Tiny Machine Learning Environment: Enabling Intelligence on Constrained Devices

Running machine learning algorithms (ML) on constrained devices at the extreme edge of the network is problematic due to the computational overhead of ML algorithms, available resources on the embedded platform, and application budget (i.e., real-time requirements, power constraints, etc.). This required the development of specific solutions and development tools for what is now referred to as TinyML. In this dissertation, we focus on improving the deployment and performance of TinyML applications, taking into consideration the aforementioned challenges, especially memory requirements. This dissertation contributed to the construction of the Edge Learning Machine environment (ELM), a platform-independent open-source framework that provides three main TinyML services, namely shallow ML, self-supervised ML, and binary deep learning on constrained devices. In this context, this work includes the following steps, which are reflected in the thesis structure. First, we present the performance analysis of state-of-the-art shallow ML algorithms including dense neural networks, implemented on mainstream microcontrollers. The comprehensive analysis in terms of algorithms, hardware platforms, datasets, preprocessing techniques, and configurations shows similar performance results compared to a desktop machine and highlights the impact of these factors on overall performance. Second, despite the assumption that TinyML only permits models inference provided by the scarcity of resources, we have gone a step further and enabled self-supervised on-device training on microcontrollers and tiny IoT devices by developing the Autonomous Edge Pipeline (AEP) system. AEP achieves comparable accuracy compared to the typical TinyML paradigm, i.e., models trained on resource-abundant devices and then deployed on microcontrollers. Next, we present the development of a memory allocation strategy for convolutional neural networks (CNNs) layers, that optimizes memory requirements. This approach reduces the memory footprint without affecting accuracy nor latency. Moreover, e-skin systems share the main requirements of the TinyML fields: enabling intelligence with low memory, low power consumption, and low latency. Therefore, we designed an efficient Tiny CNN architecture for e-skin applications. The architecture leverages the memory allocation strategy presented earlier and provides better performance than existing solutions. A major contribution of the thesis is given by CBin-NN, a library of functions for implementing extremely efficient binary neural networks on constrained devices. The library outperforms state of the art NN deployment solutions by drastically reducing memory footprint and inference latency. All the solutions proposed in this thesis have been implemented on representative devices and tested in relevant applications, of which results are reported and discussed. The ELM framework is open source, and this work is clearly becoming a useful, versatile toolkit for the IoT and TinyML research and development community

The impact of COVID-19 on the mental health of Lebanese pharmacists: A national cross-sectional study

IntroductionThe COVID-19 pandemic has induced a global mental health crisis with variable consequences. This study aimed to assess the psychological impact of COVID-19 regarding anxiety, insomnia, depression, and response to trauma on pharmacists in Lebanon during COVID-19, and to identify factors contributing to psychological distress.MethodsThis was a cross-sectional study among pharmacists that involved the use of the 7-item Generalized Anxiety Disorder (GAD-7), 7-item Insomnia Severity Index (ISI), Patient Health Questionnaire 9-item depression module (PHQ-9), and Impact of Event Scale revised (IES-R) subscales. Descriptive statistical analyses were performed to determine the study distribution. The associations between the scores and the participants’ characteristics were assessed using the Chi-square test. Four binary logistic regression models were used to evaluate the association between the scores and the potential confounders, followed by four multivariable logistic regressions. An alpha of 0.05 was used to determine statistical significance.ResultsParticipants comprised 311 pharmacists from all Lebanese districts, of whom 251 (80.7%) were females and 181 (58.2%) aged between 26 and 35 years. The majority of the participants were community pharmacists (n = 178, 57.2%). A considerable proportion of participants had symptoms of anxiety (n = 128, 41.2%), insomnia (n = 64, 20.6%), depression (n = 157, 50.5%), and subjective stress (n = 227, 78.8%). Higher anxiety (aOR: 1.73, 95% CI: 1.08; 2.78, p-value: 0.02), higher depression (aOR: 3.06, 95% CI: 1.73; 5.39, p-value: 0.001), and higher stress (aOR: 1.86, 95 percent CI: 1.11; 3.14, p-value: 0.02) scores were significantly associated with pharmacists who reported that their work involves contact with infected/suspected COVID-19 patients. Interestingly, pharmacists who expressed concern about contracting COVID-19 infection had significantly higher anxiety (aOR: 2.35, 95% CI: 1.40; 3.94, p-value: 0.001) and higher depression scores (aOR: 2.64, 95% CI: 1.49; 4.67, p-value: 0.001) respectively.ConclusionThe preliminary results from pharmacists in Lebanon reflect increase in stress, burden, and frustration felt by pharmacists, creating a negative impact on their mental health and well-being during the global pandemic. As frontline healthcare workers, the role of pharmacists in the community should not be overlooked, and their mental health should be well investigated

