Challenge of forecasting demand of medical resources and supplies during a pandemic: A comparative evaluation of three surge calculators for COVID-19.

Ever since the World Health Organization (WHO) declared the new coronavirus disease 2019 (COVID-19) as a pandemic, there has been a public health debate concerning medical resources and supplies including hospital beds, intensive care units (ICU), ventilators and protective personal equipment (PPE). Forecasting COVID-19 dissemination has played a key role in informing healthcare professionals and governments on how to manage overburdened healthcare systems. However, forecasting during the pandemic remained challenging and sometimes highly controversial. Here, we highlight this challenge by performing a comparative evaluation for the estimations obtained from three COVID-19 surge calculators under different social distancing approaches, taking Lebanon as a case study. Despite discrepancies in estimations, the three surge calculators used herein agree that there will be a relative shortage in the capacity of medical resources and a significant surge in PPE demand if the social distancing policy is removed. Our results underscore the importance of implementing containment interventions including social distancing in alleviating the demand for medical care during the COVID-19 pandemic in the absence of any medication or vaccine. The paper also highlights the value of employing several models in surge planning.

Resistin-like molecule-ß (RELM-ß) targets airways fibroblasts to effect remodelling in asthma: from mouse to man.

BACKGROUND: RELM-ß has been implicated in airways inflammation and remodelling in murine models. Its possible functions in human airways are largely unknown. The aim was to address the hypothesis that RELM-ß plays a role in extracellular matrix deposition in asthmatic airways. METHODS: The effects of RELM-ß gene deficiency were studied in a model of allergen exposure in mice sensitised and challenged with Aspergillus fumigatus (Af). RELM-ß expression was investigated in bronchial biopsies from asthmatic patients. Direct regulatory effects of RELM-ß on human lung fibroblasts were examined using primary cultures and the MRC5 cell line in vitro. RESULTS: Sensitisation and challenge of wild-type mice with Af-induced release of RELM-ß with a time course coincident with that of procollagen in the airways. Af-induced expression of mRNA encoding some, but not all ECM in the lung parenchyma was attenuated in RELM-ß-/- mice. RELM-ß expression was significantly increased in the bronchial submucosa of human asthmatics compared with controls, and its expression correlated positively with that of fibronectin and α-smooth muscle actin. In addition to epithelial cells, macrophages, fibroblasts and vascular endothelial cells formed the majority of cells expressing RELM-ß in the submucosa. Exposure to RELM-ß increased TGF-ß1, TGF-ß2, collagen I, fibronectin, smooth muscle α-actin, laminin α1, and hyaluronan and proteoglycan link protein 1 (Hapl1) production as well as proliferation by human lung fibroblasts in vitro. These changes were associated with activation of ERK1/2 in MRC5 cells. CONCLUSION: The data are consistent with the hypothesis that elevated RELM-ß expression in asthmatic airways contributes to airways remodelling at least partly by increasing fibroblast proliferation and differentiation with resulting deposition of extracellular matrix proteins.

Pathogenicity of H5N8 avian influenza virus in chickens and in duck breeds and the role of MX1 and IFN-α in infection outcome and transmission to contact birds.

This study examined the pathogenicity, immunogenicity, and transmission potential of the H5N8 HPAI clade 2.3.4.4b virus in three breeds of ducks and in broiler chickens. Chickens, Muscovy, Pekin, and Mallard ducks (n = 10) received a dose of 6 log10 EID50 of HPAIV H5N8 directly. Nine contact chickens were introduced to each group on the day of infection. All infected chickens died, with MDT of 7.6 days. Muscovy and Pekin ducks died by 11.1% and 10%, respectively, with MDTs of 7 and 6 days. No Mallards died but showed more severe clinical disease than Pekin ducks. Mallards had the highest MX1 gene expression in the lung and spleen and IFN-α in the spleen. MX1 expression levels were lower in the spleen and lung of Pekin ducks, in the spleen of chickens and in the lung of Muscovy ducks than in noninfected controls. However, viral shedding was higher in ducks than in chickens and was highest in Mallards. 66.7% of chickens placed in contact with infected chickens died and 77.8% of in-contact chickens to infected three duck breeds died. In conclusion, there was a diversity in sensitivity and immunogenicity for HPAIV H5N8 among duck breeds, resulting in diverse infection outcomes and transmissibility to contacts. This study provides duck/chicken interface models for HPAIV transmission to poultry.

