'Nowhere and no one is safe': spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023

BACKGROUND

Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel's adherence to International Humanitarian Law (IHL).

METHODS

We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran's I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered.

RESULTS

During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran's I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance.

CONCLUSION

Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials' statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.

A new biomaterial of nanofibers with the microalga Spirulina as scaffolds to cultivate with stem cells for use in tissue engineering

The association of stem cells (SCs) with biomaterials promises to be the protagonist for future regenerative medicine in the treatment of tissue and organ lesions. Stem cells were cultivated in scaffolds constructed by the electrospinning technique, using poly-D,L-lactic acid (PDLLA) associated or not with Spirulina biomass (PDLLA/Sp), which has bioactive components of interest for tissue engineering (TE). Physicochemical analyses were performed, such as morphology, fiber diameter, degradability, residual solvent, roughness, contact angle with water, among others. SCs adhesion, proliferation and scaffold cytotoxicity were also evaluated. Nanofibers without beads and with characteristics similar to the natural extracellular matrix (ECM) in terms of mechanical and topographical properties were obtained. In biological tests it was found that SCs adhered more and had greater viability in the PDLLA/Sp molds, when compared with the PDLLA scaffolds. The scaffolds were shown to be atoxic for the SCs. It can be concluded that the scaffolds developed in this work have the characteristics to be a new biomaterial suitable for use in TE.

Recombinant factor VIIa in trauma patients without coagulation disorders

Recombinant activated factor VIIa (rFVIIa) has many clinical applications for patients with congenital bleeding disorders and in a variety of clinical settings. Additional studies in the future are ongoing and should provide the clinical anesthesiologist an additional option during certain bleeding states. Specific recommendations as to timing of administration and frequent monitoring of ionized calcium status are suggested at this time. Optimization of fibrinogen levels, platelet levels, pH, and body temperature will enhance efficacy of rFVIIa.

The beneficial impact of temporary porto-caval shunt in orthotopic liver transplantation: a single center analysis

The use of temporary porto-caval shunt (TPCS) has been shown to improve hemodynamic stability and renal function in patients undergoing orthotopic liver transplantation (OLT). We evaluated the impact of TPCS in OLT and analyzed the differences according to model for end-stage liver disease (MELD), donor risk index (DRI) and D-MELD. This is a retrospective single-center analysis of 148 consecutive OLT. Fifty-eight OLT were performed using TPCS and 90 without TPCS. Donor and recipient data with pre-OLT, intraoperative and postoperative variables were reviewed. Overall graft survival was 89.9% at 3 months and 81.7% at 1 year. Graft survival at 3 months and 1 year was 93.1% and 79.2%, respectively, in TPCS group versus 85.6% and 82.2%, respectively, in non-TPCS group (P = NS). Intraoperative packed red blood cells requirement was lower in TPCS group (7.5 ± 5.8 vs. 12.2 ± 14.2, P = 0.006) and non-TPCS group required higher intraoperative total dose of phenylephrine (16% vs. 28%, P = 0.04). TPCS group had lower 30-day postoperative mortality (1.7% vs. 10%, P = 0.04), no difference was observed at 90 days. Graft survival was lower in patients with high DRI; in this group graft loss was higher at 1 month (25% vs. 4.3%, P = 0.005) and 3 months (25% vs. 4.3%, P = 0.005) when TPCS was not used. TPCS improves perioperative outcome, this being more evident when high-risk grafts are placed into high-risk patients.

The awake Glidescope intubation: an additional alternative to the difficult intubation

BACKGROUND

The incidence of difficult intubations has consistently remained between 8 and 9%. We found a novel approach to the difficult intubation using a Glidescope in the awake spontaneously breathing patient.

METHODS

In a difficult airway, the same approach for an awake fiberoptic intubation including excellent nerve blocks and sedation can be used with a Glidescope in the same fashion as a fiberoptic bronchoscope.

RESULTS

The skill level for the awake Glidescope appears to be less, making it a useful tool for emergency room physicians and critical care physicians when used for awake intubation. It is particularly useful for the patient who fails the airway exam and also has macroglossia.

CONCLUSION

This case report confirms that while not applicable to every patient, the awake Glidescope intubation does add to the previous existing armamentarium in this clinically challenging situation.

Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States

OBJECTIVE

Transesophageal echocardiography (TEE) during liver transplantation (LT) has been shown to be helpful in managing fluid therapy, monitoring myocardial function, and identifying intraoperative LT complications. The present study sought to investigate the current utilization of TEE by anesthesiologists during LT as well as issues of training and credentialing in this monitoring modality.

