Heat and salinity budgets at the Stratus mooring in the southeast Pacific

Author Posting. © American Geophysical Union, 2014. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Journal of Geophysical Research: Oceans 119 (2014): 8162–8176, doi:10.1002/2014JC010256.The surface layer of the southeast Pacific Ocean (SEP) requires an input of cold, fresh water to balance heat gain, and evaporation from air-sea fluxes. Models typically fail to reproduce the cool sea surface temperatures (SST) of the SEP, limiting our ability to understand the variability of this climatically important region. We estimate the annual heat budget of the SEP for the period 2004–2009, using data from the upper 250 m of the Stratus mooring, located at 85°W 20°S, and from Argo floats. The surface buoy measures meteorological conditions and air-sea fluxes; the mooring line is heavily instrumented, measuring temperature, salinity, and velocity at more than 15 depth levels. We use a new method for estimating the advective component of the heat budget that combines Argo profiles and mooring velocity data, allowing us to calculate monthly profiles of heat advection. Averaged over the 6 year study period, we estimate a cooling advective heat flux of −41 ± 29 W m−2, accomplished by a combination of the mean gyre circulation, Ekman transport, and eddies. This compensates for warming fluxes of 32 ± 4 W m−2 due to air-sea fluxes and 7 ± 9 W m−2 due to vertical mixing and Ekman pumping. A salinity budget exhibits a similar balance, with advection of freshwater (−60 psu m) replenishing the freshwater lost through evaporation (47 psu m) and Ekman pumping (14 psu m).This work was supported by NOAA's Climate Program Office and by NSF grant OCE-0745508.2015-05-2

Structure and surface properties of eddies in the southeast Pacific Ocean

Author Posting. © American Geophysical Union, 2013. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Journal of Geophysical Research: Oceans 118 (2013): 2295–2309, doi:10.1002/jgrc.20175.A number of studies have posited that coastally generated eddies could cool the southeast Pacific Ocean (SEP) by advecting cool, upwelled waters offshore. We examine this mechanism by characterizing the upper-ocean properties of mesoscale eddies in the SEP with a variety of observations and by estimating the surface-layer eddy heat flux divergence with satellite data. Cyclonic and anticyclonic eddies observed during two cruises featured deep positive salinity anomalies along the 26.5 kg m−3isopycnal, indicating that the eddies had likely trapped and transported coastal waters offshore. The cyclonic eddies observed during the cruises were characterized by shoaling isopycnals in the upper 200 m and cool near-surface temperature anomalies, whereas the upper-ocean structure of anticyclonic eddies was more variable. Using a variety of large-scale observations, including Argo float profiles, drifter records, and satellite sea surface temperature fields, we show that, relative to mean conditions, cyclonic eddies are associated with cooler surface temperatures and that anticyclonic eddies are associated with warmer surface temperatures. Within each data set, the mean eddy surface temperature anomalies are small and of approximately equal magnitude but opposite sign. Eddy statistics drawn from satellite altimetry data reveal that cyclonic and anticyclonic eddies occur with similar frequency and have similar average radii in the SEP. A satellite-based estimate of the surface-layer eddy heat flux divergence, while large in coastal regions, is small when averaged over the SEP, suggesting that eddies do not substantially contribute to cooling the surface layer of the SEP.This work was supported by NOAA’s Climate Program Office and by NSF Grant OCE-0745508. Microwave OI SST data are produced by Remote Sensing Systems and sponsored by National Oceanographic Partnership Program (NOPP), the NASA Earth Science Physical Oceanography Program, and the NASA MEaSUREs DISCOVER Project

Stratus 11 : Eleventh Setting of the Stratus Ocean Reference Station Cruise on board RV Moana Wave, March 31 - April 16, 2011, Arica - Arica, Chile

The Ocean Reference Station at 20°S, 85°W under the stratus clouds west of northern Chile is being maintained to provide ongoing climate-quality records of surface meteorology, air-sea fluxes of heat, freshwater, and momentum, and of upper ocean temperature, salinity, and velocity variability. The Stratus Ocean Reference Station (ORS Stratus) is supported by the National Oceanic and Atmospheric Administration’s (NOAA) Climate Observation Program. It is recovered and redeployed annually, with past cruises that have come between October and January. A NOAA vessel was not available, so this cruise was conducted on the chartered ship, Moana Wave, belonging to Stabbert Maritime. During the 2011 cruise on the Moana Wave to the ORS Stratus site, the primary activities were the recovery of the subsurface part of the Stratus 10 WHOI surface mooring, deployment of a new (Stratus 11) WHOI surface mooring, in-situ calibration of the buoy meteorological sensors by comparison with instrumentation installed on the ship by staff of the NOAA Earth System Research Laboratory (ESRL), and collection of underway and on station oceanographic data to continue to characterize the upper ocean in the stratus region. The Stratus 10 mooring had parted, and the surface buoy and upper part had been recovered earlier. Underway CTD (UCTD) profiles were collected along the track and during surveys dedicated to investigating eddy variability in the region. Surface drifters and subsurface floats were also launched along the track. The intent was also to visit a buoy for the Pacific tsunami warning system maintained by the Hydrographic and Oceanographic Service of the Chilean Navy (SHOA). This DART (Deep- Ocean Assessment and Reporting of Tsunami) buoy had been deployed in December 2010.Funding was provided by the National Oceanic and Atmospheric Administration under Grant No. NA0900AR432012

Stratus 12 : twelfth setting of the Stratus Ocean Reference Station

The Ocean Reference Station at 20°S, 85°W under the stratus clouds west of northern Chile is being maintained to provide ongoing climate-quality records of surface meteorology, air-sea fluxes of heat, freshwater, and momentum, and of upper ocean temperature, salinity, and velocity variability. The Stratus Ocean Reference Station (ORS Stratus) is supported by the National Oceanic and Atmospheric Administration’s (NOAA) Climate Observation Program. It is recovered and redeployed annually. A NOAA vessel was not available, so this cruise was conducted on the Melville, operated by the Scripps Institution of Oceanography. During the 2012 cruise on the Melville to the ORS Stratus site, the primary activities were the deployment of the Stratus 12 WHOI surface mooring, recovery of the previous (Stratus 11) WHOI surface mooring, in-situ calibration of the buoy meteorological sensors by comparison with instrumentation installed on the ship, and collection of underway and on station oceanographic data to continue to characterize the upper ocean in the stratus region. Underway CTD (UCTD) profiles were collected along the track. Surface drifters and subsurface floats were also launched along the track.Funding was provided by the National Oceanic and Atmospheric Administration under Grant No. NA09OAR4320129

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

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

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

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

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