Logistical Considerations and Clinical Outcomes Associated With Converting Operating Rooms Into an Intensive Care Unit During the Coronavirus Disease 2019 Pandemic in a New York City Hospital.

BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged as a public health crisis that disrupted normal patterns of health care in the New York City metropolitan area. In preparation for a large influx of critically ill patients, operating rooms (ORs) at NewYork-Presbyterian/Columbia University Irving Medical Center (NYP-Columbia) were converted into a novel intensive care unit (ICU) area, the operating room intensive care unit (ORICU). METHODS: Twenty-three ORs were converted into an 82-bed ORICU. Adaptations to the OR environment permitted the delivery of standard critical care therapies. Nonintensive-care-trained staff were educated on the basics of critical care and deployed in a hybrid staffing model. Anesthesia machines were repurposed as critical care ventilators, with accommodations to ensure reliable function and patient safety. To compare ORICU survivorship to outcomes in more traditional environments, we performed Kaplan-Meier survival analysis of all patients cared for in the ORICU, censoring data at the time of ORICU closure. We hypothesized that age, sex, and obesity may have influenced the risk of death. Thus, we estimated hazard ratios (HR) for death using Cox proportional hazard regression models with age, sex, and body mass index (BMI) as covariables and, separately, using older age (65 years and older) adjusted for sex and BMI. RESULTS: The ORICU cared for 133 patients from March 24 to May 14, 2020. Patients were transferred to the ORICU from other ICUs, inpatient wards, the emergency department, and other institutions. Patients remained in the ORICU until either transfer to another unit or death. As the hospital patient load decreased, patients were transferred out of the ORICU. This process was completed on May 14, 2020. At time of data censoring, 55 (41.4%) of patients had died. The estimated probability of survival 30 days after admission was 0.61 (95% confidence interval [CI], 0.52-0.69). Age was significantly associated with increased risk of mortality (HR = 1.05, 95% CI, 1.03-1.08, P < .001 for a 1-year increase in age). Patients who were ≥65 years were an estimated 3.17 times more likely to die than younger patients (95% CI, 1.78-5.63; P < .001) when adjusting for sex and BMI. CONCLUSIONS: A large number of critically ill COVID-19 patients were cared for in the ORICU, which substantially increased ICU capacity at NYP-Columbia. The estimated ORICU survival rate at 30 days was comparable to other reported rates, suggesting this was an effective approach to manage the influx of critically ill COVID-19 patients during a time of crisis.

The basis of the immunomodulatory activity of malaria pigment (hemozoin).

The most common and deadly form of the malaria parasite, Plasmodium falciparum, is responsible for 1.5-2.7 million deaths and 300-500 million acute illnesses annually [Bremen in J. Trop. Med. Hyg. 64:1-11 (2001); World Health Organization (2002)]. Hemozoin, the biomineral formed to detoxify the free heme produced during parasitic hemoglobin catabolism, has long been suspected of contributing to the pathological immunodeficiencies that occur during malarial infection. While there is a growing consensus in the literature that native hemozoin maintains immunosuppressive activity, there is considerable controversy over the reactivity of the synthetic form, beta-hematin (BH). Given the emerging importance of hemozoin in modulating a host immune response to malarial infection, a careful examination of the effects of the constitutive components of the malaria pigment on macrophage response has been made in order to clarify the understanding of this process. Herein, we present evidence that BH alone is unable to inhibit stimulation of NADPH oxidase and inducible nitric oxide synthase, the key enzymes involved in oxidative burst, and is sensitive to the microbicidal agents of these enzymes both in vitro and in vivo. Further, by systematically examining each of the malaria pigment's components, we were able to dissect their impact on the immune reactivity of a macrophage model cell line. Reactions between BH and red blood cell (RBC) ghosts effectively reconstituted the observed immunomodulatory reactivity of native hemozoin. Together, these results suggest that the interaction between hemozoin and the RBC lipids results in the generation of toxic products and that these products are responsible for disrupting macrophage function in vivo.