DESIGN

A survey distributed by electronic mail.

SETTING

LT centers in the United States in which more than 50 liver transplantation procedures were performed annually.

PARTICIPANTS

Survey respondents were contact persons in the LT divisions of the anesthesiology department of selected centers.

INTERVENTIONS

Data collection only.

MEASUREMENT AND MAIN RESULTS

A total of 40 high-volume LT centers were identified, and survey responses were received from 30 of those. Among 217 anesthesiologists, 86% performed TEE in some or all LT cases. Most users performed a limited-scope examination, although some performed a comprehensive TEE examination during LT. Most users acquired their TEE skills informally. Only 12% of users were board certified to perform TEE, and only 1 center reported having a policy related to credentialing requirements for TEE.

CONCLUSIONS

There is high utilization of intraoperative TEE by anesthesiologists to perform limited-scope examinations during LT cases. Training to perform such examinations is mostly informal, and credentialing processes are lacking. An opportunity exists to establish guidelines, training programs, and standards for quality assurance in the use of this valuable monitoring modality.

Early-onset scleral and corneal ectasias following low-dose mitomycin-C-augmented trabeculectomy in a uveitic glaucoma patient

A case of early-onset sclerolimbal ectasia following low-dose topical mitomycin C application during uveitic glaucoma surgery is reported. Intraoperative and postoperative clinical courses were consistent with sclerolimbal ectasia. Adjunctive utilization of intraoperative low-dose 0.02% mitomycin C for the management of chronic uveitic glaucoma patients who are under concomitant systemic immunosuppressive regimen may enhance the risk of subacute postoperative sclerolimbal ectasia. Mitomycin C concentrations < 0.02%, decreased scleral exposure time, and a strict informed consent policy are strongly recommended in this subset of uveitic patients.

Propofol: a new treatment strategy for refractory migraine headache

Migraine headache remains a treatment dilemma in headache clinics, pain clinics, and emergency departments throughout the country. In the late nineties, investigators reported that a standard hypnotic anesthetic, propofol (2,6 di-isopropylphenol), dramatically improved pain scores of patients suffering from refractory migraine headaches. Case reports over the last few years have appeared in the medical literature describing the use of propofol for migraine treatment. Dosing regimens are not clear, and mechanisms of action to terminate or markedly curtail ongoing intractable headaches are not described. This case report, of two hospitalized patients with refractory migraine, increases the existing literature on the use of propofol therapy in migraine headache. In the first case, three different scenarios and dosages are described in the same patient. In the second case, the use of different dosages of propofol is described. A self-reported scale was employed by the patients to determine the efficacy of propofol therapy. In the first case, the patient's self-reported migraine score was an average of 100/100 and decreased to 10/100. In the second case, the patient's self-reported migraine score improved from 92/100 to 40/100. We propose that the improvements in the self-reported migraine score in both patients after propofol therapy may be due to GABAA agonist effects and cerebral vasoconstriction.

Factorial validity of the Childhood Trauma Questionnaire in men and women

In an effort to confirm the factorial validity of the Childhood Trauma Questionnaire (CTQ) across sex, the items from the CTQ for 916 university students were subjected to confirmatory factor analysis. Results indicated that the factor structure for the CTQ was significantly different for men and women. For women, the items from the Physical Abuse subscale did not create a stable factor and thus appear not to be conceptually valid. Conversely, for men, the five-factor model provided a relatively good fit to the data. This investigation provides important information regarding sex differences in the factorial validity of the CTQ. Implications and future research directions are discussed.

Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis

PURPOSE

To report a case of systemic corticosteroid toxicity resulting from topical and periocular therapy.

METHODS

Treatment and follow-up of an 11-year-old male with uveitis are illustrated. Initial presentation of the patient was bilateral iridocyclitis, for which he was treated with prednisolone acetate 1% every 2 hours for 6 months. Subsequently, posterior uveitis developed, necessitating posterior subtenon injections.

RESULTS

After initial topical corticosteroid therapy, the patient developed a cushingoid habitus accompanied by increased lanugo hair, acanthosis nigricans, posterior subcapsular lens opacities, and increased intraocular pressure. Cushingoid stigmata worsened after administration of posterior subtenon injection of corticosteroids. The patient's truncal obesity worsened, and his linear growth stopped.

CONCLUSIONS

Systemic toxic effects may develop as a result of topical and local use of ophthalmic corticosteroid preparations in susceptible patients.

Novel multiagent chemotherapy for bone marrow relapse of pediatric acute lymphoblastic leukemia

BACKGROUND

Despite improvements in the treatment of pediatric acute lymphoblastic leukemia, approximately one in five patients will develop recurrent disease. The majority of these patients do not survive. This limited institution study sought to improve event-free survival (EFS) by intensification of chemotherapy.

PROCEDURE

Twenty-one patients with either an isolated marrow (n = 16) or a combined marrow and central nervous system relapse (n = 5) received treatment according to Children's Hospital of Philadelphia protocol CHP-540. Six patients had an initial remission of <36 months, and five patients had relapsed within 1 year of completion of phase III therapy. Induction and reinduction therapy consisted of idarubicin, vincristine, dexamethasone, asparaginase, and triple intrathecal chemotherapy. Consolidation and reconsolidation therapy employed high-dose cytarabine, etoposide, and asparaginase given in a sequential manner. Maintenance therapy included courses of high- or low-dose cytarabine followed by sequential etoposide and asparaginase pulse, moderate-dose methotrexate with delayed leukovorin rescue, and vincristine/dexamethasone pulses. Therapy continued for 2 years from the start of interim maintenance in the 16 patients who did not receive a bone marrow transplant (BMT). Two patients underwent an HLA-identical sibling BMT specified by protocol. Four received a nonprotocol-prescribed alternative donor BMT.

RESULTS

The complete remission induction rate was 95%. With a median follow-up from date of relapse of 49 months in survivors, the actuarial EFS based on intent to treat is 75%. There were three toxic deaths in patients in CR and two deaths from relapse.

CONCLUSIONS

This regimen is toxic but effective and deserves study in a larger setting.

Anxiety disorders in the elderly

Although the epidemiology, neurobiology, and treatment of anxiety disorders have received considerable attention in the child and adult literature, they have not received the same consideration in the geriatric population. This disparity is remarkable given the prevalence and associated costs of these disorders that can persist into late life. Further, although a considerable amount is known about these disorders in younger age groups, it is unclear whether the phenomenology of anxiety evolves over the course of the aging process. Thus, conclusions drawn based on younger populations of anxious adults may not hold true for older cohorts. This article reviews issues of epidemiology, phenomenology, neurobiology, and medical comorbidity, as well as pharmacologic and psychotherapeutic treatments in older adults.

Stroke prevention trial in sickle cell anemia

Stroke occurs in 7-8% of children with Sickle Cell Disease (Hb SS) and is a major cause of morbidity. Rates of recurrence have been reduced from 46-90% to less than 10% through chronic blood transfusions. Prevention of first stroke, however, would be preferable because even one stroke can cause irreversible brain injury. Transcranial Doppler (TCD) ultrasound can detect arterial blood flow rates associated with subsequent stroke risk. By combining TCD screening and a potentially effective treatment, first stroke may be prevented. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) is the first stroke prevention trial in Hb SS and the first randomized, controlled use of transfusion in Hb SS. This multi-center trial is designed to test whether reducing sickle hemoglobin to 30% or less with periodic blood transfusions will reduce first-time stroke by at least 70% compared to standard care. Primary endpoints will be clinically evident symptoms of cerebral infarction with consistent findings on Magnetic Resonance Imaging and Angiography (MRI/MRA) or symptomatic intracranial hemorrhage. Secondary endpoints will be asymptomatic brain lesions detected by MRI in brain areas not involved in primary endpoints. The design calls for a 6-month start-up interval, 18 months of TCD screening and randomization, and observation for stroke from entry through month 54. Key features of the trial are standardized TCD and MRI/MRA protocols interpreted blindly, and blinded adjudication of endpoints. The sample size (60 per treatment group) is based on prospective data relating TCD velocity to risk of stroke. A time-averaged mean velocity of > or = 200 cm/sec is associated with a 46% risk of cerebral infarction over 39 months. The sample size is sufficient to detect 70% reduction in the primary endpoint at 90% power. This trial will determine if transfusion is effective in the primary prevention of stroke. Secondary aims may further the understanding of the effects of transfusion on the brain and guide future research into cerebrovascular disease in Hb SS.

Factor V Leiden is not responsible for stroke in patients with sickling disorders and is uncommon in African Americans with sickle cell disease

Cerebrovascular accidents in patients with sickle cell anemia are among the most devastating complications of the disease. It has recently been demonstrated that some patients have a hypercoagulable state on the basis of the presence of an abnormal factor V molecule, factor V Leiden. We undertook this study to evaluate the presence of factor V Leiden in sickle cell patients with stroke. Eighty-two patients with either Hgb SS, Hgb SC, or Hgb S(beta+)-thalassemia comprised the study population. Of the 82 patients in the study, 19 of them had a history of stroke. In our study population, none of the stroke patients possessed the factor V Leiden mutation. One of the non-stroke patients was a heterozygote for the mutation (P = 1.00). The overall frequency of the factor V Leiden allele in our population is 0.6%. The estimated prevalence for this mutation is reportedly between 3 and 7% in Caucasian populations. We conclude that the gene frequency for factor V Leiden is less common in Africa Americans with sickle cell disease. Furthermore, factor V Leiden does not appear to be responsible for the development of stroke in sickle cell patients.

Anesthetic Implications for Children Undergoing Computerized Tomography-Guided Stereotactic Brain Biopsy

Anesthesiologists spend much of their time administering anesthesia to children outside of the operating room, especially for neuroradiological evaluation. Neuroradiological procedures include magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography, myelography, pneumoencephalography, and arteriography. Each of these procedures presents a "working environment" that compromises the ability to deliver a safe and well-monitored anesthetic (1). CT-guided stereotactic brain biopsy in children requires two anesthetic locations (2). The stereotactic guidance apparatus renders the airway inaccessible both during CT and during transport to the operating room. We report a case of a child undergoing CT-guided stereotactic brain biopsy to elucidate the anesthetic considerations of this logistically difficult procedure.

Multiagent chemotherapy in relapsed acute lymphoblastic leukemia in children

Twenty-seven evaluable children with early first bone marrow relapse of acute lymphoblastic leukemia were treated with an intensive induction/consolidation and ongoing maintenance therapy. Induction therapy consisted of a 35-day course of daunomycin, vincristine, and prednisone, immediately followed by teniposide, cytosine arabinoside (Ara-C), and L-asparaginase. Intrathecal methotrexate, hydrocortisone, and Ara-C were given through the induction/consolidation phase. Twenty-three of 27 patients achieved remission by the end of induction/consolidation. Maintenance with the same drugs in a modified dosage schedule continued for approximately 2 years. A small subgroup of patients who were M3 at day 35 but M1 at day 56 (end of induction/consolidation) and had a cumulative event-free survival (EFS) of only 0.40 at 6 months, all had relapsed by 15 months. However, the EFS for M1 patients by day 35 and maintained on chemotherapy was 0.64 at 12 months and 0.32 at 30, 36, and 48 months, respectively. Although good reinduction and remission duration rates at 12 to 24 months were achieved and an apparent plateau in survival occurs at 30 months, fall-off in survival would not be unexpected with probably less than 20% alive after 5 years.

Spondyloepiphyseal dysplasia, mild autosomal dominant type is not due to primary defects of type II collagen

A mild autosomal dominant form of spondyloepiphyseal dysplasia (SED) is present in several generations of a South African family of English stock. This phenotype differs from that of any other previously described. Although type II collagen defects have been found in some families with SED congenita, the phenotype in our family showed discordant segregation with COL2A1 gene associated restriction fragment length polymorphisms (RFLPs), the markers for the structural locus of type II collagen. It is evident that the SED group of disorders is heterogeneous.

The chick chorioallantoic membrane as a model system for the study of tissue invasion by viral transformed cells

The chick chorioallantoic membrane (CAM) was used as an assay system to investigate the the invasive properties of viral transformed NIH/3Y3 cells. Scanning electron microscopy demonstrated that single Kirsten sarcoma virus (KiSV)-transformed cells passed between the epithelial cells of the CAM ectoderm within 6 hr of application, while viable NIH/3T3 cells did not penetrate the ectoderm within 24 hr. The transformed cells entered the mesoderm of the CAM and formed tumors of proliferating cells. The application of 5 X 10(5) KiSV-transformed cells resulted in the formation of donor cells resulted in the formation of the donor cell tumors within 5 days in 43% of the membranes. No tumors were formed when as many as 5 X 10(6) NIH/3T3 cells were applied to the membrane. NIH/3T3 cells transformed by the Abelson leukemia virus or the Moloney sarcoma virus also ivaded the CAM and formed tumors of proliferating cells within the mesoderm, while cells infected with the Moloney leukemia virus did not. NIH/3T3 cells inoculated onto the CAM 8 days after infection and transformation with KiSV formed tumors with a frequency similar to that of KiSV transformed cells that have been passaged in culture for many generations. Cells that formed invasive tumors within the mesoderm also attracted loops of host blood vessels.