Maintaining trauma center operational readiness during a pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is a slow-moving global disaster with unique challenges for maintaining trauma center operations. University Medical Center New Orleans is the only level 1 trauma center in New Orleans, LA, which became an early hotspot for COVID-19. Intensive care unit surge capacity, addressing components including space, staff, stuff, and structure, is important in maintaining trauma center operability during a high resource-strain event like a pandemic. We report management of the trauma center's surge capacity to maintain trauma center operations while assisting in the care of critically ill COVID-19 patients. Lessons learned and recommendations are provided to assist trauma centers in planning for the influx of COVID-19 patients at their centers.

Critically Ill Adults With Coronavirus Disease 2019 in New Orleans and Care With an Evidence-Based Protocol.

BACKGROUND: Characteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown. RESEARCH QUESTION: What are the outcomes of critically ill adults with COVID-19 admitted to a network of hospitals in New Orleans, Louisiana, and what is an evidence-based protocol for care associated with improved outcomes? STUDY DESIGN AND METHODS: In this multi-center, retrospective, observational cohort study of ICUs in four hospitals in New Orleans, Louisiana, we collected data on adults admitted to an ICU and tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 9, 2020 and April 14, 2020. The exposure of interest was admission to an ICU that implemented an evidence-based protocol for COVID-19 care. The primary outcome was ventilator-free days. RESULTS: The initial 147 patients admitted to any ICU and tested positive for SARS-CoV-2 constituted the cohort for this study. In the entire network, exposure to an evidence-based protocol was associated with more ventilator-free days (25 days; 0-28) compared with non-protocolized ICUs (0 days; 0-23, P = .005), including in adjusted analyses (P = .02). Twenty patients (37%) admitted to protocolized ICUs died compared with 51 (56%; P = .02) in non-protocolized ICUs. Among 82 patients admitted to the academic safety net hospital's ICUs, the median number of ventilator-free days was 22 (interquartile range, 0-27) and mortality rate was 39%. INTERPRETATION: Care of critically ill COVID-19 patients with an evidence-based protocol is associated with increased time alive and free of invasive mechanical ventilation. In-hospital survival occurred in most critically ill adults with COVID-19 admitted to an academic safety net hospital's ICUs despite a high rate of comorbidities.

The histopathologic reliability of tissue taken from cadavers within the gross anatomy laboratory.

The purpose of this study was to examine the histopathologic reliability of embalmed cadaveric tissue taken from the gross anatomy laboratory. Tissue samples from hearts, livers, lungs, and kidneys were collected after the medical students' dissection course was completed. All of the cadavers were embalmed in a formalin-based fixative solution. The tissue was processed, embedded in paraffin, sectioned at six micrometers, and stained with H&E. The microscope slides were evaluated by a board certified pathologist to determine whether the cellular components of the tissues were preserved at a high enough quality to allow for histopathologic diagnosis. There was a statistically significant relationship between ratings and organ groups. Across all organs, there was a smaller proportion of "poor" ratings. The lung group had the highest percentage of "poor" ratings (23.1%). The heart group had the least "poor" ratings (0.0%). The largest percentage of "satisfactory" ratings were in the lung group (52.8%), and the heart group contained the highest percentage of "good" ratings (58.5%) The lung group had the lowest percentage of "good" ratings (24.2%). These results indicate that heart tissue is more reliable than lung, kidney, or liver tissue when utilizing tissue from the gross anatomy laboratory for research and/or educational purposes. This information advises educators and researchers about the quality and histopathologic reliability of tissue samples obtained from the gross anatomy laboratory. Anat Sci Educ 11: 207-214. © 2017 American Association of Anatomists.

How the Integration of Pathology in the Gross Anatomy Laboratory Affects Medical Students.

PROBLEM: The main objective of this project was to integrate pathologists into the gross anatomy laboratory setting to increase the exposure that early medical students receive to pathologists as clinicians. INTERVENTION: Pathologists visited the gross anatomy laboratory 3 times throughout the 15-week course to assist medical students in determining the cause of death of the cadaver being dissected. CONTEXT: This intervention was implemented with 1st-semester medical students for 2 consecutive years (a total of 100 dissection teams consisting of 4 students in each team). OUTCOME: A quantitative content analysis was performed on the students' end of the course assignments to determine whether the students learned a greater percentage of pathologic information by having interactions with pathologists in the gross lab and to identify trends in the way medical students diagnosed their "first patient" (i.e., the cadaver). The students who had interactions with pathologists in the laboratory had significantly more pathology in their narrative than the students who did not receive pathologist interaction. They were also more likely to conclude that the cadaver they dissected actually died from a cause other than the one listed on the death certificate (18.3%; n = 15) compared to the students who had no pathologist interaction (1.8%; n = 2). A postintervention survey indicated that 65% of students felt that interaction with pathologists helped them understand the clinical application of gross anatomy, more than 40% become more interested in pathology, and 74% would have liked to have had more pathologist interaction. LESSONS LEARNED: This intervention demonstrated a way to increase pathologist interaction within the undergraduate medical curriculum and enhance the educational environment of the gross anatomy laboratory.

