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

Characterization of greater middle eastern genetic variation for enhanced disease gene discovery

The Greater Middle East (GME) has been a central hub of human migration and population admixture. The tradition of consanguinity, variably practiced in the Persian Gulf region, North Africa, and Central Asia1-3, has resulted in an elevated burden of recessive disease4. Here we generated a whole-exome GME variome from 1,111 unrelated subjects. We detected substantial diversity and admixture in continental and subregional populations, corresponding to several ancient founder populations with little evidence of bottlenecks. Measured consanguinity rates were an order of magnitude above those in other sampled populations, and the GME population exhibited an increased burden of runs of homozygosity (ROHs) but showed no evidence for reduced burden of deleterious variation due to classically theorized ‘genetic purging’. Applying this database to unsolved recessive conditions in the GME population reduced the number of potential disease-causing variants by four- to sevenfold. These results show variegated genetic architecture in GME populations and support future human genetic discoveries in Mendelian and population genetics

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

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

Invasive micropapillary carcinoma of ampulla of Vater in a young female with negative lymph nodes: A case report and review of literature

Invasive micropapillary carcinoma (IMPC) is an extremely rare and aggressive subtype of adenocarcinoma that was first described in breast cancer. It is characterised by an inside-out growth pattern with frequent lymphatic spread. Only few cases are described in the rare ampullo-pancreatobiliary location. In this case report, the diagnosis was unexpected given the patient's age and gender, as well as the negative nodal status. Despite the reported aggressive behaviour of this tumour, no optimal treatment strategy for IMPC in the ampulla of Vater has been established. In addition, this variant is not included in the recent WHO of the digestive system

The value of the apparent diffusion coefficient value in the Liver Imaging Reporting and Data System (LI-RADS) version 2018

Purpose: To assess role of the apparent diffusion coefficient (ADC) in the Liver Imaging Reporting and Data System (LI-RADS) version 2018 for the prediction of hepatocellular carcinoma (HCC). Material and methods: Retrospective analysis of 137 hepatic focal lesions in 108 patients at risk of HCC, who underwent magnetic resonance imaging of the liver. Hepatic focal lesions were classified according to LI-RADS-v2018, and ADC of hepatic lesions was calculated by 2 independent blinded reviewers. Results: The mean ADC of LR-1 and LR-2 were 2.11 ± 0.47 and 2.08 ± 0.47 × 10-3 mm2/s, LR-3 were 1.28 ± 0.12 and 1.36 ± 0.16 × 10-3 mm2/s, LR-4, LR-5 and LR-TIV were 1.07 ± 0.08 and 1.08 ± 0.12 × 10-3 mm2/s and LR-M were 1.02 ± 0.09 and 1.00 ± 0.09 × 10-3 mm2/s by both observers, respectively. There was excellent agreement of both readings for LR-1 and LR-2 (r = 0.988), LR-3 (r = 0.965), LR-4, LR-5 and LR-TIV (r = 0.889) and LR-M (r = 0.883). There was excellent correlation between ADC and LI-RADS-v2018 (r = –0.849 and –0.846). The cut-off ADC used to differentiate LR-3 from LR-4, LR-5, and LR-TIV were ≤ 1.21 and ≤ 1.23 × 10-3 mm2/s with AUC of 0.948 and 0.926. Conclusions: Inclusion of ADC to LI-RADS-v2018 improves differentiation variable LI-RADS categories and can helps in the prediction of HCC

The role of magnetic resonance enterography and diffusion-weighted imaging in pediatric inflammatory bowel disease compared to endoscopic and clinical activity scores: pilot study

