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

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 &lt; 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

Deep sentiments in Roman Urdu text using Recurrent Convolutional Neural Network model

Although over 64 million people worldwide speak Urdu language and are well aware of its Roman script, limited research and efforts have been made to carry out sentiment analysis and build language resources for the Roman Urdu language. This article proposes a deep learning model to mine the emotions and attitudes of people expressed in Roman Urdu - consisting of 10,021 sentences from 566 online threads belonging to the following genres: Sports; Software; Food & Recipes; Drama; and Politics. The objectives of this research are twofold: (1) to develop a human-annotated benchmark corpus for the under-resourced Roman Urdu language for the sentiment analysis; and (2) to evaluate sentiment analysis techniques using the Rule-based, N-gram, and Recurrent Convolutional Neural Network (RCNN) models. Using Corpus, annotated by three experts to be positive, negative, and neutral with 0.557 Cohen's Kappa score, we run two sets of tests, i.e., binary classification (positive and negative) and tertiary classification (positive, negative and neutral). Finally, the results of the RCNN model are analyzed by comparing it with the outcome of the Rule-based and N-gram models. We show that the RCNN model outperforms baseline models in terms of accuracy of 0.652 for binary classification and 0.572 for tertiary classification

Sentiment analysis for Urdu online reviews using deep learning models

This is an accepted manuscript of an article published by Wiley in Expert Systems, available online at https://doi.org/10.1111/exsy.12751 The accepted version of the publication may differ from the final published version.Most existing studies are focused on popular languages like English, Spanish, Chinese, Japanese, and others, however, limited attention has been paid to Urdu despite having more than 60 million native speakers. In this paper, we develop a deep learning model for the sentiments expressed in this under-resourced language. We develop an open-source corpus of 10,008 reviews from 566 online threads on the topics of sports, food, software, politics, and entertainment. The objectives of this work are bi-fold (1) the creation of a human-annotated corpus for the research of sentiment analysis in Urdu; and (2) measurement of up-to-date model performance using a corpus. For their assessment, we performed binary and ternary classification studies utilizing another model, namely LSTM, RCNN Rule-Based, N-gram, SVM, CNN, and LSTM. The RCNN model surpasses standard models with 84.98 % accuracy for binary classification and 68.56 % accuracy for ternary classification. To facilitate other researchers working in the same domain, we have open-sourced the corpus and code developed for this research

Carapace length-weight and carapace width-weight relationship of <em>Portunus pelagicus</em> (Linnaeus, 1758) in Pakistani waters northern Arabian Sea

890-896The carapace length-weight and carapace width-weight relationship of Portunus pelagicus analysis were conducted from Pakistani waters. Total of 897 specimen of both sexes combined were measured in which 478 female and 419 male specimen during January to November 2015. The carapace length-weight of both sexes combined were calculated as W = 0.2888*2.73 (R2 = 0.860). However the carapace width-weight of both sexes were as W = 0.1198*2.79 (R2 = 0.870). The carapace length-weight of separate sexes (male and female) of P. pelagicus were also calculated as W = 0.967*2.91(R2 = 0.874) and carapace width-weight were as W = 0.8138*2.95 (R2 = 0.882). While the carapace width-weight and length-weight of male were calculated as W = 0.967*2.44 (R2 = 0.795), W = 0.204*2.56 (R2 = 0.809), respectively. The present study shows that the growth of P. pelagicus is isomateric from Pakistani waters

Knowledge and practice about mycetoma infection among community pharmacists in Khartoum State: A descriptive cross-sectional study

Mycetoma is classified as a neglected tropical disease, and despite its spread in Sudan, most physicians and pharmacists do not pay attention to the symptoms and proper treatment of mycetoma. Thus, this study aimed to evaluate knowledge and practice on mycetoma among community pharmacists in Khartoum state. A cross-sectional descriptive study was carried out among community pharmacists in Khartoum state, in the period from August to October 2021. Data was collected from the seven localities within Khartoum state using a validated self-administered questionnaire. The knowledge and practice of community pharmacists were assessed, and their association with demographic characteristics was calculated. Out of 347 pharmacists, 59.9% were females, 64.8% were between 22 and 28 years of age, and 79.3% were bachelor holders. Most of the participants (52.7%) had sufficient knowledge about mycetoma, the most common source of information was lectures (36.6%), more than half participants heard about the Mycetoma Research Center, and most of the cases seen by the participants were in the community (30.5%). There was no association between demographic data and knowledge score, except for knowing about the Mycetoma Research Center and attending workshops and seminars. Moreover, more than half of the participants showed good practice with mycetoma patients. The findings of the current study reflect that more efforts are needed to increase the knowledge and improve the practice of community pharmacists toward mycetoma

Efficacy and Tolerability of Isocitrate Dehydrogenase Inhibitors in Patients With Acute Myeloid Leukemia: A Systematic Review of Clinical Trials