Pathology Image Of The Month: Recurrent Urinary Tract Infections In a 48-year-Old Female Hyperintensities in the Globus Pallidi.

A 48-year-old female presented to her physician complaining of intermittent lower abdominal pain radiating to the right lower back. At the time of presentation, she was afebrile and denied any urinary symptoms such as dysuria, frequency or urgency. Physical exam was unremarkable, other than obesity, and her abdominal exam was noncontributory. Medical history, however, was notable for recurrent, Proteus mirabilis culture-proven urinary tract infections requiring antibiotic treatment for the prior three years along with hypertension, uterine fibroids post hysterectomy, diabetes and asthma. Complete blood count was within normal limits, and urine dipstick showed 1+ blood, 1+ protein and 2+ leukocytes. Full renal function labs, urine cytology, radioisotope renography and abdominopelvic CT scanning with contrast were all ordered and a laparoscopic right nephrectomy was recommended based on the results. The bisected right kidney is shown below in Figure 1. She was discharged home on post-operative day one and her follow up urology appointments indicate resolution of both her urinary tract infections and her abdominal pain.

Pathology Image Of the Month: Rapidly Progressive Hemorrhagic Cellulitis of Bilateral Lower Extremities with Subsequent Septic Shock and Death.

A 51-year-old man presented to a community based emergency department with bilateral lower extremity swelling that began four days prior and that had evolved into recent blister formation on the left lower extremity. Medical history was significant only for hypertension and a recent self-described episode of "food poisoning" five days earlier characterized by diarrhea, nausea, and vomiting that quickly resolved. Physical exam revealed marked bilateral lower extremity edema and an ecchymotic rash below the knee. In addition to the rash, there were large flaccid bullae on the left leg, mostly intact but some notable for draining of scanty serosanguinous fluid. The patient was tachycardic with a rate of 114 bpm and initial labs showed thrombocytopenia (platelets 56 x 103/uL [140-440 x 103/uL]), hypoglycemia (15mg/dl [70-105mg/dl]), an elevated creatinine (2.7mg/dL [0.7- 1.25mg/dL]), and aspartate aminotransferase (AST 156U/L [5- 34U/L]). Two sets of blood cultures were drawn, broad spectrum antibiotics including doxycycline were empirically initiated and then he was subsequently transported to a tertiary care hospital for escalation of care. Within hours of presentation to the tertiary care facility, the rash appeared progressively hemorrhagic and bullous, lactic acidosis and coagulopathy developed and hemodynamic instability and septic shock necessitated endotracheal intubation and vasopressors. He was taken to the operating room for skin debridement but was emergently converted to bilateral above the knee lower extremity amputations due to the extent of the soft tissue necrosis. The patient remained intubated and in critical condition following surgery and the ecchymotic rash reappeared at the amputation sites. A newly developed ecchymotic rash with bullae formation was noted on the right upper extremity forearm. At that time, the clinicians were notified that four out of four blood culture bottles from admission were rapidly growing a microorganism. The family elected for withdrawal of care, and the patient died approximately 72 hours following presentation. A full and unrestricted autopsy was authorized by the Coroner's Office.

Identifying the Challenges of "Small" Pathology Residency Programs and Creating Collaborative Solutions.

The majority of pathology residency training programs in the United States are considered to be small training programs. Small training programs, regardless of specialty, encounter unique challenges that have been documented in the literature. With the implementation of the Next Accreditation System (NAS), and other Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, adequate personnel and other resources are necessary. An online survey was conducted on the pathology program directors' section listserv to help identify characteristics and challenges of small pathology residency training programs. A discussion group on small pathology residency programs was held at the 2015 Association of Pathology Chairs/Program Directors annual meeting, where the results of the survey were discussed and small breakout groups followed the discussion of the survey. The results of the online survey and discussion groups are discussed in this paper.

Postmortem Aortic Dissection: An Artifact of the Embalming Process.

