Process improvement for traceability: A study of human fallibility

Abstract—Human analysts working with results from automated traceability tools often make incorrect decisions that lead to lower quality final trace matrices. As the human must vet the results of trace tools for mission- and safety-critical systems, the hopes of developing expedient and accurate tracing procedures lies in understanding how analysts work with trace matrices. This paper describes a study to understand when and why humans make correct and incorrect decisions during tracing tasks through logs of analyst actions. In addition to the traditional measures of recall and precision to describe the accuracy of the results, we introduce and study new measures that focus on analyst work quality: potential recall, sensitivity, and effort distribution. We use these measures to visualize analyst progress towards the final trace matrix, identifying factors that may influence their performance and determining how actual tracing strategies, derived from analyst logs, affect results

Convective initiation and storm life‐cycles in convection‐permitting simulations of the Met Office Unified Model over South Africa

Convective initiation is a challenge for convection‐permitting models due to its sensitivity to sub‐km processes. We evaluate the representation of convective storms and their initiation over South Africa during four summer months in Met Office Unified Model simulations at 1.5‐km horizontal grid length. Storm size distributions from the model compare well against radar observations, but rainfall in the model is predominantly produced by large storms (50 km in diameter or larger) in the evening, whereas radar observations show most rainfall occurs throughout the afternoon, from storms 10‐50 km in diameter. In all months, modelled maximum number of storm initiations occurs at least 2 hours prior to the radar‐observed maximum. However, the diurnal cycle of rainfall compares well between model and observations, suggesting the numerous storm initiations in the simulations do not produce much rainfall. Modelled storms are generally less intense than in the radar observations, especially in early summer. In February, when tropical influences dominate, the simulated storms are of similar intensity to observed storms. Simulated storms tend to reach their peak intensity in the first 15 minutes after initiation, then gradually become less intense as they grow. In radar observations, storms reach their peak intensity 15‐30 minutes into their life cycle, stay intense as they grow larger, then gradually weaken after they have reached their maximum diameter. Two November case studies of severe convection are analysed in detail. Higher resolution grid length initiates convection slightly earlier (300 m cf. 1.5 km) with the same science settings. Two 1.5‐km simulations that apply more sub‐grid mixing have delayed convective initiation. Analysis of soundings indicates little difference in convective indices, suggesting that differences in convection may be attributed to choices in sub‐grid mixing parameters

Reducing the duration of untreated psychosis and its impact in the U.S.: the STEP-ED study

Background: Early intervention services for psychotic disorders optimally interlock strategies to deliver: (i) Early Detection (ED) to shorten the time between onset of psychotic symptoms and effective treatment (i.e. Duration of Untreated Psychosis, DUP); and (ii) comprehensive intervention during the subsequent 2 to 5 years. In the latter category, are teams (‘First-episode Services’ or FES) that integrate several empirically supported treatments and adapt their delivery to younger patients and caregivers. There is an urgent need to hasten access to established FES in the U.S. Despite improved outcomes for those in treatment, these FES routinely engage patients a year or more after psychosis onset. The Scandinavian TIPS study was able to effectively reduce DUP in a defined geographic catchment. The guiding questions for this study are: can a U.S. adaptation of the TIPS approach to ED substantially reduce DUP and improve outcomes beyond existing FES? Methods/Design The primary aim is to determine whether ED can reduce DUP in the US, as compared to usual detection. ED will be implemented by one FES (STEP) based in southern Connecticut, and usual detection efforts will continue at a comparable FES (PREPR) serving the greater Boston metropolitan area. The secondary aim is to determine whether DUP reduction can improve presentation, engagement and early outcomes in FES care. A quasi-experimental design will compare the impact of ED on DUP at STEP compared to PREPR over 3 successive campaign years. The campaign will deploy 3 components that seek to transform pathways to care in 8 towns surrounding STEP. Social marketing approaches will inform a public education campaign to enable rapid and effective help-seeking behavior. Professional outreach and detailing to a wide variety of care providers, including those in the healthcare, educational and judicial sectors, will facilitate rapid redirection of appropriate patients to STEP. Finally, performance improvement measures within STEP will hasten engagement upon referral. Discussion STEP-ED will test an ED campaign adapted to heterogeneous U.S. pathways to care while also improving our understanding of these pathways and their impact on early outcomes. Trial registration ClinicalTrials.gov: NCT02069925. Registered 20 February 2014

Resisting the mantle of the monstrous feminine : women's construction and experience of premenstrual embodiment

The female reproductive body is positioned as abject, as other, as site of defciency and disease, the epitome of the ‘monstrous feminine.’ Premenstrual change in emotion, behavior or embodied sensation is positioned as a sign of madness within, necessitating restraint and control on the part of the women experiencing it (Ussher 2006). Breakdown in this control through manifestation of ‘symptoms’ is diagnosed as PMS (Premenstrual Syndrome) or PMDD (Premenstrual Dysphoric Disorder), a pathology deserving of ‘treatment.’ In this chapter, we adopt a feminist material-discursive theoretical framework to examine the role of premenstrual embodiment in relation to women’s adoption of the subject position of monstrous feminine, drawing on interviews we have conducted with women who self-diagnose as ‘PMS sufferers.’ We theorize women’s self-positioning as subjectifcation, wherein women take up cultural discourse associated with idealized femininity and the reproductive body, resulting in self-objectifcation, distress, and self-condemnation. However, women can resist negative cultural constructions of premenstrual embodiment and the subsequent self-policing. We describe the impact of women-centered psychological therapy which increases awareness of embodied change, and leads to greater acceptance of the premenstrual body and greater self-care, which serves to reduce premenstrual distress

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

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme

Background: The Global Alliance for Chronic Diseases comprises the majority of the world’s public researchfunding agencies. It is focussed on implementation research to tackle the burden of chronic diseases inlow- and middle-income countries and amongst vulnerable populations in high-income countries. In itsinaugural research call, 15 projects were funded, focussing on lowering blood pressure-related diseaseburden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategiesundertaken in each of these projects.Methods: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity andmotivation of the various actors who were integral to each project (e.g. community members, non-physicianhealth workers and doctors in projects focussed on service delivery). Teams then mapped the interventionsthey were implementing and determined the principal policy categories in which those interventions wereoperating. Guidance was provided on the use of Behaviour Change Wheel to support consistency inresponses across teams. Ratings were iteratively discussed and refined at several group meetings.Results: There was marked variation in the perceived capabilities, opportunities and motivation of the variousactors who were being targeted for behaviour change strategies. Despite this variation, there was a highdegree of synergy in interventions functions with most teams utilising complex interventions involvingeducation, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policycategories were also targeted across teams particularly in the areas of guidelines, communication/marketingand service provision with few teams focussing on fiscal measures, regulation and legislation.Conclusions: The large variation in preparedness to change behaviour amongst the principal actors across theseprojects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken.The findings highlight the importance of contextual factors in driving success and failure of research programmes.Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide agreater understanding of factors that might influence scale-up of intervention strategies

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