Resistin-like molecule-ß is a human airway remodelling mediator.

Though implicated in vascular remodelling, a role for the resistin-like molecule (RELM)-ß in human airway remodelling remains unexplored. We hypothesised that RELM-ß expression is increased in the airways of asthmatics and regulates airways epithelial cell function. Expression of RELM-ß in the bronchial mucosa and its concentrations in bronchoalveolar lavage (BAL) fluid from asthmatics and controls were measured by immunohistochemistry and ELISA, respectively. Proliferation assays, Western blotting, ELISA and real-time PCR were employed to detect effects of RELM-ß on airways epithelial cells. RELM-ß expression was increased in the bronchial mucosa and BAL fluid of asthmatics compared with controls. In the asthmatics, the numbers of mucosal RELM-ß+ cells correlated inversely with forced expiratory volume in 1 s (r=-0.531, p=0.016), while the numbers of epithelial RELM-ß+ cells correlated positively with those of mucin (MUC)5AC+ cells. In vitro, interleukin-13 enhanced RELM-ß expression by primary human airways epithelial cells, while RELM-ß itself acted on these cells to induce proliferation, expression of MUC5AC, extracellular signal-regulated kinase (ERK)/mitogen-activated protein kinase (MAPK)-phosphatidylinositol 3-kinase (PI3K)/Akt phosphorylation and elevated expression of transforming growth factor-ß2, epidermal growth factor and vascular endothelial growth factor. RELM-ß has the potential to contribute to airway remodelling in diseases such as asthma by acting on epithelial cells to increase proliferation, mucin and growth factor production, at least partly via ERK/MAPK-PI3K/Akt signalling pathways.

Pareidolia in Schizophrenia and Bipolar Disorder.

While there are many studies on pareidolia in healthy individuals and patients with schizophrenia, to our knowledge, there are no prior studies on pareidolia in patients with bipolar disorder. Accordingly, in this study, we, for the first time, measured pareidolia in patients with bipolar disorder (N = 50), and compared that to patients with schizophrenia (N = 50) and healthy controls (N = 50). We have used (a) the scene test, which consists of 10 blurred images of natural scenes that was previously found to produce illusory face responses and (b) the noise test which had 32 black and white images consisting of visual noise and 8 images depicting human faces; participants indicated whether a face was present on these images and to point to the location where they saw the face. Illusory responses were defined as answers when observers falsely identified objects that were not on the images in the scene task (maximum illusory score: 10), and the number of noise images in which they reported the presence of a face (maximum illusory score: 32). Further, we also calculated the total pareidolia score for each task (the sum number of images with illusory responses in the scene and noise tests). The responses were scored by two independent raters with an excellent congruence (kappa > 0.9). Our results show that schizophrenia patients scored higher on pareidolia measures than both healthy controls and patients with bipolar disorder. Our findings are agreement with prior findings on more impaired cognitive processes in schizophrenia than in bipolar patients.

Do Different Types of Intelligence and Its Implicit Theories Vary Based on Gender and Grade Level?

The current study investigated correlations among gifted students' academic performance; emotional, social, analytical, creative, and practical intelligence; and their implicit theories of intelligence. Furthermore, it studied the effect of gender and grade on these variables. The participants included 174 gifted fifth (41.4%) and sixth (58.6%) grade students, comprising 53.4% male and 46.6% female. The following analytical, creative, and practical intelligence tests were administered: Aurora Battery, the emotional intelligence scale, the implicit theories of intelligence scale, and an assessment scale of students' performances. The results revealed significant correlations among academic performance, kinds of intelligence, and implicit theories of intelligence. There were no significant differences between the male and female students in these measures. There were, however, significant differences between the fifth and sixth grade students, with the sixth-grade students showing higher levels of all kinds of intelligence, except emotional intelligence. Moreover, the results indicated that the intelligence measures were non-significantly affected by either gender or gender-grade interaction. Overall, our results showed that most types of intelligence are related to giftedness, and that there were no gender differences among gifted students on measures of intelligence.

The Impact of Different Types of Abuse on Depression.

Despite a large amount of research on depression and abuse, there is still a controversy on how abuse is measured and on childhood trauma's effect on the physiological function of adults. Here, we attempt to clarify the relationship between different types of abuse and depression while focusing on childhood abuse. This article, unlike prior research, provides an overview that addresses physical, psychological, and sexual abuse and their psychological impact on the victims. Results show that abuse is a vulnerability factor for a variety of mental and physical health problems and that psychological abuse is strongly associated with depression. More research is needed to understand (a) the role of abuse in the development and maintenance of depression and, in particular, longitudinal studies that also account for the large number of risk and protective factors that influence this relationship and (b) how different types of abuse can influence response to treatment among survivors with depression, in order to provide effective trauma-focused approaches to manage depressive symptoms.

Investigating Principal Working Memory Features in Generalized, Panic, and Social Anxiety Spectrum Disorders.

Anxiety spectrum disorders are characterized by excessive and uncontrollable worrying about potential negative events in the short- and long-term future. Various reports linked anxiety spectrum disorders with working memory (WM) deficits despite conflicting results stemming from different study approaches. It remains unclear, however, how different anxiety spectrum disorders such as generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD), differ in WM function. In this study, we utilized verbal, numerical, and sequential evaluations of WM to cover most possible facets of the WM data space. We used principal component analysis to extract the uncorrelated/whitened components of WM based on these measures. We evaluated medication-free patients with GAD, SAD, and PD patients as well as matched healthy individuals using a battery that measures WM duration and load. We found that patients with GAD and SAD, but not PD, exhibited poor performance only in the WM principal component that represents maintenance. There were no other significant differences between the four groups. Further, different WM components significantly predicted the severity of anxiety symptoms in the groups. We explored the clinical utility of WM components for differentiating patients with anxiety spectrum disorders from healthy individuals. By only using the WM components that represent maintenance and encoding, we managed to differentiate patients from controls in 84% of cases. For the first time, we present multiple novel approaches to examine cognitive function and design cognitive screening, and potentially diagnostics, for psychiatric disorders.

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.

A novel technique for fascial fixation of laparoscopic adjustable gastric band ports.

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons.

BACKGROUND: This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. METHODS: From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. RESULTS: Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency. CONCLUSION: Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

The impact of laparoscopy on bariatric surgery.

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

Removal of an infected ventricular septal defect patch after tetralogy repair.

An infected Dacron ventricular septal defect (VSD) patch was removed 15 years after repair of tetralogy of Fallot. Cardiopulmonary bypass was not utilized, and no significant hemorrhage was encountered. The patient recovered uneventfully and continues to do well 7 years after surgery without infection or residual VSD.

Management of giant coronary artery aneurysm with fistulization into the right atrium.

A giant right coronary artery aneurysm communicating with the right atrium is reported. Its diagnosis using echocardiography, computed tomography of the chest, and angiography is illustrated. The operative management of this rare cardiac pathology is described. The role of operation in such a large aneurysm is emphasized.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred.

BACKGROUND: There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery. METHODS: Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included. RESULTS: The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration. CONCLUSION: Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

[Extracardiac pulmonary bypass in the treatment of tricuspid atresia]. / Dérivation bicavo-pulmonaire extracardiaque dans le traitement de l'atrésie tricuspide.

