Foundational Theory for Understanding Policy Routing Dynamics

In this paper we introduce a theory of policy routing dynamics based on fundamental axioms of routing update mechanisms. We develop a dynamic policy routing model (DPR) that extends the static formalism of the stable paths problem (introduced by Griffin et al.) with discrete synchronous time. DPR captures the propagation of path changes in any dynamic network irrespective of its time-varying topology. We introduce several novel structures such as causation chains, dispute fences and policy digraphs that model different aspects of routing dynamics and provide insight into how these dynamics manifest in a network. We exercise the practicality of the theoretical foundation provided by DPR with two fundamental problems: routing dynamics minimization and policy conflict detection. The dynamics minimization problem utilizes policy digraphs, that capture the dependencies in routing policies irrespective of underlying topology dynamics, to solve a graph optimization problem. This optimization problem explicitly minimizes the number of routing update messages in a dynamic network by optimally changing the path preferences of a minimal subset of nodes. The conflict detection problem, on the other hand, utilizes a theoretical result of DPR where the root cause of a causation cycle (i.e., cycle of routing update messages) can be precisely inferred as either a transient route flap or a dispute wheel (i.e., policy conflict). Using this result we develop SafetyPulse, a token-based distributed algorithm to detect policy conflicts in a dynamic network. SafetyPulse is privacy preserving, computationally efficient, and provably correct.National Science Foundation (CISE/CCF 0820138, CISE/CSR 0720604, CISE/CNS 0524477, CNS/ITR 0205294, CISE/EIA RI #0202067

TCP over CDMA2000 Networks: A Cross-Layer Measurement Study

Modern cellular channels in 3G networks incorporate sophisticated power control and dynamic rate adaptation which can have a significant impact on adaptive transport layer protocols, such as TCP. Though there exists studies that have evaluated the performance of TCP over such networks, they are based solely on observations at the transport layer and hence have no visibility into the impact of lower layer dynamics, which are a key characteristic of these networks. In this work, we present a detailed characterization of TCP behavior based on cross-layer measurement of transport, as well as RF and MAC layer parameters. In particular, through a series of active TCP/UDP experiments and measurement of the relevant variables at all three layers, we characterize both, the wireless scheduler in a commercial CDMA2000 network and its impact on TCP dynamics. Somewhat surprisingly, our findings indicate that the wireless scheduler is mostly insensitive to channel quality and sector load over short timescales and is mainly affected by the transport layer data rate. Furthermore, we empirically demonstrate the impact of the wireless scheduler on various TCP parameters such as the round trip time, throughput and packet loss rate

On the Interaction between TCP and the Wireless Channel in CDMA2000 Networks

In this work, we conducted extensive active measurements on a large nationwide CDMA2000 1xRTT network in order to characterize the impact of both the Radio Link Protocol and more importantly, the wireless scheduler, on TCP. Our measurements include standard TCP/UDP logs, as well as detailed RF layer statistics that allow observability into RF dynamics. With the help of a robust correlation measure, normalized mutual information, we were able to quantify the impact of these two RF factors on TCP performance metrics such as the round trip time, packet loss rate, instantaneous throughput etc. We show that the variable channel rate has the larger impact on TCP behavior when compared to the Radio Link Protocol. Furthermore, we expose and rank the factors that influence the assigned channel rate itself and in particular, demonstrate the sensitivity of the wireless scheduler to the data sending rate. Thus, TCP is adapting its rate to match the available network capacity, while the rate allocated by the wireless scheduler is influenced by the sender's behavior. Such a system is best described as a closed loop system with two feedback controllers, the TCP controller and the wireless scheduler, each one affecting the other's decisions. In this work, we take the first steps in characterizing such a system in a realistic environment

TCP over CDMA2000 Networks: A Cross-Layer Measurement Study

Modern cellular channels in 3G networks incorporate sophisticated power control and dynamic rate adaptation which can have significant impact on adaptive transport layer protocols, such as TCP. Though there exists studies that have evaluated the performance of TCP over such networks, they are based solely on observations at the transport layer and hence have no visibility into the impact of lower layer dynamics, which are a key characteristic of these networks. In this work, we present a detailed characterization of TCP behavior based on cross-layer measurement of transport layer, as well as RF and MAC layer parameters. In particular, through a series of active TCP/UDP experiments and measurement of the relevant variables at all three layers, we characterize both, the wireless scheduler and the radio link protocol in a commercial CDMA2000 network and assess their impact on TCP dynamics. Somewhat surprisingly, our findings indicate that the wireless scheduler is mostly insensitive to channel quality and sector load over short timescales and is mainly affected by the transport layer data rate. Furthermore, with the help of a robust correlation measure, Normalized Mutual Information, we were able to quantify the impact of the wireless scheduler and the radio link protocol on various TCP parameters such as the round trip time, throughput and packet loss rate

Declarative Transport: No More Transport Protocols to Design, Only Policies to Specify

Transport protocols are an integral part of the inter-process communication (IPC) service used by application processes to communicate over the network infrastructure. With almost 30 years of research on transport, one would have hoped that we have a good handle on the problem. Unfortunately, that is not true. As the Internet continues to grow, new network technologies and new applications continue to emerge putting transport protocols in a never-ending flux as they are continuously adapted for these new environments. In this work, we propose a clean-slate transport architecture that renders all possible transport solutions as simply combinations of policies instantiated on a single common structure. We identify a minimal set of mechanisms that once instantiated with the appropriate policies allows any transport solution to be realized. Given our proposed architecture, we contend that there are no more transport protocols to design—only policies to specify. We implement our transport architecture in a declarative language, Network Datalog (NDlog), making the specification of different transport policies easy, compact, reusable, dynamically configurable and potentially verifiable. In NDlog, transport state is represented as database relations, state is updated/queried using database operations, and transport policies are specified using declarative rules. We identify limitations with NDlog that could potentially threaten the correctness of our specification. We propose several language extensions to NDlog that would significantly improve the programmability of transport policies.NSF (CISE/CNF 0820138, CISE/CNS 070604, CISE/CNS 0524477, CNS/ITR 0205294, CISE/EIA RI 0202067

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

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

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