Knowledge, attitude and practice of Lebanese community pharmacists with regard to self-management of low back pain

Purpose: To determine the knowledge, attitude and reported practice of Lebanese community pharmacists who advise persons who present with low back pain.Methods: This was a multi-center cross-sectional study conducted in over 300 community pharmacies across Lebanon from December 2017 to May 2018. Pharmacists working at a community pharmacy were considered eligible, and those who volunteered to participate completed the questionnaire. The questionnaire was designed for self-completion by the pharmacist and included demographic questions about the respondent, questions that assessed knowledge and attitude toward low back pain, and questions about treatment to reflect and characterize the nature of practice. The primary outcome was to determine the knowledge, attitude and reported practice of the Lebanese pharmacists advising people who presented with low back pain. The secondary outcome was to assess factors that affect knowledge, attitude, and practice.Results: The response of 320 community pharmacists was analysed. The proportion of pharmacists with good knowledge about low back pain (51. 7 %) was slightly higher than those with poor knowledge (48. 3 %). Oral therapy was the most prescribed dosage form for back pain compared to local patch and cream. Among oral dosage forms, non-steroidal anti-inflammatory drugs were the most prescribed medications (42 %). Of the patients’ referral to the physician if necessary, 73.1 % of the referrals were by pharmacists.Conclusion: Community pharmacists in Lebanon demonstrate an acceptable level of knowledge of back pain, yet major gaps still exist, particularly in terms of the quality of advice. Hence, more education is needed to provide better quality of advice. Keywords: Attitude, Knowledge, Low back pain, Reported practice, Quality of advic

Role of Sucralfate in Promoting Healing of Post Band Variceal Ulcer

Background: The role of Sucralfate to be slightly superior to placebo in accelerating the healing process of oesophageal ulcerations after sclerotherapy had been elicited. Currently, its role in the healing process of oesophageal ulcerations after ligation has not been clarified.Objectives: to assess the use of sucralfate after variceal band ligation and to clarify its role in healing of post variceal band ligation ulcers. Methods: Sixty two patients with oesophageal varices eligible for band ligation represented the population of the study. The patients were allocated into two groups: Group I (study group): Included 31 patients in whom endoscopic band ligation was done then received sucralfate 1 gm every 6 hours for 2 weeks. Group II (control group): Included 31 patients in whom endoscopic band ligation was done then received placebo every 6 hours for 2 weeks.  Results: During the follow up endoscopy, 2 weeks after band ligation we observed that: All post-banding ulcers in both groups were superficial, 12 patients (38.7%) in the study group developed post-band ulcers versus 23 patients (74.2%) in the control group with a statistically significant difference (p-value, 0.005). Also, there was a statistically significant difference between both groups regarding the size of the post banding ulcers as the mean size of ulcers was 2.7 mm ± 1.2 in study group whereas it was 3.8mm ± 1.7 in control group with P value (0.043).Conclusion: Sucralfate has a significant role in decreasing the rate of occurrence of variceal post-banding ulcers and as well their size.Key words: Endoscopic variceal band ligation (EVL); Sucralfate; Clinical pharmac

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

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

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

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)