Video-Assisted Mini-Thoracotomy Versus Anterior Thoracotomy Mitral Valve Replacement: Intraoperative Time and Hospitalization

Objectives: Minimally invasive mitral valve surgery (MIMVS) was introduced to avoid a full sternotomy through smaller or alternative chest wall incisions to reduce complications. We present our experience with MIMVS through two of its techniques. Methods: This prospective single-centre study was conducted on a total of 34 cases, divided into two groups: Group A (VAMVR) included 17 patients who underwent video-assisted mitral valve replacement. Group B (ATMVR) included 17 patients who underwent right anterior thoracotomy mitral valve replacement, comparing intraoperative procedures and the results of both techniques .Results: In the studied cases, the mean intraoperative time was 4.38 ± 0.69 hours, which widely ranged from 3 to 6 hours, with no significant difference between both techniques. It was 4.35 ± 0.7 hours in VAMVR and 4.41 ± 0.7 in ATMVR. mean ventilation time of 3.96 ± 1.08 hours. The mechanical ventilation time was 4.24 ± 1.1 hours in VAMVR cases and 3.68 ±1.1 hours in the ATMVR group. The mean overall ICU stay duration was 1.75 ± 0.33 days, with no impact of the technique used on this time, as it was 1.71 ± 0.25 days in VAMVR patients and 1.79 ± 0.4 in ATMVR patients. The total hospital stay time was about 5.71 ± 0.91 days, ranging from 4 to 8 days, with no impact of the procedure used on this time as it was 5.6 ± 0.94 days in VAMVR cases and 5.8 ± 0.88 days in ATMVR cases. Conclusions: There was no impact of the technique used in MIMVS, whether video-assisted or right anterior thoracotomy mitral valve replacement, on intraoperative time and ICU and hospital stays

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

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 < 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

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

A Hybrid Online Classifier System for Internet Traffic Based on Statistical Machine Learning Approach and Flow Port Number

Internet traffic classification is a beneficial technique in the direction of intrusion detection and network monitoring. After several years of searching, there are still many open problems in Internet traffic classification. The hybrid classifier combines more than one classification method to identify Internet traffic. Using only one method to classify Internet traffic poses many risks. In addition, an online classifier is very important in order to manage threats on traffic such as denial of service, flooding attack and other similar threats. Therefore, this paper provides some information to differentiate between real and live internet traffic. In addition, this paper proposes a hybrid online classifier (HOC) system. HOC is based on two common classification methods, port-base and ML-base. HOC is able to perform an online classification since it can identify live Internet traffic at the same time as it is generated. HOC was used to classify three common Internet application classes, namely web, WhatsApp and Twitter. HOC produces more than 90% accuracy, which is higher than any individual classifiers

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

Internet traffic classification algorithm based on hybrid classifiers to identify online games traffic

Classification of interactive applications such as online games has gained more attention in the last few years. However, most of the current classification methods were only valid for offline classification. The three common classification methods i.e. port, payload and statistics based have some limitations. This paper exploits the advantages of all the three methods by combining them to produce a new classification algorithm called SSPC (Signature Static Port Classifier). In the proposed algorithm, each of the three classifiers will individually classify the same traffic flow. Based on some priority rules, SSPC makes classification decision for each flow. The SSPC algorithm was used to classify online game (LOL) traffic in two stages, initially offline and later online. SSPC produces a higher accuracy of 91% on average for online classification when compared with other classifiers. In addition, as demonstrated in the real time online experiments done, SSPC algorithm uses a short time to classify traffic and thus it is suitable to be used for online classificatio

Ambiguity and concepts in real time online internet traffic classification

Internet traffic classification gained significant attention in the last few years. Identifying the Internet applications in the real time is one of the most significant challenges in network traffic classification. Most of the proposed classification methods are limited to offline classification and cannot support online classification. This paper aims to highlight the ambiguity in the definition of online classification. Therefore, some of the previous online classification works are discussed and analyzed. This analysing is to check how far the real time online classification was achieved. The results indicate that most of the previous works consider a real Internet traffic but did not consider a real time online classification. In addition, the paper provides a real time classifier which was proposed and used in [1] [2] [3], to show how to perform a real time online classificatio