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

Reintegración de capas pictóricas contemporánea mate: un nuevo enfoque utilizando polímeros naturales

Different painting techniques, materials and application methods that characterise contemporary artworks, with predominantly matt surfaces and uniform tones, make retouching one of the most complicated conservation treatments, since sameness is the main target. The retouching intervention carried out at the Galleria Nazionale d’Arte Moderna e Contemporanea in Rome on Tempi prospettici (1969), an installation by the Italian artist Carlo Alfano, gave the opportunity to investigate a method to obtain different matt/glossy values through the use of natural polymers as binders. The binders chosen (different polysaccharides, cellulose derivatives and isinglass) were analysed, both individually and mixed, through colorimetric and glossmetric measurements. The pigment-binder ratio and the addition of silica to get a modulation of the matt appearance of paint formulations were also evaluated. The comparation of the colorimetric values of painting samples and those of the original paint led to the identification of the best solution for the retouching of the artworkDiferentes técnicas de pintura, materiais e métodos de aplicação que caracterizam as obras de arte contemporâneas, com predominância das superfícies mates e tons uniformes, tornam a reintegração cromática um dos tratamentos de conservação mais complicados, já que a semelhança é o principal alvo. A intervenção de reintegração realizadas na Galleria Nazionale d’Arte Moderna e Contemporanea de Roma, em Tempi prospettici (1969), uma instalação do artista italiano Carlo Alfano, deu a oportunidade de investigar um método para obter diferentes valores mates / brilhantes através do uso de polímeros naturais como aglutinantes. Os aglutinantes escolhidos (diferentes polissacarídeos, derivados de celulose e cola de esturjão) foram analisados, individualmente e misturados, por meio de medidas colorimétricas e glossimétricas. Foram também avaliadas a proporção pigmento-aglutinante e a adição de sílica para obter a modulação da aparência mate das formulações de tinta. A comparação dos valores colorimétricos das amostras de pintura e os da tinta original levou à identificação da melhor solução para a reintegração da obra de arte.Las diferentes técnicas de pintura, materiales y métodos de aplicación que caracterizan las obras de arte contemporáneas, con predominio de superficies mate y tonos uniformes, hacen de la reintegración cromática uno de los tratamientos de conservación más complicados, ya que la similitud es el objetivo principal. La intervención de reintegración realizada en Galleria Nazionale d’Arte Moderna e Contemporanea en Roma, en Tempi prospettici (1969), una instalación del artista italiano Carlo Alfano, dio la oportunidad de investigar un método para obtener diferentes valores mate / brillante a través de uso de polímeros naturales como aglutinantes. Los aglutinantes elegidos (diferentes polisacáridos, derivados de celulosa y pegamento de esturión) se analizaron, individualmente y mezclados, utilizando medidas colorimétricas y glosimétricas. La relación pigmento-aglutinante y la adición de sílice también se evaluaron para obtener la modulación de la apariencia mate de las formulaciones de pintura. La comparación de los valores colorimétricos de las muestras de pintura y los de la pintura original condujo a la identificación de la mejor solución para la reintegración de la obra de arte

Special-Effect and Conventional Pigments in Black Light Art: A Multi-Technique Approach to an In-Situ Investigation

Since their introduction in the early decades of the 20th century, fluorescent pigments have found progressively wider applications in several fields. Their chemical composition has been optimized to obtain the best physical properties, but is not usually disclosed by the manufacturers. Even the other class of luminescent pigments, namely the phosphorescent ones, is now produced industrially. The peculiar optical properties of these pigments have attracted more and more the attention of famous artists since the middle of the last century. The Italian Black Light Art movement exploits the possibility of conveying different aesthetical messages depending on the kind of radiation (UV or visible) with which the artwork is illuminated. In the present work, a non-invasive in-situ investigation based on Raman, fluorescence, and visible-reflectance spectroscopies was performed on a series of Black Light Art paintings exhibited in Milan (Italy) in 2017, succeeding in the identification of the materials used by the artists. In particular, the use of both fluorescent and phosphorescent pigments, alone or combined with conventional synthetic organic pigments, has been recognized

Ring-eye blue beads in Iron Age central Italy - Preliminary discussion of technology and possible trade connections

The Iron Age was a remarkable period in glass technology development and its spread across the Mediterranean. Communities that populated what is nowadays Central Italy underwent profound changes during this period forming more complex societies, developing proto-urban and urban centres, and incorporating into a wide trade network of the Mediterranean Sea and beyond. Glass objects in that small region are frequently found in burial sites dated to the first half of the first millennium BCE, with small blue beads with simple ring eyes being among the most abundant types. Fifty-six objects of this type (both whole beads and fragments) were studied with a non-invasive approach by means of Optical Microscopy, Fibre Optics Reflectance Spectroscopy, and portable X-ray Fluorescence spectroscopy. The analyses were conducted at the Museo Nazionale Etrusco di Villa Giulia and at the Museo delle Civilt`a (both in Rome, Italy). Five samples from the main set were also analysed with a Scanning Electron Microscope coupled to an Energy Dispersive Spectrometer. The data gave preliminary information on the raw materials used to prepare the glass, the manufacturing techniques, and offered some hints to (tentatively) locate the region of provenance. In particular, the analyses established that the beads are soda-lime-silica glass and the source of cobalt, used as the blue colorant, could be an ore from Egypt. Within this general frame, a smaller group showed a different compositional pattern. These preliminary results contribute new knowledge for tracing exchange routes within the Mediterranean during the Iron Age