BACKGROUND: Acute myeloid leukemia (AML) is a hematological malignancy due to anomalous differentiation and proliferation of hematopoietic stem cells with myeloid blast buildup. Induction chemotherapy is considered the first line of treatment in most patients with AML. However, targeted therapy in the form of FLT-3, IDH, BCL-2, and immune checkpoint inhibitors, can be considered as the first line depending on their molecular profile, resistance to chemotherapy, comorbidities, etc. This review aims to assess the tolerability and efficacy of isocitrate dehydrogenase (IDH) inhibitors in AML. METHODS: We searched Medline, WOS, Embase, and clinicaltrials.gov. PRISMA guidelines were followed in this systematic review. 3327 articles were screened, and 9 clinical trials (N = 1119) were included. RESULTS: In randomized clinical trials (RCTs), objective response (OR) was reported in 63-74% of the patients with IDH inhibitors + azacitidine as compared to 19-36 % of the patients with azacitidine monotherapy in newly diagnosed (ND) medically unfit patients. Survival rates were significantly improved with the use of ivosidenib. OR was reported in 39.1-46 % of the patients who relapsed/refractory to chemotherapy. ≥Grade 3 IDH differentiation syndrome and QT prolongation were reported in 3.9-10 % and 2-10 % of the patients, respectively. CONCLUSION: IDH inhibitors (ivosidenib for IDH-1 and enasidenib for IDH-2) are safe and effective in treating ND medically unfit or relapsed refractory patients with IDH mutation. However, no survival benefit was reported with enasidenib. More randomized multicenter double-blinded clinical studies are needed to confirm these results and compare them with other targeting agents

329: Assessing national critical care capacity: A snapshot of facilities across Pakistan

Introduction: As the COVID-19 pandemic threatens to strain health care systems worldwide, the presence of gaps in the global critical care capacity has become glaringly obvious, particularly in less developed countries like Pakistan. To identify existing gaps, an assessment of the critical care units across Pakistan was carried out.Methods: A novel checklist for assessing critical care units was developed based on the Partners in Health 4S Framework. Our checklist evaluated the following key components: Space/Infrastructure, Staffing, Stuff/Equipment, and Systems/Protocols. A series of surveys was conducted using telephonic and on-site interviews at hospitals identified by the Ministry of Health in Pakistan.Results: Critical care facilities at 53 hospitals were surveyed. The majority were from the public sector (62%) and located in metropolitan cities (62%). In terms of infrastructure, the majority of units were adequate, with gaps primarily being identified for negative-pressure rooms (21%), donning-doffing areas (58%) and isolation rooms (64%). In terms of staffing, the majority of hospitals had trainee doctors (94%) and nursing staff (100%) available, with gaps being identified in terms of presence of qualified intensivists (47%) and ancillary staff (ethicists – 17%, dietitians – 45%). Furthermore, an adequate nurse-to-patient ratio of 1:2 or 1:3 was only present in 53% of the hospitals. Equipment was present in the majority of facilities including ventilators (96%, n=9.7±1.1) and BIPAP machines (85%, n=4.5±0.6), with a relative lack of high-flow nasal cannulas (64%, n=3.2±0.9). More than 80% of hospitals had protocols in place for COVID-19 management and staffing, but fewer had them for patient surge (60%), clinician credentialing (58%) and risk mitigation (49%). On chi-square analysis, statistically significant differences (p\u3c0.05) were noted between public and private sectors as well as metropolitan and rural hospitals in terms of availability of negative pressure rooms, ancillary staff like dietitians, and optimal nurse-to-patient ratio.Conclusions: The results from this study will be pivotal to guide policy makers in devising strategies for improving the quality of critical care units across Pakistan during the COVID-19 pandemic and beyond

329: Assessing National Critical Care Capacity: A Snapshot of Facilities Across Pakistan

Introduction: As the COVID-19 pandemic threatens to strain health care systems worldwide, the presence of gaps in the global critical care capacity has become glaringly obvious, particularly in less developed countries like Pakistan. To identify existing gaps, an assessment of the critical care units across Pakistan was carried out.Methods: A novel checklist for assessing critical care units was developed based on the Partners in Health 4S Framework. Our checklist evaluated the following key components: Space/Infrastructure, Staffing, Stuff/Equipment, and Systems/Protocols. A series of surveys was conducted using telephonic and on-site interviews at hospitals identified by the Ministry of Health in Pakistan.Results: Critical care facilities at 53 hospitals were surveyed. The majority were from the public sector (62%) and located in metropolitan cities (62%). In terms of infrastructure, the majority of units were adequate, with gaps primarily being identified for negative-pressure rooms (21%), donning-doffing areas (58%) and isolation rooms (64%). In terms of staffing, the majority of hospitals had trainee doctors (94%) and nursing staff (100%) available, with gaps being identified in terms of presence of qualified intensivists (47%) and ancillary staff (ethicists – 17%, dietitians – 45%). Furthermore, an adequate nurse-to-patient ratio of 1:2 or 1:3 was only present in 53% of the hospitals. Equipment was present in the majority of facilities including ventilators (96%, n=9.7±1.1) and BIPAP machines (85%, n=4.5±0.6), with a relative lack of high-flow nasal cannulas (64%, n=3.2±0.9). More than 80% of hospitals had protocols in place for COVID-19 management and staffing, but fewer had them for patient surge (60%), clinician credentialing (58%) and risk mitigation (49%). On chi-square analysis, statistically significant differences (p\u3c0.05) were noted between public and private sectors as well as metropolitan and rural hospitals in terms of availability of negative pressure rooms, ancillary staff like dietitians, and optimal nurse-to-patient ratio.Conclusions: The results from this study will be pivotal to guide policy makers in devising strategies for improving the quality of critical care units across Pakistan during the COVID-19 pandemic and beyond