On the Difficulty of Securing Web Applications using CryptDB

CryptDB has been proposed as a practical and secure middleware to protect databases deployed on semi-honest cloud servers. While CryptDB provides sufficient protection under Threat-1, here we demonstrate that when CryptDB is deployed to secure the cloud hosted database of a realistic web application, an attacker to database or a Malicious Database Administrator (mDBA) can easily steal information, and even escalate his privilege to become the administrator of the web application. Our attacks, fall under a restricted form of Threat-2 where we only assume that the attackers or the mDBA tampers with the CryptDB protected database and is opens an ordinary user account through the web application. Our attacks, are carried out assuming perfectly secure proxy and application servers. Therefore, the attacks work without recovering the master key residing on the proxy server. At the root of the attack lies the lack of any integrity checks for the data in the CryptDB database. We propose a number of practical countermeasures to mitigate attacks targeting the integrity of the CryptDB database. We also demonstrate that the data integrity is not sufficient to protect the databases, when query integrity and frequency attacks are considered

GENERAL CHARACTERISTICS OF CEREBRAL PALSY PATIENTS

Amaç: Çalışmanın amacı Dokuz Eylül Üniversitesi Tıp Fakültesi serebral palsi polikliniğinde izlenen hastaların genel özelliklerinin araştırılmasıdır. Gereç ve yöntem: Dokuz Eylül Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı ve Ortopedi ve Travmatoloji Anabilim Dalı tarafından yürütülen serebral palsi polikliniğinde 2002 - 2006 yılları arasında standart muayene yöntemleri ile izlenen 150 hasta retrospektif olarak değerlendirildi. Bulgular: Hastaların yaş ortalamaları 7,56 ± 4,68 yıl ve tanı konma yaşı 4,95 ± 4,86 ay olarak saptandı. Etiyolojik faktörler açısından bakıldığında %60,1 prenatal, %29,4 perinatal ve %11,5 olguda postnatal nedenler sorumlu olarak bulundu. Olguların fizik tedavi ve rehabilitasyona başlama yaşı 2,89 ± 5,96 yıl idi ve %80,5'inin bir rehabilitasyon merkezinde düzenli bir tedavi hizmeti aldığı saptandı. Serebral palsi tipi açısından yapılan değerlendirmede %20,7'sini hemiplejik tip, %42'sini diplejik tip ve %37,3'ünü de tüm vücut tutulumu olan kuadriplejik olguların oluşturduğu görüldü. Olguların 42 (%28)'sinde cerrahi ve 50 (% 33,3)'sinde botulinum toksin enjeksiyonu uygulaması yapılmıştı. Sonuç: Serebral palsi çocukluk çağında en sık görülen ve önemli sakatlık nedeni olabilen bir hastalıktır. Bu olguların düzenli olarak izlemi ve gerekli tedavi yaklaşımlarının zamanında uygulanması değerlendirme ve tedavisinde bir multidisipliner yaklaşım gerektirmektedir. Objective: The aim of this study was to investigate the general characteristic of cerebral palsy patients who observed cerebral palsy out patient clinic. Material and method: In this study, one hundred fifty cerebral palsy patients who followed cerebral palsy outpatient clinic between 2002-2006 in the Department of Physical Medicine and Rehabilitation and Department of Orthopaedics, Dokuz Eylul University School of Medicine, were retrospectively evaluated. Results: The mean age of the patients was 7.56 ± 4.68 years and mean age of diagnosis was 4.95 ± 4.86 months. Patients were grouped according to the etiological factors, 60.1% prenatal, 29.4% perinatal and 11.5% postnatal causes. Patients had begun rehabilitation program at 2.89±5.96 year and 80.5% of our patients were followed -on regular rehabilitation program. We classified patient according to the body involvement, 20.7% hemiplegic type, 42% diplegic type and 37.3% total body involvement. Forty-two (28%) of patients had been operated on and fifty (33.3%) of patients had been applied botulinum toxin injection. Conclusion: Cerebral palsy is one of the most common causes of disability in childhood leading functional limitation. Multidisciplinary approach is very important to evaluate and treatment of cerebral palsy patients

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

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