Adversarial Deep Reinforcement Learning for Cyber Security in Software Defined Networks

This paper focuses on the impact of leveraging autonomous offensive approaches in Deep Reinforcement Learning (DRL) to train more robust agents by exploring the impact of applying adversarial learning to DRL for autonomous security in Software Defined Networks (SDN). Two algorithms, Double Deep Q-Networks (DDQN) and Neural Episodic Control to Deep Q-Network (NEC2DQN or N2D), are compared. NEC2DQN was proposed in 2018 and is a new member of the deep q-network (DQN) family of algorithms. The attacker has full observability of the environment and access to a causative attack that uses state manipulation in an attempt to poison the learning process. The implementation of the attack is done under a white-box setting, in which the attacker has access to the defender's model and experiences. Two games are played; in the first game, DDQN is a defender and N2D is an attacker, and in second game, the roles are reversed. The games are played twice; first, without an active causative attack and secondly, with an active causative attack. For execution, three sets of game results are recorded in which a single set consists of 10 game runs. The before and after results are then compared in order to see if there was actually an improvement or degradation. The results show that with minute parameter changes made to the algorithms, there was growth in the attacker's role, since it is able to win games. Implementation of the adversarial learning by the introduction of the causative attack showed the algorithms are still able to defend the network according to their strengths

Intensive care organisation

Abstract: In the last two decennia, the mixed population general intensive care unit (ICU) with a ‘closed format’ setting has gained in favour compared to the specialized critical care units with an ‘open format’ setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/ trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (‘closed format’) next to its standard general mixed ICU

Transformation of health care and the new model of care in Saudi Arabia: Kingdom's Vision 2030

The Kingdom of Saudi Arabia espoused "Vision 2030" as a strategy for economic development and national growth. The vision demonstrated the Kingdom's objectives to become a pioneer nation globally by achieving three main goals: a vibrant society, a thriving economy, and an ambitious nation. To fulfill this, the Kingdom launched a national transformation program (NTP) as outlined in "vision 2030" in June 2016. The health care transformation is one of the eight themes of the NTP's. The history of health care facilities in the Kingdom is almost a century. Although the Kingdom has made notable progress in improving its population's health over recent decades, it needs to modernize the health care system to reach the "vision 2030" goal. This article aims to describe the new Model of Care (MOC) according to the recent Saudi health care transformation under the Kingdom's vision 2030. The MOC concept started with understanding the current state and collecting learnings. It is based on the six systems of care (SOC)- keeping well, planned procedure, women & children, urgent problems, chronic conditions, and the last phase of life. The SOC is cut across different "service layers" to support people's stay well and efficiently get them healthy again when they need care. The new MOC describes a total of forty-two interventions, of which twenty-seven split across the six SOC and the rest fifteen cut-across the multiple SOC. Implementation of all MOC interventions will streamline the Saudi health care system to embrace the Kingdom's "vision 2030"

Intensive care performance: how should we monitor performance in the future?

Abstract Intensive care faces economic challenges. Therefore evidence proving both effectiveness and efficiency, i.e. cost-effectiveness, of delivered care is needed. Today, the quality of care is an important issue in the health care debate. How do we measure quality of care, and how accurate and representative is this measurement? In the fol

Management of Hemodynamically Unstable Pelvic Ring Fractures

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants' demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group's time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6-20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury

Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study

Background: Early hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality. Methods: A 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected. Results: Four hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified. Conclusions: Despite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED