Infection Prevention, Operational Workflows, and Implementation Checklists for Whole-Lung Low-Dose Radiation Therapy (LD-RT) for COVID-19-Related Pneumonia

Purpose/Objective(s)

Low-Dose Radiation Therapy (LD-RT) is an emerging treatment option for patients with COVID-19 related pneumonia. Infectivity of the SARS-CoV-2 virus complicates incorporation of LD-RT into existing radiation oncology clinics.

Materials/Methods

The first phase I/II trial of LD-RT for COVID-19-related pneumonia implemented novel operational protocols to address risk of infection and respiratory events. Patients were transported from hospital rooms to linear accelerators and treated with 0.5 Gy or 1.5 Gy using pre-planned, two-dimensional treatments prepared using diagnostic x-rays and caliper measurements. Workflows were revised over time to balance infection risks with implementation burden.

Results

Between April 24 and December 7, 2020, fifty-two patients were enrolled and forty were treated. The end-to-end process comprised 16 distinct teams and > 120 cooperating staff members (> 50 core radiation oncology staff). The trial was operationalized at two hospitals at the onset of the COVID-19 pandemic, prior to vaccine availability. Teams included trial leadership/screening (n > 4), inpatient floor staff (n > 10), clinical trials staff and coordinators (n = 8), transport (n = 2), radiation therapists (n > 20), respiratory therapists (n = 5), radiation nursing (n > 7), ICU nursing (n = 4), rapid response teams (n = 4), medical physics (n > 4), dosimetry (n > 3), infection prevention (n > 3), environmental services (n > 6), security (n = 7), lab personnel (n = 1), and physicians from radiation oncology (n = 7), infectious diseases (n = 2), pulmonary/critical care medicine (n = 2), anesthesia (n = 2), and internal medicine (n > 20) [total > 120]. All non-intubated patients were transported by a multi-disciplinary team, consisting of a physician, nurse, transporter, infection prevention specialist, and (when needed) a respiratory therapist. Treatments occurred after normal clinic hours, were initiated by team huddles, check lists, and included personal protective equipment supervision at multiple time points. Transport routes were 880 to 1760 feet (0.33 miles) one-way, with 1 to 3 elevator banks and required 20-35 minutes for round-trip transport and treatment. Oxygen supplementation in non-intubated patients ranged from 2 to 15 L/min. One intubated patient was transported with a portable ventilator and accompanying ICU staff. There were no code-level events during transport. No patient-facing staff contracted COVID-19 from trial activities. Workflow burden was successfully reduced and protocols relaxed over time with increased staff experience.

Conclusion

Whole-lung low-dose radiation therapy (LD-RT) for COVID-19-related pneumonia was successfully incorporated into existing workflows at a major academic university. Forty patients were treated with no code-level events, and no staff contracted the virus during eight months of trial accrual. Instructional materials and implementation check lists are provided.

Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders

OBJECTIVE

Repeated hospital admissions (RHA) for ongoing pressure ulcer (PU) care remains a significant challenge in the clinical management of the spinal cord injury/disorders (SCI/D) population. The current study investigated the significance of risk factors for PU treatment and RHA.

METHOD

A retrospective chart review of veterans admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC) Spinal Cord Injury (SCI) unit for Category III or IV PUs was carried out. A random sample of 105 individuals with SCI/D, evaluated by the Wound Care Team (WCT) from 2006 to 2009 was assessed. Multiple PU development risk factors were extracted from the electronic health record system using standardised data collection forms and entered into the Spinal Cord Injury Pressure Ulcer Database (SCIPUD). Potential associations with RHA were analysed.

RESULTS

Twenty variables were initially identified as potentially related to PU development. Descriptive statistics and statistically significant associations between risk factors and RHA were determined. Demographic factors showed no significant association with RHA. Duration of injury, power wheelchair use and sub-optimally managed spasticity (SMS) were significantly associated with higher RHA. Sub-optimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA.