Challenges and opportunities to delivering cardiac imaging training: a national survey by the Italian college of cardiac radiology

Background: Delivering consistent levels of training in cardiac imaging to radiologist is of pivotal importance because of the increasing clinical indications to coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR). Our study sought to capture the heterogeneity of cardiac imaging training programs and to explore residents' vision on cardiac imaging both in the present and in the future. Methods: Two web-based surveys were created. The first was administered to all chief residents from the 42 University Hospitals within Italy, aiming to explore the local educational offer in cardiac imaging. The second was administered via social media to all Italian residents, including questions about their overall vision regarding cardiac imaging. Results: 42/42 University Hospitals responded to the first survey and 235 residents to the second. There was at least a 64-slice CT scanner and a 1.5 T MR scanner per center. In the majority of sites, the weekly routine consisted of more than 10 CCTA and more than 5 CMR. Approximately, half of the centers used advanced CCTA and CMR techniques. The majority of the interviewed resident (94%) perceived cardiac imaging training to be moderately to very important, while requirement for external educational resources was advocated in 25% of the cases. Conclusion: Our survey highlighted a significant awareness of radiology residents regarding the importance of cardiac imaging in their training curriculum. All centers met the technical requirements for cardiac imaging, limiting its use to basic applications in around half of cases. Implementation of an educational network might be the key for supporting the growth of this subspecialty field

Raw materials for copper-coloured glass beads: a contribution to our knowledge of their circulation and production in iron age Italy

Several types of (mostly) blue-green glass beads from Iron-Age archaeological sites in Central Italy were studied using a range of spectroscopic techniques: portable X-Ray Fluorescence spectrometry, Fibre Optics Reflectance Spectroscopy, Scanning Electron Microscopy coupled with Energy Dispersive X-ray Spectrometry, micro-Raman spectroscopy and Laser Ablation Inductively Coupled Plasma Mass Spectrometry. Complementary information was gathered from each technique and discussed in the frame of the archaeological typology of the objects. The systematic evaluation of the results allowed us to draw some conclusions on the raw materials employed for primary production and to highlight some provenance indicators in the glass. Some of the beads found in the Iron Age (IA) contexts were preliminarily attributed to the Final Bronze Age (FBA) production based on their typology, and the compositional data obtained in this work confirmed that they were low magnesium high potassium (LMHK) glass, typical of FBA in the Italian peninsula. Other beads were assigned to low magnesium glass (LMG) or high magnesium glass (HMG), thus giving further information on the fluxing agents employed in the Early Iron Age (EIA) and beyond. Colour variations among the beads reflected their chemical composition, with different bead typologies coloured in a specific way. In some instances, it was possible to establish different origins for the colouring raw materials. The provenance of the samples was difficult to place, but the chemical evidence suggested a subdivision within the raw glass used to produce the beads: for one set of samples, a local origin of the glass could be hypothesised, whereas several production sites in the Near East were suggested for most of the beads considered in this study. Some preliminary clues for the local working of imported glass were also highlighted for one typological group

Molecular characterization of precise in vivo targeted gene integration in human cells using AAVHSC15.

Targeted gene integration via precise homologous recombination (HR)-based gene editing has the potential to correct genetic diseases. AAV (adeno-associated virus) can mediate nuclease-free gene integration at a disease-causing locus. Therapeutic application of AAV gene integration requires quantitative molecular characterization of the edited sequence that overcome technical obstacles such as excess episomal vector genomes and lengthy homology arms. Here we describe a novel molecular methodology that utilizes quantitative next-generation sequencing to characterize AAV-mediated targeted insertion and detects the presence of unintended mutations. The methods described here quantify targeted insertion and query the entirety of the target locus for the presence of insertions, deletions, single nucleotide variants (SNVs) and integration of viral components such as inverted terminal repeats (ITR). Using a humanized liver murine model, we demonstrate that hematopoietic stem-cell derived AAVHSC15 mediates in vivo targeted gene integration into human chromosome 12 at the PAH (phenylalanine hydroxylase) locus at 6% frequency, with no sign of co-incident random mutations at or above a lower limit of detection of 0.5% and no ITR sequences at the integration sites. Furthermore, analysis of heterozygous variants across the targeted locus using the methods described shows a pattern of strand cross-over, supportive of an HR mechanism of gene integration with similar efficiencies across two different haplotypes. Rapid advances in the application of AAV-mediated nuclease-free target integration, or gene editing, as a new therapeutic modality requires precise understanding of the efficiency and the nature of the changes being introduced to the target genome at the molecular level. This work provides a framework to be applied to homologous recombination gene editing platforms for assessment of introduced and natural sequence variation across a target site