Global Value Chain Governance in the MNE: A Dynamic Hierarchy Perspective

The pandemic crisis caused a severe shock to global value chains and led to supply shortages for complex medical goods such as respiratory ventilators. What followed were calls to reshore production for security, and the loss of efficiencies from foreign global value chain (GVC) operations for the multinational enterprise. This article merges internalization and GVC theory to demonstrate a dynamic hierarchy managerial response to these crisis conditions. An optimally configured GVC under hierarchy governance can resiliently eliminate global supply line ruptures yet maintain the benefits of global efficiency.

Proteomic profiling of MIS-C patients indicates heterogeneity relating to interferon gamma dysregulation and vascular endothelial dysfunction

Multi-system Inflammatory Syndrome in Children (MIS-C) is a major complication of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in pediatric patients. Weeks after an often mild or asymptomatic initial infection with SARS-CoV-2 children may present with a severe shock-like picture and marked inflammation. Children with MIS-C present with varying degrees of cardiovascular and hyperinflammatory symptoms. Here we perform a comprehensive analysis of the plasma proteome of more than 1400 proteins in children with SARS-CoV-2. We hypothesize that the proteome would reflect heterogeneity in hyperinflammation and vascular injury, and further identify pathogenic mediators of disease. We show that protein signatures demonstrate overlap between MIS-C, and the inflammatory syndromes macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA). We demonstrate that PLA2G2A is an important marker of MIS-C that associates with TMA. We find that IFNγ responses are dysregulated in MIS-C patients, and that IFNγ levels delineate clinical heterogeneity.

Changes in a Hospital’s Costs and Revenues Before and After COVID-19: A Case Study of an Iranian Hospital

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has caused a severe shock to the world economy and, consequently, healthcare systems. Objectives: The current study aimed to investigate changes in costs and revenues of an Iranian hospital before and after the COVID-19 pandemic to answer the following question: "How can hospital costs and revenues change during the COVID-19 pandemic?" Methods: This descriptive cross-sectional study was conducted retrospectively at the Masih Daneshvari Hospital in 2020. Accounting software available at the hospital (Azarakhsh for salary costs and PMQ for medical equipment costs) was used to collect cost information. Also, the hospital information system software was used to collect revenue information. The 2019 financial year was considered the base year, and the period February-August 2020 was considered the COVID-19 outbreak period. The data were entered into Excel software and analyzed using descrip¬tive statistics methods. Results: Before the COVID-19 outbreak, the Masih Daneshvari Hospital was facing many cost problems, and the new crisis added to the severity of the problems. In total, the hospital's revenue declined by 9%, and its costs increased by 70%. Therefore, in the fiscal year ending in March 2020, the hospital balance was reported to be $-607,143 (-68,000 million Iranian Rial). Conclusions: The soaring healthcare expenditures revealed that the hospital was not ready to deal with the disease. As the COVID-19 outbreak grows rapidly in Iran, there is a pressing need to increase medical capacities and inpatient beds to treat infected patients. Hospitals in the country face financial problems and should be supported by the Ministry of Health and Medical Education.

Proteomic Profiling of MIS-C Patients Reveals Heterogeneity Relating to Interferon Gamma Dysregulation and Vascular Endothelial Dysfunction

Multi-system Inflammatory Syndrome in Children (MIS-C) is a major complication of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic in pediatric patients. Weeks after an often mild or asymptomatic initial infection with SARS-CoV-2 children may present with a severe shock-like picture and marked inflammation. Children with MIS-C present with varying degrees of cardiovascular and hyperinflammatory symptoms. We performed a comprehensive analysis of the plasma proteome of more than 1400 proteins in children with SARS-CoV-2. We hypothesized that the proteome would reflect heterogeneity in hyperinflammation and vascular injury, and further identify pathogenic mediators of disease. Protein signatures demonstrated overlap between MIS-C, and the inflammatory syndromes macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA). We demonstrate that PLA2G2A is a key marker of MIS-C that associates with TMA. We found that IFNγ responses are dysregulated in MIS-C patients, and that IFNγ levels delineate clinical heterogeneity.

Subcellular Injury of ASMEs Involves in the Genesis of Refractory Hypotension in Severe Shock

The Refractory Hypotension (RH) leads to severe hypoperfusion which results in vital organ failure and death. It has been shown that one of the main reasons for RH is Arteriolar Smooth Muscle Cell (ASMC) hyperpolarization, which results in the inhibition of L-type calcium channel and Ca2+ influx after vasoconstrictor stimulation, that finally leads to refractory hypotension during severe shock. The activation of KATP channels by depletion of intracellular ATP content causes ASMC hyperpolarization. It is usually recognized that the depletion of ATP content originates from microcirculatory disturbance and refractory hypotension is only a functional problem of ASMC with treatment using vasopressors, and no morphological changes of smooth muscle cell were reported in RH. This review shows that mitochondrial damage is another important reason for depletion of ATP level and that protection of mitochondrial dysfunction can increase the blood pressure and survival rate during severe shock, which indicated that subcellular injury of ASMCs is involved in the genesis of refractory hypotension. Protecting and repairing ASMC subcellular injury is a new approach to treatment of severe shock.

SURGICAL TREATMENT OF VASCULAR INJURY WITH TRAUMATIC SHOCK

Aim of study. Identify the features and offer the best tactics for the surgical treatment of vascular injuries in traumatic shock. Material and methods. The clinic has 36 patients with hemorrhagic and traumatic shock. Of them: 33 men (91.6%), women 3 (8.3%). We found, among those admitted to the clinic, 36 patients with hemorrhagic and traumatic shock. So, in 5 patients, the condition was extremely serious. The use of angiography and MSCT is of great importance for the early diagnosis of traumatic vascular damage.Results. We have performed 36 different operations for patients with shock after vascular injury: vessel ligature — 19; lateral suture — 5. Of them: at the same time imposed side seam venous vessels; сircular suture — 4; autovenous shunting — 3; prosthetics — 4: primary amputation — 1 and 7 patients with epineural suture. Along with this, severe shock, massive tissue damage and irreversible ischemia were indications for limb amputation in 1 (2,7%) patients with vascular damage. Arrosive bleeding was observed, only in one patient. In 24 (94,4%) patients, wound healing was primary, in 2 (5,5%) patients, wounds healed by secondary intention.Conclusions. The high efficiency of timely application of reconstructive- restorative operations — autovenous shunting and vascular prosthetics after stabilization of hemodynamic parameters depends on the degree of traumatic and hemorrhagic shock.

Long-term 5-year outcome of the randomized IMPRESS in severe shock trial: percutaneous mechanical circulatory support versus intra-aortic balloon pump in severe cardiogenic shock

Funding Acknowledgements Type of funding sources: None. Background The role of percutaneous mechanical circulatory support (pMCS) in cardiogenic shock (CS) is still a subject of debate. The IMPRESS in Severe Shock trial is still the largest RCT on the effectiveness of pMCS in CS patients. We performed a follow-up at 5-years of the IMPRESS in Severe Shock trial to assess differences in long-term clinical outcome and functional status between pMCS and intra-aortic balloon pump (IABP) treated patients. Methods The IMPRESS in Severe Shock trial (NTR3450) is an investigator-initiated, multicentre, randomized, open-label trial. Between June 2012 and September 2015, a total of 48 patients with severe CS from AMI with ST-segment elevation undergoing immediate revascularisation were randomized to pMCS with the Impella CP (n = 24) or IABP (n = 24). The trial design and primary end-point results (30-day all-cause mortality) have been previously published. For the 5-year assessment, all-cause mortality and the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) were evaluated. MACCE consisted of death, myocardial re-infarction, repeat PCI, CABG and stroke. In survivors, a structured interview was conducted and follow-up echocardiography was obtained. Data were analysed according to the intention-to-treat principle. Results Long-term follow-up was performed 5.5 years (IQR 5.3-6.5) after initial randomization and completed for all patients regarding mortality status. Five-year mortality was 50% (n = 12/24) in the pMCS group and 63% (n = 15/24) in the IABP group (RR 0.87, 95% CI 0.47-1.59, p = 0.65). After 6 months, only 3 additional deaths occurred, all in the IABP group. MACCE occurred in 12/24 (50%) of the pMCS patients versus 19/24 (79%) of the IABP patients (p = 0.07) (Figure 1). Myocardial re-infarction occurred in 1 pMCS patient and in 2 IABP patients, repeat PCI in 3 IABP patients, CABG in 1 IABP patient and stroke in 2 pMCS patients and in 2 IABP patients. Among 5-year survivors, follow-up interview was successfully conducted in 11/12 (92%) pMCS and 7/9 (78%) IABP patients. All patients except for one were in NYHA class I or II (pMCS n = 10 [91%] and IABP n = 7 [100%], p = 1.00) and none of the patients had residual angina complaints. Echocardiography was obtained in 10/12 (83%) pMCS and 6/9 (67%) IABP patients. There were no differences in LVEF between the two groups (pMCS 52 ±11% vs. IABP 48 ±10%, p = 0.53). Conclusions In this randomized trial of patients with CS after AMI, there was no difference in long-term 5-year mortality between pMCS (by Impella CP) and IABP treated patients, supporting previously published 30-day and 6-month data. Interestingly, we did observe a not significantly different (p = 0.07) higher occurrence of MACCE in the IABP group. Abstract Figure. Kaplan Meier Impella vs. IABP: MACCE

Atypical Severe Shock-like Reactions in Adolescents After Trimethoprim-Sulfamethoxazole Therapy

Severe drug hypersensitivity reactions to antibiotics are rare but trimethoprim-sulfamethoxazole (TMP-SMX) is uniquely associated with numerous and varied manifestations including a reaction resembling septic shock, first observed in human immunodeficiency virus (HIV)/AIDS patients. Over the past 25 years about 20 cases have been reported and an association with the virus and related immune system dysregulation was assumed. However, recent reports in adults have recognized similar shock-like reactions in non-HIV infected individuals. Here we review severe TMP-SMX hypersensitivity reactions and within the context of these known reactions, describe three non-HIV infected adolescent patients with shock-like reactions to TMP-SMX observed in one institution over 1.5 years.