CONCLUSION

Factors previously found to be predictive of initial PU development may not, in fact, be predictive of RHA. Some protective trends were observed, such as polypharmacy and marital status, but these did not reach statistical significance in this preliminary study of admission characteristics, warranting further research.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interests to declare.

Identifying former injecting drug users infected with hepatitis C: an evaluation of a general practice-based case-finding intervention

BACKGROUND

In Scotland, a general practice-based case-finding initiative, to diagnose and refer hepatitis C virus (HCV) chronically infected former injecting drug users (IDUs), was evaluated.

METHODS

Testing was offered in eight Glasgow general practices in areas of high deprivation and high HCV and IDU prevalence to attendees aged 30-54 years with a history of IDU. Test uptake and diagnosis rates were compared with those in eight demographically similar control practices.

RESULTS

Of 422 eligible intervention practice attendees, 218 (52%) were offered an HCV test and, of these, 121 (56%) accepted. Poor venous access in 13 individuals prevented testing. Of 105 tested, 70% (74/105) were antibody positive of which 58% (43/74) were RNA positive by PCR. Of 43 chronically infected individuals identified in intervention practices, 22 (51%) had attended specialist care within 30 months of the study, while 9 (21%) had defaulted. In control practices, 8 (22%) of 36 individuals tested were antibody positive. Test uptake and case yield were approximately 3 and 10 times higher in intervention compared with control practices, respectively.

CONCLUSIONS

Targeted case-finding in primary care demonstrated higher test uptake and diagnosis rates; however, to optimize diagnosis and referral of chronically infected individuals, alternative means of testing (e.g. dried blood spots) and retention in specialist care (e.g. outreach services) must be explored.

IL-21 contributes to the control of infection and to the severity of gastritis during Helicobacter infection (56.3)

The immune response to Helicobacter pylori involves a mixed T helper-1, T helper-2, and T helper-17 response. It has been suggested that T helper cells contribute to the gastric inflammatory response during infection, and that Th1 and Th17 subsets may be required for control of H. pylori colonization in the stomach. The relative contributions of these subsets to gastritis and control of infection are still under investigation. Expression of IL-21, which may be produced by a number of T cell subsets, has been reported to increase during H. pylori infection. IL-21 plays a role in both B cell stimulation and T cell differentiation. To investigate the role of IL-21 in H. pylori, we infected IL-21 deficient mice and wild-type littermates with H. pylori strain SS1. At 3 months post-infection, we assessed colonization, gastric inflammation, cellular infiltrate in the stomach, and cytokine profiles in the gastric tissue. Specifically, H. pylori-infected IL-21-/- mice have higher levels of H. pylori in their stomachs (4.5±0.4x107 CFU v. 4.3±2.3x106 CFU, **p=0.004), significantly less gastritis (gastritis scores 3.8±0.2 v. 1.2±0.3, ***p=0.0002), and reduced expression IL-17 and IFNγ (*p<0.05) compared to H. pylori-infected wild-type mice. Our results indicate that IL-21 contributes to the control of infection and severity of gastritis, suggesting IL-21 is required for activation of the immune response and induction of gastritis in response to H. pylori.

Electrospray ionization mass spectrometry analysis of lysophospholipids in human ascitic fluids: comparison of the lysophospholipid contents in malignant vs nonmalignant ascitic fluids

Lysophospholipids (lyso-PLs), including various glycerol-based and sphingosine-based lysophospholipids, play important roles in many biochemical, physiological, and pathological processes. The classical methods to analyze these lipids involve gas chromatography and/or high-performance liquid chromatography, which are time-consuming, cumbersome, and sometimes inaccurate due to the incomplete separation of closely related lipid species. We now describe the quantitative analysis of lyso-PLs in ascites samples from patients with ovarian cancer using electrospray ionization spectrometry. Three new classes of lyso-PL molecules are detected: alkyl-LPA, alkenyl-LPA, and methylated lysophosphatidylethanolamine. Importantly, the following lysophospholipid species are significantly increased in ascites from patients with ovarian cancer, compared to patients with nonmalignant diseases (e.g., liver failure): LPA (including acyl-, alkyl-, and alkenyl-LPA species), lysophosphatidylinositol, and sphingosylphosphorylcholine. Lysophosphorylcholine contents are also significantly different among ascitic fluids from the two groups of patients. However, the total phosphate content in ascites samples from patients with ovarian cancer is not significantly different compared to that from patients with nonmalignant disease.

A Brunner's gland adenoma as a cause of anemia

Benign tumors of the small bowel are rare. They present with many different manifestations depending on the size and location, and also cause a variety of symptoms that are often nonspecific. These include abdominal pain, dyspepsia, nausea, vomiting, and gastrointestinal bleeding that may be melena or hematemesis. Most of the time patients are asymptomatic and the lesions are discovered as an incidental finding. When bleeding occurs, and it may be severe in certain situations, the patient may develop signs of anemia, such as dyspnea, fatigue, and even high-output cardiac failure. The authors present a patient who was evaluated for melena and who was found to have a duodenal polyp that proved to be a Brunner's gland adenoma on pathology.

Temporal patterns of DNA adduct formation and glutathione S-transferase activity in the testes of rats fed aflatoxin B1: a comparison with patterns in the liver

Fisher-344 male rats were fed 1.6 ppm of aflatoxin B1 (AFB1) continuously and intermittently for several weeks. At various time periods, DNA was isolated from the testes and livers and analyzed for AFB1-DNA adducts. The ability of the testis to detoxify AFB1 was also investigated by the glutathione S-transferase (GST) activity assay and compared with that of the liver. The levels of testicular AFB1-DNA adducts were 2.4 to 8.1 times lower than those of the liver after 4 to 16 weeks of continuous treatment and 2.2 to 46.2 times lower after 8 to 20 weeks of intermittent treatment. The testicular DNA adducts markedly decreased over time. By 16 weeks of continuous and 20 weeks of intermittent exposure, they had decreased 37 and 91%, respectively. In contrast, hepatic AFB1-DNA adducts increased four-fold from 4 to 16 weeks of continuous treatment but increased at a much slower rate after intermittent exposure. In both the liver and testis, significant levels of AFB1-DNA adducts persisted for at least 1 month after ending the treatment, suggesting that this type of lesion was poorly repaired. In control rats, the testis showed significantly higher GST activity than the liver. In treated rats, these differences were significant during the first 12 weeks of continuous treatment but not at later times. Tissue-specific differences such as germ-cell depletion and increased testicular detoxification may play an important role in the observed differential pattern of DNA adduct formation between the testis and liver.

Factors determining the rate of referral, transplantation, and survival on dialysis in women with ESRD