Aortic dissection (AD) is a serious condition that affects 3/100,000 individuals a year. Recently, a case report was published describing an embalmed patient with an aortic dissection. The purpose of this study was to examine the frequency of AD among 80 embalmed cadavers and confirm the AD with histopathologic evaluation. In seven cases of grossly identified AD, six were determined to be due to the embalming procedure and only one case of true antemortem AD was confirmed. These results suggest that aortic morphology can be altered by administration of the embalming fluid and that alterations can mimic AD, not only on gross inspection but also on postmortem imaging. Awareness of this embalming artifact may prevent misdiagnosis of an aortic dissection in an embalmed patient, a point particularly useful for autopsy pathology that may include postmortem examination of an embalmed patient.

PATHOLOGY IMAGE OF THE MONTH: Sudden Cardiac Death Caused by an Uncommon Disease.

A 57-year-old female, found dead lying supine in bed, was transferred to the autopsy service for an unrestricted autopsy to be performed under the authorization by the coroner. Medical history was unknown. At the time of autopsy, an implantable cardioverter-defibrillator (ICD) was identified in the subcutaneous tissues of the left subclavicular chest, with distal leads terminating in a small amount of fibrous tissue within the right auricular appendage and along the medial wall of the right ventricle. The heart was enlarged at 430gm (312 ±78) and cross sections were notable for left ventricular hypertrophy at 1.9cm (1.0-1.5cm) and for dilatation of the right ventricular chamber on initial apical cross section. All cross sections, from cardiac apex to subvalvular base, showed broad patches of white-yellow myocardial discoloration, without obvious hemorrhage, along the free wall of the left ventricle, the free wall of the right ventricle, and within the anterior interventricular septum (Figure 1). Additional notable findings at autopsy included a vena caval filter devoid of thromboembolic material, a patent foramen ovale (0.7cm) and microscopic plexogenic arteriopathy, low grade, consistent with pulmonary hypertension within the intrapulmonary vasculature. Histology from the discolored patches of myocardium is seen in Figure 2. Special stains for microorgansims (periodic acid-Schiff, Gomori methanamine silver, and Fite) were all negative.

Pathology Image of the Month: Prolonged Fever in a Traveler.

A 23 year old Russian male cargo ship crew member arrived in the port of New Orleans after a one month voyage originating in central Africa. During the month at sea, he developed fever up to 103 degrees Fahrenheit which was unsuccessfully managed with the antipyretic, dipyrone. He subsequently developed back and stomach pain, along with diarrhea. Upon the ship's arrival to New Orleans, he was transported to a local hospital where his axillary temperature was 104 degrees Fahrenheit. He was unresponsive, tachycardic and tachypneic with a plasma bicarbonate of 16mmol/L (24-32mmol/L).

Pathology Image of the Month: Mitral Stenosis at Autopsy.

A 52-year-old woman decedent was presented to the hospital autopsy service for a coroner authorized complete autopsy following an admit urine toxicology screen that was positive for cannabinoids. Prior to admission, she was found unresponsive at home after a two month history of increasingly progressive shortness of breath. She was transported to the emergency department and resuscitated after prolonged arrest. She was then admitted to the intensive care unit and subsequently was documented to have significant anoxic brain injury. Care was withdrawn by the family and death was declared on hospital day five. Medical history was reported for type 2 diabetes mellitus, and bipolar schizoaffective disorder with multiple prior psychiatric admissions. Her medical record review revealed a transthoracic echocardiogram two months prior to admission that documented mild mitralregurgitation, moderate mitral valve stenosis and a thickened valvular and subvalvular mitral apparatus with restricted motion of the posterior leaflet. Left atrial enlargement was marked, left ventricular hypertrophy was moderate, and pulmonary hypertension was graded as severe. The ejection fraction was estimated at 70 percent. She was discharged with outpatient follow-up to the cardiology department but was noncompliant with recommendations.

Pathology Image of the Month:Cough and Shortness of Breath in a Noncompliant Patient with HIV/AIDS.

