New Control Algorithms for the Robust Operation and Stabilization of Active Distribution Networks

The integration of renewable distributed generation units (DGs) alters distribution systems so that rather than having passive structures, with unidirectional power flow, they become active distribution networks (ADNs), with multi-directional power flow. While numerous technical, economic, and environmental benefits are associated with the shift toward ADNs, this transition also represents important control challenges from the perspective of both the supervisory and primary control of DGs. Voltage regulation is considered one of the main operational control challenges that accompany a high penetration of renewable DGs. The intermittent nature of renewable energy sources, such as wind and solar energy, can significantly change the voltage profile of the system and can interact negatively with conventional schemes for controlling on-load tap changers (OLTCs). Another factor is the growing penetration of plug-in electric vehicles (PEVs), which creates additional stress on voltage control devices due to their stochastic and concentrated power profiles. These combined generation and load power profiles can lead to overvoltages, undervoltages, increases in system losses, excessive tap operation, infeasible solutions (hunting) with respect to OLTCs, and/or limits on the penetration of either PEVs or DGs. With regard to the dynamic control level, DG interfaces are typically applied using power electronic converters, which lack physical inertia and are thus sensitive to variations and uncertainties in the system parameters. Grid impedance (or admittance), which has a substantial effect on the performance and stability of primary DG controllers, is nonlinear, time-varying, and not passive in nature. In addition, constant-power loads (CPLs), such as those interfaced through power electronic converters, are also characterized by inherited negative impedance that results in destabilizing effects, creating instability and damping issues. Motivated by these challenges, the research presented in this thesis was conducted with the primary goal of proposing new control algorithms for both the supervisory and primary control of DGs, and ultimately of developing robust and stable ADNs. Achieve this objective entailed the completion of four studies: Study#1: Development of a coordinated fuzzy-based voltage regulation scheme with reduced communication requirements Study#2: Integration of PEVs into the voltage regulation scheme through the implementation of a vehicle-to-grid reactive power (V2GQ) support strategy Study#3: Creation of an estimation tool for multivariable grid admittance that can be used to develop adaptive controllers for DGs Study#4: Development of self-tuning primary DG controllers based on the estimated grid admittance so that stable performance is guaranteed under time-varying DG operating points (dispatched by the schemes developed in Study#1 and Study#2) and under changing grid impedance (created by network reconfiguration and load variations). As the first research component, a coordinated fuzzy-based voltage regulation scheme for OLTCs and DGs has been proposed. The primary reason for applying fuzzy logic is that it provides the ability to address the challenges associated with imperfect information environments, and can thus reduce communication requirements. The proposed regulation scheme consists of three fuzzy-based control algorithms. The first control algorithm was designed to enable the OLTC to mitigate the effects of DGs on the voltage profile. The second algorithm was created to provide reactive power sharing among DGs, which will relax OLTC tap operation. The third algorithm is aimed at partially curtailing active power levels in DGs so as to restore a feasible solution that will satisfy OLTC requirements. The proposed fuzzy algorithms offer the advantage of effective voltage regulation with relaxed tap operation and with utilization of only the estimated minimum and maximum system voltages. Because no optimization algorithm is required, it also avoids the numerical instability and convergence problems associated with centralized approaches. OPAL real-time simulators (RTS) were employed to run test simulations in order to demonstrate the success of the proposed fuzzy algorithms in a typical distribution network. The second element, a V2GQ strategy, has been developed as a means of offering optimal coordinated voltage regulation in distribution networks with high DG and PEV penetration. The proposed algorithm employs PEVs, DGs, and OLTCs in order to satisfy the PEV charging demand and grid voltage requirements while maintaining relaxed tap operation and minimum curtailment of DG active power. The voltage regulation problem is formulated as nonlinear programming and consists of three consecutive stages, with each successive stage applying the output from the preceding stage as constraints. The task of the first stage is to maximize the energy delivered to PEVs in order to ensure PEV owner satisfaction. The second stage maximizes the active power extracted from the DGs, and the third stage minimizes any deviation of the voltage from its nominal value through the use of available PEV and DG reactive power. The primary implicit objective of the third stage problem is the relaxation of OLTC tap operation. This objective is addressed by replacing conventional OLTC control with a proposed centralized controller that utilizes the output of the third stage to set its tap position. The effectiveness of the proposed algorithm in a typical distribution network has been validated in real time using an OPAL RTS in a hardware-in-the loop (HiL) application. The third part of the research has resulted in the proposal of a new multivariable grid admittance identification algorithm with adaptive model order selection as an ancillary function to be applied in inverter-based DG controllers. Cross-coupling between the and grid admittance necessitates multivariable estimation. To ensure persistence of excitation (PE) for the grid admittance, sensitivity analysis is first employed as a means of determining the injection of controlled voltage pulses by the DG. Grid admittance is then estimated based on the processing of the extracted grid dynamics by the refined instrumental variable for continuous-time identification (RIVC) algorithm. Unlike nonparametric identification algorithms, the proposed RIVC algorithm provides a parametric multivariable model of grid admittance, which is essential for designing adaptive controllers for DGs. HiL applications using OPAL RTS have been utilized for validating the proposed algorithm for both grid-connected and isolated ADNs. The final section of the research is a proposed adaptive control algorithm for optimally reshaping DG output impedance so that system damping and bandwidth are maximized. Such adaptation is essential for managing variations in grid impedance and changes in DG operating conditions. The proposed algorithm is generic so that it can be applied for both grid-connected and islanded DGs. It involves three design stages. First, the multivariable DG output impedance is derived mathematically and verified using a frequency sweep identification method. The grid impedance is also estimated so that the impedance stability criteria can be formulated. In the second stage, multi-objective programming is formulated using the -constraint method in order to maximize system damping and bandwidth. As a final stage, the solutions provided by the optimization stage are employed for training an adaptation scheme based on a neural network (NN) that tunes the DG control parameters online. The proposed algorithm has been validated in both grid-connected and isolated distribution networks, with the use of OPAL RTS and HiL applications.1 yea