The determinants of referral for transplantation in women have not been well-studied. Similarly, factors determining survival on dialysis and the rate of transplantation in women remain controversial. Women have been reported to have lower rates of transplantation than men, and black women have the lowest rates of all groups. We questioned whether black women were referred at lower rates than whites and if race and other socioeconomic factors predicted referral, rate of renal transplantation, and patient survival on dialysis. All women in Allegheny or Philadelphia counties in Pennsylvania initiating dialysis between January 1, 1990, and December 31, 1992, were eligible for this study. Information was requested by questionnaire from each dialysis unit in these areas. Of the 383 eligible patients, completed questionnaires were obtained for 276 (72%). Ninety-three (54.7%) of the black patients and 57 (53.8%) of the white patients were referred for transplantation (P = 0.8). Declining the transplant option was the most common reason for nonreferral in both races. Patients with high school or greater education were approximately twice as likely to be referred than those with grade school educations (odds ratio [OR], 2.2; P = 0.04). Patients with coexisting illness were 67% (OR, 0.33; P = 0.004) less likely to be referred compared with patients with no other illnesses. Each additional year of age reduced the chances of being referred by 6% (OR, 0.94; P = 0.0001). Homemakers were 83% (P = 0.0008) and others 55% (P = 0.07) less likely to be referred compared with employed patients. Patients in Philadelphia County were 56% less likely to be referred compared with those in Allegheny County (P = 0.024). Race was not significantly associated with referral. Predictors of transplantation included age (RR, 0.96; confidence interval [CI], 0.93 to 0.99; P = 0.13), white race (RR, 2.2; CI, 1.3 to 4.0; P = 0.0053), presence of other illnesses (RR, 0.37; CI, 0.21 to 0.65; P = 0.0006), and employment status. White homemakers were 86% (RR, 0.14; CI, 0.03 to 0.6; P = 0.0082) less likely than those with other employment situations to receive a transplant. Factors predicting patient survival on dialysis included race, educational status, and presence of comorbid illnesses. White patients were approximately four times (RR, 3.7; CI, 1.7 to 8.1; P = 0.002) more likely to die than black patients. Patients with high school or greater education were 56% (RR, 0.44; CI, 0.2 to 0.92; P = 0.008) less likely to die than those with grade school education alone. Patients with at least one coexisting illness were approximately 1.7 times (RR, 1.68; CI, 1.1 to 2.4; P = 0.001) more likely to die than those without other illnesses. In summary, race was not a factor in referral for transplantation, but was predictive of transplantation and patient survival on dialysis. Socioeconomic factors such as educational status, age, and employment status were highly predictive of transplantation and long-term survival on hemodialysis. White homemakers unexpectedly received transplants less than any other group of dialysis patients. Further study is needed to determine why these potential transplant patients have declined or deferred transplantation.

A comparison of four patient immobilization devices in the treatment of prostate cancer patients with three dimensional conformal radiotherapy

PURPOSE

To determine the variability of patient positioning during three-dimensional conformal radiotherapy (3D-CRT) for prostate cancer treated with no immobilization or one of four immunobilization devices, and to determine the effects of patient body habitus and pelvic circumference on patient movement with each individual inmobilization technique.

METHODS AND MATERIALS

To see whether our immobilization techniques have improved day-to-day patient movement, a retrospective analysis was carried out. A total of 62 patients treated at one facility on a single machine with 3D-CRT via a four-field box technique (anterior-posterior and opposed laterals) in the supine position with either no immobilization or one of four immobilization devices. Five groups of patients were compared: (a) group 1-no immobilization; (b) group 2-alpha cradle from the waist to upper thigh; (c) group 3-alpha cradle from waist to below the knees; (d) group 4-styrofoam leg immobilizer (below knees); and (e) group 5-aquaplast cast encompassing the entire abdomen and pelvis to midthigh with alpha cradle immobilization to their lower legs and feet. Prior to starting radiotherapy, portal films of all four treatment fields were obtained 1 day before treatment. Subsequently, portal films were then obtained at least once a week. Portal films were compared with the simulation films and appropriate changes were made and verified on the next day prior to treatment. A deviation of greater than 0.5 cm or greater was considered to be clincally significant in our analysis. We studied the difference among the types of immobilization and no immobilization by looking at the frequency of movements (overall, and on each of the three axes) that a patient had during the course of his treatment. Using a logistic regression model, the probability of overall and individual directional movement for each group was obtained. In addition, the effects of patient body habitus and pelvic circumference on movement were analyzed.

RESULTS

The maximum deviation was 2 cm and the median deviation was 1.2 cm. For each patient, the probability of movement ranged from 0 to 76%, with a mean of 39%. There was no significant difference seen in overall movement with any of the immobilzation devices compared to no immobilization, but there was less vertical (9 vs. 18%; p = 0.03) and AP (6 vs. 15%; p = 0.14) movement with the aquaplast than any other group. However, when examining the lateral direction, the aquaplast had significantly more movement (32 vs. 9%; p < 0.001). When accounting for body habitus and pelvic circumference, no immobilization device was effective in reducing movement in obese patients or in patients with pelvic circumference greater than 105 cm. The aquaplast group had a significantly increased amount of lateral movement with obesity (42 vs. 23%; p < 0.05), and with pelvic circumference >105 cm (33 vs. 29%; p < 0.05).

