.5% in patients with fever of unknown origin, influenza, kidney dialysis, hepatitis C virus, and hepatitis B virus, respectively). RT-qPCR targeting the repetitive element IS1111 confirmed the presence of C. burnetii DNA. Conclusion: These results proved that apparently healthy cattle, sheep, and goats may be very important reservoirs of C. burnetii infection. In light of these data, the effect of Q fever on the replication of hepatitis virus remains unclear. Although hepatitis is one of the main aspects of acute Q fever, the influence of hepatitis on Q fever remains to be investigated. Q fever is not a reportable disease in Egypt, and clinical cases may rarely be recognized by the health-care system. Additional information on the epidemiology of C. burnetii in Egypt is warranted, including other associated problems such as the distribution of infections, pathologic hallmarks, and molecular typing

Gold Nanorod-Assisted Photothermal Therapy Decreases Bleeding during Breast Cancer Surgery in Dogs and Cats

For localized tumors, gold nanorod (AuNR)-assisted plasmonic photothermal therapy (PPTT) is a potentially effective alternative to traditional surgery, in which AuNRs absorb near-infrared light and convert it to heat in order to kill cancer cells. However, for large tumors (volume &ge; 20 cm3), an uneven distribution of AuNRs might cause inhomogeneity of the heat distribution inside the tumor. Surgery is frequently recommended for removing large tumors, but it is associated with a high risk of cancer recurrence and metastasis. Here, we applied PPTT before surgery, which showed improved treatment for large tumors. We divided the animals (eight cats/dogs) into two groups: Group I (control), where three cases were solely treated with surgery, laser, or AuNRs alone, resulting in recurrence and metastasis; and Group II, where animals were treated with PPTT before surgery. In Group II, four out of the five cases had tumor regression without any recurrence or metastasis. Interestingly, we observed that applying PPTT before surgery displayed reduced bleeding during tumor removal, supported by histopathology that showed altered blood vessels. In conclusion, our study showed that applying AuNR-assisted PPTT (AuNRs-PPTT) before surgery could significantly affect blood vessels inside the tumor, leading to a decreased amount of bleeding during surgery, which can potentially decrease the risk of metastasis and blood loss during surgery