An Ancillary Central Catheter Emergency Support Service Team Staffed by Surgical Personnel Improves Workflow During the Coronavirus Disease 2019 Crisis.

Background. The SARS-CoV-2 novel coronavirus disease 2019 (COVID-19) pandemic has posed significant challenges to urban health centers across the United States. Many hospitals are reallocating resources to best handle the influx of critical patients. Methods. At our New York City hospital, we developed the ancillary central catheter emergency support service (ACCESS), a team for dedicated central access staffed by surgical residents to assist in the care of critical COVID-19 patients. We conducted a retrospective review of all patients for whom the team was activated. Furthermore, we distributed a survey to the critical care department to assess their perceived time saved per patient. Results. The ACCESS team placed 104 invasive catheters over 10 days with a low complication rate of .96%. All critical care providers surveyed found the service useful and felt it saved at least 30 minutes of procedural time per patient, as patient to critical care provider ratios were increased from 12 patients to one provider to 44 patients to one provider. Conclusions. The ACCESS team has helped to effectively redistribute surgical staff, provide a learning experience for residents, and improve efficiency for the critical care team during this pandemic.

Laparoscopy in penetrating abdominal trauma is a safe and effective alternative to laparotomy.

INTRODUCTION: Diagnostic laparoscopy (DL) is an increasingly used modality when approaching penetrating abdominal trauma (PAT). Trauma surgeons can utilize this minimally invasive technique to quickly assess for injury in hemodynamically stable patients. DL with a confirmed injury can be repaired through therapeutic laparoscopy (TL) or conversion to exploratory laparotomy (EL). This study analyzes the use of laparoscopy as a first-line therapy for hemodynamically stable patients with PAT. METHODS: Data were reviewed of patients presenting with PAT between December 2006 and September 2016. A retrospective analysis was conducted to analyze demographics, baseline presentations, treatment protocols and outcomes. RESULTS: A total of 56 patients with PAT were initially treated with laparoscopy. Injuries included stab wounds (n = 48) and gunshot wounds (n = 8). Patients were divided into three groups: DL, DL to TL, and DL to EL. Ten patients (17.9%) required conversion to laparotomy (DL to EL). Of the 46 patients who did not require conversion, 33 patients (71.7%) underwent DL, while 13 patients (28.3%) required TL (DL to TL). There were no differences in postoperative complication rates between the groups (p = 0.565). The mean lengths of hospital stay for DL, DL to TL, and DL to EL were 3.1, 2.7, and 8.1 days, respectively (p = 0.038). No missed injuries or mortalities occurred in any of the groups. CONCLUSION: Laparoscopy can be utilized for hemodynamically stable patients with PAT. DL can be converted to TL in the hands of a skilled laparoscopist. In this study, we analyze the use of DL over a 10-year period in patients who presented to our level 1 trauma center with PAT. We also provide a comprehensive review of literature to create clear definitions, and to clarify a systematic stepwise approach of how to effectively perform DL and TL. This study adds to the body of literature supporting the role of laparoscopy in PAT, and advances the discussion regarding management.

Importance of the node of Calot in gallbladder neck dissection: an important landmark in the standardized approach to the laparoscopic cholecystectomy.

The current rate of bile duct injury (BDI) after laparoscopic cholecystectomy is 0.4%, which is an unacceptable outcome. Several surgical approaches have been suggested to mitigate the occurrence of this dreaded complication. We propose a standardized approach, using Calot's node as a critical anatomical landmark to guide gallbladder dissection and avoid BDI. We retrospectively analyzed a prospectively gathered database of 907 laparoscopic cholecystectomies using this standardized approach in our practice over a 5-year period. To date we have had no BDI and no cystic duct leak. Therefore, we suggest identification of Calot's node as an additional method to avoid BDI during laparoscopic cholecystectomy.

A case of fatal fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and persistent ventricular tachyarrhythmia associated with influenza A (H1N1) virus in a previously healthy pregnant woman.

Several studies have reported influenza A (H1N1) virus as a cause of fulminant myocarditis. We report the first fatal case of fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and ventricular tachyarrhythmia associated with influenza A (H1N1) in a previously healthy pregnant woman. A 38-year-old Asian woman, gravida 3, para 1-0-1-1, presented with flu-like symptoms. Initially, she developed wide-complex tachycardia requiring several defibrillations and was later intubated. Electrocardiogram showed ST-segment elevation. Coronary angiogram was negative and a pulmonary angiogram ruled out pulmonary embolism. Fetal compromise was noted on the monitor, and the patient underwent an emergent cesarean section. She subsequently expired. Autopsy confirmed severe myocarditis. Further testing confirmed influenza A (H1N1) virus. This case of a rare, yet lethal, complication of H1N1 infection underscores the importance of increased awareness among health care professionals to provide pregnant women with vaccination and prompt treatment.

Impaired accessory cell function in a human dendritic cell line after human immunodeficiency virus infection.

We generated human dendritic cell (DC) hybridoma cell lines by fusing HGPRT-deficient promonocytic U937 cells with immature DCs obtained by culturing peripheral blood monocytes with interleukin-4 (IL-4; 1,000 U/ml) and granulocyte-macrophage colony-stimulating factor (100 U/ml) for 7 days and mature DCs by treatment with tumor necrosis factor alpha (12.5 microg/ml) for 3 days. Only one fusion with immature DCs was successful and yielded four cell lines--HB-1, HB-2, HB-3, and HB-9--with an overall fusion efficiency of 0.0015%. The cell lines were stable in long-term culture, displayed morphological features typical of DCs, and expressed distinct class I and class II molecules not present on U937 (A*031012, B*51011, Cw*0701, DRB3*01011 52, and DR5*01011). A representative cell line, HB-2, that expressed DC markers including CD83, CD80 and CD86 could be induced to produce IL-12 through CD40 stimulation. After human immunodeficiency virus (HIV) infection, there was impairment of antigen-presenting cell (APC) function, which was manifested by an inability to stimulate allogeneic T-cell responses. There was no change in expression of major histocompatibility complex class I and class II antigens, CD83, CD40, CD4, CD11c, CD80, CD86, CD54, and CD58, or IL-12 production in the HIV-infected HB-2 cells. The HIV-infected HB-2 cells induced T-cell apoptosis in the cocultures. T-cell proliferation could be partially restored by using ddI, indinivir, and blocking anti-gp120 and anti-IL-10 antibodies. Our data suggest that there are multiple mechanisms that DCs use to inhibit T-cell responses in HIV-infected patients. The HB-2 cell line could be a useful model system to study APC function in HIV-infected DCs.