A 37- year-old man with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) was admitted to the intensive care unit following a four month history of progressive shortness of breath, productive cough, and flu-like symptoms. His HIV/AIDS was diagnosed at the age of 19 (CD4 count =15; viral load = 294,436 copies/ mL) and was complicated by hemodialysis-dependent, HIV-associated nephropathy, prior Pneumocystis pneumonia and known noncompliance with prescribed antiretroviral therapy. Chest film at admission was interpreted as diffuse bilateral interstitial and airspace opacities with a right sided layering density representative of laminar pleural effusion. Bacterial blood cultures were subsequently negative. A bronchoalveolar lavage was performed and an image from the cytologic cell block is seen above in Figure 1. The patient's respiratory status continued to deteriorate and he was converted to comfort care. Following death, an unlimited autopsy examination was requested by the family and authorized by the coroner. At autopsy, additional gross pathologic findings included 350ml of chylous appearing pleural fluid and serous ascites (700ml). Histopathology revealed intra-alveolar acute fibrinopurulent exudate, chronic pericarditis and end-stage nephropathy. Similar cells to those shown above in Figure 1 were identified in lung epithelium and in pancreatic acinar cells. Special stain for Pneumocystis was negative.

Pathology Image of the Month: Abdominal Pain and Peripheral Eosinophilia.

A 69 year-old man presented to his primary care physician with abdominal discomfort. Medical history was notable for diabetes, chronic obstructive pulmonary disease with recent (one week prior) steroid use and hypertension. Surgical history was significant for a remote sigmoid hemicolectomy for diverticulitis with a synthetic mesh abdominal repair. He was admitted to the hospital for suspected gastroparesis. An upper GI series showed a distended stomach with delayed gastric motility. He underwent esophagogastroduodenoscopy and a duodenal biopsy was taken. He remained afebrile but had an elevated white blood cell count of 19.1 x 103/mcL (4.5 - 11.0 x 103/mcL) with 28.8 percent eosinophils on differential. Microscopic images of the duodenal biopsy are shown below.

Pathology image of the month: death in a young adult with sickle cell disease.

A 27-year-old African-American female with known sickle cell disease was admitted for sickle cell crisis and presumed sepsis. The patient's past medical history was complicated by multiple sickle cell-related complications, including seizures and multiple prior blood transfusions. Her hospital course included Staphylococcus epidermidis bacteremia, for which broad spectrum antibiotics were prescribed. On hospital day nine, the patient was found unresponsive and declared dead after unsuccessful efforts at resuscitation. An unlimited autopsy examination was conducted under authorization of the coroner. Findings included numerous pathologic features ascribed to sickle cell disease, including systemic siderosis and splenic atrophy [weight 10 gm (140±78)], fibrosis, and Gamna Gandy nodules. Additional autopsy findings included cardiomegaly with a heart weight of 450 gm (312±78), right atrial and right ventricular chamber dilatation, and hepatomegaly with a liver weight of 2650 gm (1475±362). The image below demonstrates microscopic examination of the lung parenchyma.

Pathology image of the month. Black esophagus detected at autopsy in a patient with abdominal pain and bloody diarrhea. DIAGNOSIS: Acute esophageal necrosis, ischemic and pseudomembranous colitis.

A 73-year-old African-American male was transported to the emergency department due to what emergency personnel described as "coffee ground emesis." He was pronounced dead shortly after arrival. An unlimited autopsy examination was conducted under authorization of the coroner's office. Medical record review revealed that the decedent had been discharged from the hospital just one day prior to his death following a three-day admission for abdominal pain, bloody diarrhea, and a 22-lb unintentional weight loss. Medical history documented hypertension, chronic obstructive lung disease, and a 57-pack-year smoking history. Alcohol abuse was also endorsed, but cessation of use was reported six months prior. During that admit, he was treated for volume-depletion, a urinary tract infection, and suspected infective colitis with antibiotics. Symptoms had resolved on hospital day three, and the patient was discharged home with a two-week course of ciprofloxacin and metronidazole and a follow-up colonoscopy appointment in one month. At the time of autopsy, the decedent was described as cachectic. Figure 1a shows the decedent's esophagus, opened longitudinally. Figure 1b shows the corresponding histology from the esophagus. Other findings documented at autopsy included ischemic bowel disease in the descending colon with patchy superimposed pseudomembranous colitis, emphysematous change, papillary renal cell carcinoma of the right kidney, microscopic prostatic adenocarcinoma, hepatic fibrosis, and intact hepatic hemangiomata.

Activation of c-Myc and Cyclin D1 by JCV T-Antigen and ß-catenin in colon cancer.