CONCLUSIONS

There was no significant reduction in overall patient movement noted with any of the immobilization devices compared to no immobilization. The aquaplast group had reduced vertical and AP movement of greater than 0.5 cm. There was significantly more lateral movement with aquaplast appreciated in obese patients or patients with pelvic circumferences greater than 105 cm. The aquaplast immobilization appears to be useful in reducing movement in two very clinicaly important dimensions (AP and vertical). Despite our findings, other immobilization may still be useful especially in the treatment of nonobese patients. It is clear that the optimal immobilization technique and patient positioning are yet to be determined.

Splenic trauma following endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a safe diagnostic and therapeutic procedure. Splenic injury after ERCP is extremely rare and only two cases have been reported in the English literature. A subcapsular splenic hematoma is reported after ERCP and the mechanism of injury and possible preventive measures are discussed.

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated. Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.(ABSTRACT TRUNCATED AT 250 WORDS)

Purtscher's retinopathy: a case of visual impairment associated with multiple trauma

This case study describes a patient with multiple trauma associated with acute visual impairment. Funduscopic examination revealed scattered and confluent cotton wool exudates bilaterally. This retinopathy was first described by Othmar Purtscher, an Austrian ophthalmologist, in 1910, which he later referred to as "angiopathia retinae traumatica."

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and biliary drainage

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and endoscopic biliary drainage have dramatically changed the diagnosis and management of disorders of the pancreas and hepatobiliary tract. Endoscopic retrograde cholangiopancreatography will provide a high-resolution study that will define accurately the nature and location of the disease process involving the pancreas or bile ducts. Although sonography, CT, and, recently, MRI may provide clues to the diagnosis, it often remains for endoscopic retrograde cholangiopancreatography to establish the diagnosis with certainty. Endoscopic sphincterotomy has been invaluable in the management of common bile-duct stones. In patients who have had their gallbladders removed, sphincterotomy has avoided reoperation in the same field and the risk of general anesthesia. Sphincterotomy also is assuming an increasingly important role in the management of common-duct stones in patients with their gallbladders in situ who are poor operative candidates. In these patients, sphincterotomy likewise avoids the risk of general anesthesia and the surgical stress of opening a major body cavity. The technique has also proved to be helpful in the palliative treatment of ampullary and distal common bile-duct carcinomas in those patients who are poor operative candidates. Finally, sphincterotomy has found a role in the treatment of choledochal cysts and may provide relief of pain in those patients with the elusive diagnoses of postcholecystectomy syndromes, biliary dyskinesias, and sphincter of Oddi dysfunction. Endoscopic biliary drainage is becoming an increasingly popular option for the palliation of malignant biliary obstruction. In those patients who are poor operative candidates, the risk of general anesthesia and major surgery is avoided. In those patients with obviously incurable tumors, endoscopic drainage allows for a brief hospitalization without surgery in the face of a short life expectancy.

Effect of low concentrations of dihydrostreptomycin on drug resistance in enteric bacteria

Beagle dogs were fed a diet containing 0, 2, or 10 mug of dihydrostreptomycin (DSM) per g of feed. The 2-mug/g level was selected to represent a residue level of the antibiotic. In both treatment groups, medicated feed resulted in a shift from a predominantly streptomycin (SM)-susceptible coliform fecal population to an SM-resistant population. The proportion of resistant organisms was significant (P < 0.01) for both treatment groups. A definitive response did not occur with animals maintained on DSM-free diets. An increase in the prevalence of DSM-resistant organisms was observed after 15 days of DSM-supplemented feeding and persisted during the posttreatment phase of the study. The predominant pattern of resistance was SM-sulfamethoxypyridazine. Fifty-nine percent of SM-resistant strains transferred resistant determinants by conjugation to Escherichia coli K-12 recipients.