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

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Intrauterine diabetic milieu instigates dysregulated adipocytokines production in F1 offspring

Abstract Background Intrauterine environment plays a pivotal role in the origin of fatal diseases such as the metabolic syndrome. Diabetes is associated with low-grade inflammatory state and dysregulated adipokines production. The aim of this study is to investigate the effect of maternal diabetes on adipocytokines (adiponectin, leptin and TNF-\u3b1) production in F1 offspring in rats. Methods The offspring groups were as follows: F1 offspring of control mothers under control diet (CD) ( CF1-CD ), F1 offspring of control mothers under high caloric diet (HCD) ( CF1-HCD ), F1 offspring of diabetic mothers under CD ( DF1-CD ), and F1 offspring of diabetic mothers under HCD ( DF1-HCD ). Every 5\ua0weeks post-natal, 10 pups of each subgroup were culled to obtain blood samples for biochemical analysis. Results The results indicate that DF1-CD and DF1-HCD groups exhibited hyperinsulinemia, dyslipidemia, insulin resistance and impaired glucose homeostasis compared to CF1-CD ( p\u2009>\u20090.05 ). DF1-CD and DF1-HCD groups had high hepatic and muscular depositions of TGs. The significant elevated NEFA level only appeared in offspring of diabetic mothers that was fed HCD. DF1-CD and DF1-HCD groups demonstrated low serum levels of adiponectin, high levels of leptin, and elevated levels of TNF-\u3b1 compared to CF1-CD ( p\u2009>\u20090.05 ). These results reveal the disturbed metabolic lipid profile of offspring of diabetic mothers and could guide further characterization of the mechanisms involved. Conclusion Dysregulated adipocytokines production could be a possible mechanism for the transgenerational transmittance of diabetes, especially following a postnatal diabetogenic environment. Moreover, the exacerbating effects of postnatal HCD on NEFA in rats might be prone to adipcytokine dysregulation. Furthermore, dysregulation of serum adipokines is a prevalent consequence of maternal diabetes and could guide further investigations to predict the development of metabolic disturbances

Effect of Food Safety Management Practices on Milk Quality and Subclinical Mastitis in Dairy Cow Farms

The study aimed to investigate the effect of management practices based on the principles of hazard analysis critical control points system application in dairy farms on bulk milk tank quality and the subclinical mastitis prevalence. The study was conducted on two dairy farms located in Dakahlia Governorate, Egypt using observation and questionnaire. Furthermore, cow hygiene scoring, subclinical mastitis prevalence using California Mastitis Testing, and electrical conductivity were evaluated. In addition, the organoleptic, chemical, and microbiological quality of bulk milk tanks were assessed. The results showed that farm I had better adoption of farm management practices (66.19%) than farm II (33.80%). The mean of udder and leg hygiene scores for cows showed no significant variation between both farms. The prevalence of subclinical mastitis in farm I was 0% (0/108), while it reached 6.25% (6/96) in farm II. No evidence of any abnormality during organoleptic examination on both farms. Referring to the chemical analyses, there was a higher significant difference between protein and SNF (p&lt;0.05) in farm I than in farm II. However, this was not the case for fat, in which farm II showed a higher significance (p&lt;0.05). Furthermore, farm I showed a significantly lower (p&lt;0.05) somatic cell count. On the other hand, the total bacterial count (TBC), titratable acidity, and pH had no significant difference in both farms. Finally, these ensure the importance of hygiene management practices for udder health and milk quality.