During the last decade, mounting evidence has implicated the human neurotropic virus JC virus in the pathology of colon cancer. However, the mechanisms of JC virus-mediated oncogenesis are still not fully determined. One candidate to mediate these effects is the viral early transcriptional product T-Antigen, which has the ability to inactivate cell cycle regulatory proteins such as p53. In medulloblastomas, T-Antigen has been shown to bind the Wnt signaling pathway protein ß-catenin; however, the effects of this interaction on downstream cell cycle regulatory proteins remain unknown. In light of these observations, we investigated the association of T-Antigen and nuclear ß-catenin in colon cancer cases and the effects of this complex in the activation of the transcription and cell cycle regulators c-Myc and Cyclin D1 in vitro. Gene amplification demonstrated the presence of viral sequences in 82.4% of cases and we detected expression of T-Antigen in 64.6% of cases by immunohistochemistry. Further, we found that T-Antigen and ß-catenin co-localized in the nuclei of tumor cells and we confirmed the physical binding between these two proteins in vitro. The nuclear presence of T-Antigen and ß-catenin resulted in the significant enhancement of TCF-dependent promoter activity and activation of the ß-catenin downstream targets, c-Myc and Cyclin D1. These observations provide further evidence for a role of JCV T-Antigen in the dysregulation of the Wnt signaling pathway and in the pathogenesis of colon cancer.

Pathology case of the month. Altered mental status, alcohol abuse, and hyperammonemia. DIAGNOSIS: Mallory-Denk bodies (a.k.a. Mallory's hyaline)­seen most commonly in alcoholic liver disease.

A 74-year-old woman with a past medical history of diabetes, hypertension, and alcohol abuse was brought to the emergency department and subsequently admitted to the intensive care unit with an altered mental status and weakness. Laboratories revealed acute renal failure (BUN 15 mg/dL, creatinine 2.5 mg/dL), elevated serum transaminase (AST of 83 IU/L), hyperammonemia (187 ug/dL), and marked normocytic anemia requiring transfusion of three units of packed red cells (hemoglobin 4.3 g/dL; hematocrit 13.1%). Blood ethanol level at the time of admission was less than 5 mg/dL, and full urine toxicology was negative. Alcohol abuse was reported to consist of, on average, "one pint of gin per day." Her hospital course was nine days and included complete inotropic blood pressure support and intubation. On the ninth day, she was declared dead, and authorization for an unrestricted autopsy was granted by the coroner. At autopsy, two liters of serous ascitic fluid was drained from the peritoneal cavity, and non-ruptured, distended varices were identified at the gastroesophageal junction. Additional findings included changes compatible with hypertensive cardiovascular disease, including hypertrophy of the interventricular cardiac septum and glomerulosclerosis along with renal atrophy. The liver weighed 1,300 grams (normal 1,475 gm±362) and was markedly discolored yellow-tan. Its parenchyma was more firm than usual. Representative microscopic sections from the decedent's liver are shown in the image below.

Pathology case of the month: sudden unexplained death in a young adult with known alcohol abuse.

A 35-year-old, recently deceased woman with a medical history known only to include Hepatitis C and alcohol abuse was transferred to the autopsy service for an unrestricted autopsy under coroner authorization following a sudden unexplained death. External examination revealed marked scleral icterus and cutaneous jaundice. Internal examination was remarkable for 3 liters of ascitic fluid and established cirrhosis with a micronodular pattern (nodules all <0.3 cm in diameter). Numerous, small, firm vegetations were identified along the edges of the tricuspid, mitral, and aortic valves. There was no obvious necrosis or tissue destruction seen grossly. Zones of prominent myocardial discoloration and hemorrhage were seen in all regions (anterior, lateral, and posterior) of the left ventricular myocardium, as well as within the interventricular septal myocardium. Multiple punctate lesions, up to 2 cm in diameter with a greenish hue and associated with tissue necrosis were seen overlying the cerebral cortex, as well as within the intracerebral parenchyma. Tissues were fixed in formalin for subsequent microscopic examination, and representative images from the aortic valve, and from the cerebral cortex, are seen below.

Pathology Image of the Month: Black Thyroid.

A 54-year-old Caucasian male had a witnessed collapse on the street. He was transported to the emergency department and subsequently pronounced dead. An unlimited autopsy examination was conducted under authorization of the coroner. Medical record review later revealed that the decedent had a history of alcohol abuse, chronic obstructive pulmonary disease, congestive heart failure, and chronic osteomyelitis treated by minocycline 100 mg twice daily. Autopsy revealed the cause of death to be ruptured gastroesophageal varices with nearly one liter of recent hemorrhage in the stomach and gastrointestinal tract. Other findings compatible with a history of alcoholism included hepatosplenomegaly, hepatic steatosis, and early bridging fibrosis. The decedent's thyroid was multinodular and enlarged at 50 gm. The thyroid gland, in its entirety, is shown below with serial sections made longitudinally through the gland capsule to reveal the underlying parenchyma.