Abstract Background Inflammatory bowel disease (IBD) is considered as significant cause of morbidity in children with a global rise in its pediatric onset recently. Our study aimed to assess the facility of magnetic resonance enterography (MRE) and diffusion-weighted imaging (DWI) to identify the activity of pediatric IBD in correlation with clinical and endoscopic activity scores. Twenty-four patients of IBD who underwent clinical examination, ileocolonoscopy and MRE and DWI within less than 14 days were prospectively included. For all Crohn’s cases (9/24), the simplified endoscopic activity score for Crohn’s disease (SES-CD) and magnetic resonance enterography global score (MEGS) were acquired, while for all UC (15/24) cases, MRE score and Mayo endoscopic score were calculated. Sensitivity and specificity of MRE for detection disease activity against clinical and endoscopic scores were compared. Pathological reference for disease activity was based on assessment for mucosal inflammatory changes on endoscopic biopsy in all cases. Results There was a perfect inter-observer agreement (kappa 0.81–1) regarding wall thickening and mural edema, with substantial agreement (kappa 0.61–0.8) for MRE severity score, mural diffusion restriction, mesenteric edema and vascular congestion, while mural enhancement and for number of active LNs revealed moderate agreement (kappa 0.41–0.6). There was a significant positive correlation between MEGS and SES-CD in Crohn’s cases as well as between Mayo endoscopic score and MRE severity in UC cases (r = 0.970, p > 0.001 and r = 0.544, p = 0.036, respectively). MRE compared to endoscopic findings and clinical activity scores revealed high accuracy (95.8%) with 87.5%, 80%, 96% and 94.1% for sensitivity, specificity, PPV and NPV, respectively. Conclusion MR enterography is a noninvasive reliable imaging modality of high accuracy for the diagnosis of pediatric IBD severity compared to endoscopic activity scores and pathological severity

Endoluminal ultrasound versus magnetic resonance imaging in assessment of rectal cancer after neoadjuvant therapy

Abstract Background Accurate rectal tumor staging guides the choice of treatment options. EUS and MRI are the main modalities for staging. Aim of the work To compare the performance of EUS and MRI for loco-regional staging of anorectal cancer after neo-adjuvant therapy. Methods Seventy-three (37 male, 36 female) patients with rectal cancer after neo-adjuvant chemoradiotherapy were enrolled. Histopathological staging after surgery were used as reference for comparing the yield of loco-regional staging for EUS and MRI. EUS and MRI were done 1 month after completion of neo-adjuvant therapy. Results Regarding post-surgical T staging, eight patients had early tumor (T2 = 16 and T1 = 9) and thirty six were locally advanced (T3 = 36), while N staging, forty patients with negative nodes and 33 were positive (N1 = 22 and N2 = 11). Comparing EUS to MRI, it showed a higher sensitivity (95.7% vs. 78.7%), specificity (84.6% vs. 68.0%) and accuracy (91.8% vs. 75.3%) for staging early and locally advanced tumor. Also, it had a higher sensitivity (78.8% vs. 69.7%), specificity (75.0% vs. 65.0%) and accuracy (76.7% vs. 67.1%) for detection of lymph nodes. Conclusion EUS appears to be more accurate than MRI in loco-regional staging of rectal carcinoma after neo-adjuvant therapy

Lithium adsorption from aqueous solution using aluminum hydroxide: Characterization, optimization by response surface methodology, kinetic modelling, and isotherm studies

The growing need for Lithium (Li) chemicals for industrial application demands finding affordable and environmentally friendly ways of producing them beyond conventional land mining. Adsorption is a promising technique for Li recovery as it selectively extracts Li from aqueous resources at a low cost and with minimal energy requirements. The use of adsorption for Li recovery is important for promoting a circular economy and decreasing natural Li in the environment. Thus, this study aim to assess the efficiency of aluminum hydroxide (Al(OH)3) as an adsorbent for Li recovery from aqueous solution by adjusting the amount of adsorbent, time, Li concentration, and pH. The use of Al(OH)3 provides selective separation of Li ions and can be used as a simple and cost-effective method for purifying Li-containing solutions. The optimal conditions for the adsorption process were determined using the Box-Behnken in response surface methodology (RSM). The findings revealed that the highest removal was anticipated with a 1150 mg/L adsorbent dose, 4.5 pH, 1150 mg/L initial concentration, and 255 minutes contact time. The outcome of the finding supports the use of Al (OH)3 as a suitable choice for recovering Li due to its greater capacity for sorption and higher percentage of Li absorbed. The analysis of the isotherm and kinetic experiment results showed that the Temkin isotherm and the pseudo-first-order model were well-fitting, with R2 values of 0.998 and 0.999, respectively. This study emphasizes the effectiveness of Al(OH)3 in recovering Li and details the optimal adsorption process. As a result, Al(OH)3 has been presumed to be the most suitable choice for Li recovery because it outperforms other available adsorbents with high sorption ability

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