An Exploratory Study of Response Shift in Health-Related Quality of Life and Utility Assessment Among Patients with Osteoarthritis Undergoing Total Knee Replacement Surgery in a Tertiary Hospital in Singapore

AbstractObjectiveTo investigate the influence of response shift (RS) on health-related quality of life (HRQOL) and utility assessment among patients undergoing total knee replacement.MethodsConsenting patients undergoing total knee replacement were interviewed to determine their HRQOL by using the six-dimensional health state short form, derived from SF-36, and the EuroQol five-dimensional questionnaire at baseline (pretest 1) and the six-dimensional health state short form, derived from SF-36, at 6 (pretest 2) and 18 months after surgery (post-test). RS was studied by using a “then-test” approach by contacting participants 18 months after surgery and asking them to evaluate their HRQOL at baseline (then-test 1) and at 6 (then-test 2) and 18 months after surgery. RS was calculated as the score difference between pretest and then-test scores for a given time point. Relationships between RS and external variables were explored by using univariate and multiple liner regression analyses.ResultsIn 74 subjects (63% response rate, median age 68 years), median (interquantile range) six-dimensional health state short form, derived from SF-36, scores for then-tests at baseline (0.48 [0.42–0.49]) and at 6 months (0.72 [0.66–0.79]) after surgery were significantly different from respective pretest scores (0.61 [0.58–0.68] at baseline, P = 0.000; 0.69 [0.63–0.72] at 6 months, P = 0.000), showing RS at both time points. RS at baseline (0.14 [0.08–0.20]) was significantly larger than that at 6 months (−0.05 [0.14 to 0.00], P = 0.000). EuroQol five-dimensional questionnaire pretest and then-test scores at baseline also differed significantly (0.69 [0.17–0.73] vs. −0.18 [−0.23 to 0.00], P = 0.000). RS at baseline was not affected by assessed demographic or medical variables. RS at 6 months was greater in subjects with more years of education (16% of variance in multiple liner regression, P < 0.01).ConclusionRS was present and impacted HRQOL and utility assessment among patients undergoing total knee replacement before and 6 months after surgery

Kalman Filter Models for the Prediction of Individualised Thermal Work Strain

It is important to monitor and assess the physiological strain of individuals working in hot environments to avoid heat illness and performance degradation. The body core temperature (Tc) is a reliable indicator of thermal work strain. However, measuring Tc is invasive and often inconvenient and impractical for real-time monitoring of workers in high heat strain environments. Seeking a better solution, the main aim of the present study was to investigate the Kalman filter method to enable the estimation of heat strain from non-invasive measurements (heart rate (HR) and chest skin temperature (ST)) obtained ‘online’ via wearable body sensors. In particular, we developed two Kalman filter models. First, an extended Kalman filter (EFK) was implemented in a cubic state space modelling framework (HR versus Tc) with a stage-wise, autoregressive exogenous model (incorporating HR and ST) as the time update model. Under the second model, the online Kalman filter (OFK) approach builds up the time update equation depending only on the initial value of Tc and the latest value of the exogenous variables. Both models were trained and validated using data from laboratory- and outfield-based heat strain profiling studies in which subjects performed a high intensity military foot march. While both the EKF and OKF models provided satisfactory estimates of Tc, the results showed an overall superior performance of the OKF model (overall root mean square error, RMSE = 0.31°C) compared to the EKF model (RMSE = 0.45°C)

Maritime threat response

This report was prepared by Systems Engineering and Analysis Cohort Nine (SEA-9) Maritime Threat Response, (MTR) team members.Background: The 2006 Naval Postgraduate School (NPS) Cross-Campus Integrated Study, titled “Maritime Threat Response” involved the combined effort of 7 NPS Systems Engineering students, 7 Singaporean Temasek Defense Systems Institute (TDSI) students, 12 students from the Total Ship Systems Engineering (TSSE) curriculum, and numerous NPS faculty members from different NPS departments. After receiving tasking provided by the Wayne E. Meyer Institute of Systems Engineering at NPS in support of the Office of the Assistant Secretary of Defense for Homeland Defense, the study examined ways to validate intelligence and respond to maritime terrorist attacks against United States coastal harbors and ports. Through assessment of likely harbors and waterways to base the study upon, the San Francisco Bay was selected as a representative test-bed for the integrated study. The NPS Systems Engineering and Analysis Cohort 9 (SEA-9) Maritime Threat Response (MTR) team, in conjunction with the TDSI students, used the Systems Engineering Lifecycle Process (SELP) [shown in Figure ES-1, p. xxiii ] as a systems engineering framework to conduct the multi-disciplinary study. While not actually fabricating any hardware, such a process was well-suited for tailoring to the team’s research efforts and project focus. The SELP was an iterative process used to bound and scope the MTR problem, determine needs, requirements, functions, and to design architecture alternatives to satisfy stakeholder needs and desires. The SoS approach taken [shown in Figure ES-2, p. xxiv ]enabled the team to apply a systematic approach to problem definition, needs analysis, requirements, analysis, functional analysis, and then architecture development and assessment.In the twenty-first century, the threat of asymmetric warfare in the form of terrorism is one of the most likely direct threats to the United States homeland. It has been recognized that perhaps the key element in protecting the continental United States from terrorist threats is obtaining intelligence of impending attacks in advance. Enormous amounts of resources are currently allocated to obtaining and parsing such intelligence. However, it remains a difficult problem to deal with such attacks once intelligence is obtained. In this context, the Maritime Threat Response Project has applied Systems Engineering processes to propose different cost-effective System of Systems (SoS) architecture solutions to surface-based terrorist threats emanating from the maritime domain. The project applied a five-year time horizon to provide near-term solutions to the prospective decision makers and take maximum advantage of commercial off-the-shelf (COTS) solutions and emphasize new Concepts of Operations (CONOPS) for existing systems. Results provided insight into requirements for interagency interactions in support of Maritime Security and demonstrated the criticality of timely and accurate intelligence in support of counterterror operations.This report was prepared for the Office of the Assistant Secretary of Defense for Homeland DefenseApproved for public release; distribution is unlimited

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

Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved

The number of patients with gastroesophageal problems taking proton pump inhibitors (PPIs) is increasing. Several studies suggested a possible association between PPIs and fracture risk, especially hip fractures, but the relationship remains contentious. This review aimed to investigate the longitudinal studies published in the last five years on the relationship between PPIs and fracture risk. The mechanism underlying this relationship was also explored. Overall, PPIs were positively associated with elevated fracture risk in multiple studies (n = 14), although some studies reported no significant relationship (n = 4). Increased gastrin production and hypochlorhydria are the two main mechanisms that affect bone remodeling, mineral absorption, and muscle strength, contributing to increased fracture risk among PPI users. As a conclusion, there is a potential relationship between PPIs and fracture risks. Therefore, patients on long-term PPI treatment should pay attention to bone health status and consider prophylaxis to decrease fracture risk