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

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

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

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements

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

Generation of Beam Tilt through Three-Dimensional Printed Surface

In this paper, 3D printed surfaces are presented to study this technology’s application in generating beam tilt for the electromagnetic waves in the Ku-band. Additionally, the input source is maintained by a feed horn that is additively manufactured and is coated with copper spray paint to add conductivity, which is fed by a WR-75 waveguide. The proposed beam tilt generating surface is also referred to as a Beam Deviating Surface (BDS). There is no relative gap between the BDS and the aperture of the horn, which eventually decreased the overall antenna height. The BDS layer is able to deviate the beam for a fixed elevation angle of 22.5∘ and could be consequently rotated along with the rotation of the BDS prototype. The voltage standing wave ratio value is less than two over the operating frequency range, which depicts the wideband behavior. The measured and simulated radiation patterns show that we can tilt the electromagnetic waves in ranges of up to +/−22.5∘ with a minimum side lobe level of −5 dB at frequencies from 10 to 15 GHz. This signifies the wideband characteristic of the proposed prototype, which is achieved by Vero material from Multijet Printing that is a low-cost and rapid manufacturing 3D printing technology

Miniaturized Wideband Antenna Prototype Operating over the Ku-Band

A wideband antenna is proposed based on three-dimensional printing technology. The antenna was designed using the PREPERM 10 material, with permittivity ϵr = 10, where the overall height of the proposed prototype was maintained as 12.83 mm (0.51λ), having a lateral dimension of 60 mm × 60 mm, at an operating frequency of 12 GHz (λ = 25 mm). The proposed antenna achieved a wide frequency bandwidth with a voltage standing-wave ratio (VSWR) of less than two, from 10 GHz to 15 GHz in the Ku-band, where the maximum directivity was 20 dBi over a reflection coefficient bandwidth of 50%. It showed a miniaturized non-uniform metasurface of 2.4λ × 2.4λ × 0.51λ that was placed at 16.5 mm (0.66λ) above the ground plane, which was 2.4λ × 2.4λ × 0.04λ in dimension. Thus, the overall height of the proposed antenna system from the feed source was 29.33 mm (1.17λ). The total weight of the system including the designed structures made of PREPERM 10 and ABS with copper-painted prototypes was 96 g and 79 g, respectively. The measured results were consistent with the simulated results, demonstrating the feasibility and effectiveness of the proposed method

An Efficient Slotted Waveguide Antenna System Integrated with Inside-Grooves and Modified Gaussian Slot Distribution

In this work, an efficient slotted waveguide antenna (SWA) system is designed for S-band high power microwave (HPM) applications. The designed SWA comprises of 10-slot elements placed on the broad wall of SWA with a modified Gaussian distribution (MGD), integrated with two inside-grooves and a Gaussian dielectric radome of high-density polyethylene (HDPE) material. The inside-grooves are introduced to suppress the surface current on the waveguide, which results in high gain as well as sidelobe level (SLL) reduction in the E-plane. The MGD controls the SLLs, and the unique Gaussian profile shape radome offers constant radiation characteristics. The proposed antenna system, within existing size constraints, offers a high gain of 20.1 dBi in conjunction with a high-power handling capability of greater than 100 MW. The designed SWA system has compact dimensions of 8.46&lambda;0 &times; 1.38&lambda;0 &times; 1.50&lambda;0, with SLLs of &minus;20 dB and &minus;22 dB in the H- and E-plane, respectively. The HPM antenna system, radiating at 3 GHz, is fabricated on aluminium material using the milling process. The simulated SWA system has good agreement with measured results. Moreover, the proposed SWA system offers clear advantages in terms of its robustness, design simplicity, high power handling capability, and high gain

Generation of Beam Tilt through Three-Dimensional Printed Surface

In this paper, 3D printed surfaces are presented to study this technology&rsquo;s application in generating beam tilt for the electromagnetic waves in the Ku-band. Additionally, the input source is maintained by a feed horn that is additively manufactured and is coated with copper spray paint to add conductivity, which is fed by a WR-75 waveguide. The proposed beam tilt generating surface is also referred to as a Beam Deviating Surface (BDS). There is no relative gap between the BDS and the aperture of the horn, which eventually decreased the overall antenna height. The BDS layer is able to deviate the beam for a fixed elevation angle of 22.5&#8728; and could be consequently rotated along with the rotation of the BDS prototype. The voltage standing wave ratio value is less than two over the operating frequency range, which depicts the wideband behavior. The measured and simulated radiation patterns show that we can tilt the electromagnetic waves in ranges of up to +/&minus;22.5&#8728; with a minimum side lobe level of &minus;5 dB at frequencies from 10 to 15 GHz. This signifies the wideband characteristic of the proposed prototype, which is achieved by Vero material from Multijet Printing that is a low-cost and rapid manufacturing 3D printing technology