Six patients aged 1.5 to 4 years with type 13 tricuspid atresia underwent extracardiac bicavopulmonary repair. This corrective procedure comprises control of palliative aorto-pulmonary anastomosis, the construction of an anastomosis between the superior vena cava and right pulmonary artery and the interposition of an extracardiac tube of autologous pediculated pericardium between the inferior vena cava and the main pulmonary artery. This tube, fashioned from a rectangular flap, remains attached along its right border, conserving its vascular pedicle with the pericardium. Its diameter is calibrated to that of the inferior vena cava. The postoperative course was uncomplicated: all children survived. Assisted respiration was discontinued 24 to 36 hours after surgery, and the pleural drains withdrawn after 48 to 72 hours. The rhythm remained sinusal. Central venous pressure ranged from 8 to 12 mmHg. Peripheral arterial situation was over 95%. At follow-up at 3 to 15 months, the children were very active, reflecting good exercise capacity. Holter monitoring was normal. Saturation was 94 to 97%. Doppler echocardiography showed laminar blood flow. This technique insures good venous drainage without any prosthetic thrombogenic material. In addition, the pediculated pericardium conserves a potential for growth, justifying its use in small children. Long-term evaluation is essential but the initial results are encouraging and encourage perseverance with this method.

[Subarachnoid hematoma and spinal anesthesia]. / Hématome sous-arachnoïdien et rachianesthésie.

Two cases of spinal subarachnoid haematoma occurring after spinal anaesthesia are reported. In the first case, lumbar puncture was attempted three times in a 81-year-old man; spinal anaesthesia trial was than abandoned, and the patient given a general anaesthetic. He was given prophylactic calcium heparinate soon after surgery. On the fourth day, the patient became paraparetic. Radioculography revealed a blockage between T10 and L3. Laminectomy was performed to remove the haematoma, but the patient recovered motor activity only very partially. The second case was a 67-year-old man, in whom spinal anaesthesia was easily carried out. He was also given prophylactic calcium heparinate soon after surgery. On the fourth postoperative day, pulmonary embolism was suspected. Heparin treatment was then started. Twelve hours later, lumbar and bilateral buttock pain occurred, which later spread to the neck. On the eighth day, the patient had neck stiffness and two seizures. Emergency laminectomy was carried out, which revealed a subarachnoid haematoma spreading to a level higher than T6 and below L1, with no flow of cerebrospinal fluid, and a non pulsatile spinal cord. Surgery was stopped. The patient died on the following day. Both these cases are similar to those previously reported and point out the role played by anticoagulants. Because early diagnosis of spinal cord compression is difficult, the prognosis is poor, especially in case of paraplegia.

The immunoprotective Anaplasma marginale major surface protein 2 is encoded by a polymorphic multigene family.

An Anaplasma marginale Florida msp-2 gene was cloned and expressed in Escherichia coli. Pulsed-field gel electrophoresis and Southern blot analysis revealed the presence of multiple msp-2 gene copies that were widely distributed throughout the chromosomes of all three strains examined. Genomic polymorphism among copies was greatest in the 5' end of msp-2 but also occurred in 3' regions. The presence of gene-copy-specific epitopes was indicated by the reactivity of the cloned msp-2 copy with some, but not all, monoclonal antibodies that bound native MSP-2. Multiple antigenically distinct MSP-2 molecules were expressed within strains and were coexpressed by individual A. marginale organisms. These results suggest that expression of polymorphic msp-2 gene copies is responsible for the significant percentages of A. marginale organisms within strains that do not react with individual anti-MSP-2 monoclonal antibodies. Sequence analysis revealed highly significant MSP-2 homology with two rickettsial surface proteins, A. marginale MSP-4 and Cowdria ruminantium MAP-1. Immunization with MSP-4 has been shown to induce protective immunity in a manner similar to that of immunization with MSP-2. These findings support the hypothesis that A. marginale surface proteins are targets of protective immune responses but are antigenically polymorphic.

Contralateral internal jugular vein interposition for salvage of a functioning arteriovenous fistula.

Outflow obstruction in patients with hemodialysis access can cause venous hypertension and jeopardize the patency of the access site. Numerous surgical procedures have been described to decompress an occluded subclavian vein. In this report, we describe the use of the contralateral internal jugular vein as a bypass conduit to decompress an occluded brachiocephalic vein in a patient whose dialysis was dependent on this vein access.