ENHANCING THE OPERATIONAL RESILIENCE OF CYBER- MANUFACTURING SYSTEMS (CMS) AGAINST CYBER-ATTACKS

Cyber-manufacturing systems (CMS) are interconnected production environments comprised of complex and networked cyber-physical systems (CPS) that can be instantiated across one or many locations. However, this vision of manufacturing environments ushers in the challenge of addressing new security threats to production systems that still contain traditional closed legacy elements. The widespread adoption of CMS has come with a dramatic increase in successful cyber-attacks. With a myriad of new targets and vulnerabilities, hackers have been able to cause significant economic losses by disrupting manufacturing operations, reducing outgoing product quality, and altering product designs. This research aims to contribute to the design of more resilient cyber-manufacturing systems. Traditional cybersecurity mechanisms focus on preventing the occurrence of cyber-attacks, improving the accuracy of detection, and increasing the speed of recovery. More often neglected is addressing how to respond to a successful attack during the time from the attack onset until the system recovery. We propose a novel approach that correlates the state of production and the timing of the attack to predict the effect on the manufacturing key performance indicators. Then a real-time decision strategy is deployed to select the appropriate response to maintain availability, utilization efficiency, and a quality ratio above degradation thresholds until recovery. Our goal is to demonstrate that the operational resilience of CMS can be enhanced such that the system will be able to withstand the advent of cyber-attacks while remaining operationally resilient. This research presents a novel framework to enhance the operational resilience of cyber-manufacturing systems against cyber-attacks. In contrast to other CPS where the general goal of operational resilience is to maintain a certain target level of availability, we propose a manufacturing-centric approach in which we utilize production key performance indicators as targets. This way we adopt a decision-making process for security in a way that is aligned with the operational strategy and bound to the socio-economic constraints inherent to manufacturing. Our proposed framework consists of four steps: 1) Identify: map CMS production goals, vulnerabilities, and resilience-enhancing mechanisms; 2) Establish: set targets of performance in production output, scrap rate, and downtime at different states; 3) Select: determine which mechanisms are needed and their triggering strategy, and 4) Deploy: integrate into the operation of the CMS the selected mechanisms, threat severity evaluation, and activation strategy. Lastly, we demonstrate via experimentation on a CMS testbed that this framework can effectively enhance the operational resilience of a CMS against a known cyber-attack

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research