Immobilization-Related Hypercalcemia in a COVID-19 Patient With Prolonged Intensive Care Unit Stay.

ABSTRACT: Immobilization-related hypercalcemia is an uncommon finding in patients admitted to intensive care unit. We report a case of severe hypercalcemia in a COVID-19 patient admitted to intensive care unit for hypoxemic respiratory failure. He developed an acute kidney injury requiring continuous renal replacement therapy with regional citrate anticoagulation. Citrate chelates ionized calcium and stop the coagulation cascade locally, preventing filter clotting. Calcium is then given intravenously to a specific target (normocalcemia). It is only when calcium infusion has been stopped that bone resorption and hypercalcemia were unmasked.

Simulation of the impact of people mobility, vaccination rate, and virus variants on the evolution of Covid-19 outbreak in Italy.

We have further extended our compartmental model describing the spread of the infection in Italy. As in our previous work, the model assumes that the time evolution of the observable quantities (number of people still positive to the infection, hospitalized and fatalities cases, healed people, and total number of people that has contracted the infection) depends on average parameters, namely people diffusion coefficient, infection cross-section, and population density. The model provides information on the tight relationship between the variation of the reported infection cases and a well-defined observable physical quantity: the average number of people that lie within the daily displacement area of any single person. With respect to our previous paper, we have extended the analyses to several regions in Italy, characterized by different levels of restrictions and we have correlated them to the diffusion coefficient. Furthermore, the model now includes self-consistent evaluation of the reproduction index, effect of immunization due to vaccination, and potential impact of virus variants on the dynamical evolution of the outbreak. The model fits the epidemic data in Italy, and allows us to strictly relate the time evolution of the number of hospitalized cases and fatalities to the change of people mobility, vaccination rate, and appearance of an initial concentration of people positives for new variants of the virus.

Therapeutic Rationale for Endotoxin Removal with Polymyxin B Immobilized Fiber Column (PMX) for Septic Shock.

Endotoxin removal therapy with polymyxin B immobilized fiber column (PMX) has been clinically applied for sepsis and septic shock patients since 1994. The effectiveness and usefulness of this therapy have been demonstrated for more than a quarter of a century. However, a documented survival benefit has not yet been demonstrable in a large, multicenter, randomized and controlled trial. Following the findings derived from a large sepsis clinical trial with PMX in North America, a new trial is ongoing to determine if PMX has a long-term survival benefit when administered to septic patients. Another approach to support a survival benefit from intervention with PMX is to utilize a detailed analysis available from a large clinical data base. The endotoxin adsorption capacity of PMX columns in vitro and the effectiveness of PMX columns can be further demonstrable in animal models. The capability of PMX and details of its mechanism of action to intervene in the sepsis cascade and impede organ dysfunction in septic patients is not fully understood. The surface antigen expression in monocytes and neutrophils are improved after PMX therapy. Immunomodulatory effects as a result of endotoxin removal and/or other mechanisms of action have been suggested. These effects and other potential immune effects may explain some of the improved effects upon organ dysfunction of sepsis and septic shock patients. Endotoxemia may be involved in the pathophysiology of other diseases than sepsis. A rapid diagnostic method to detect and target endotoxemia could allow us to practice precision medicine and expand the clinical indications of endotoxin removal therapy.

Uncertainty in the positioning of patients receiving treatment for brain metastases and wearing surgical mask underneath thermoplastic mask during COVID-19 crisis.

Thermoplastic masks, used along with surgical masks, enable immobilization methods to reduce the risk of infection in patients undergoing intracranial stereotactic radiosurgery and stereotactic radiotherapy (SRS/SRT) during the COVID-19 crisis. The purpose of this study was to investigate the feasibility of thermoplastic mask immobilization with a surgical mask using an ExacTrac system. Twelve patients each with brain metastases were immobilized using a thermoplastic mask and a surgical mask and only a thermoplastic mask. Two x-ray images were acquired to correct (XC) and verify (XV) the patient's position at a couch angle of 0°. Subsequently, the XC and XV images were acquired at each planned couch angle for non-coplanar beams. When the position errors were detected after couch rotation for non-coplanar beams, the errors were corrected at each planned couch angle until a clinically acceptable tolerance was attained. The position errors in the translational and rotational directions (vertical, lateral, longitudinal, pitch, roll, and yaw) were retrospectively investigated using data from the ExacTrac system database. A standard deviation of XC translational and rotational position errors with and without a surgical mask in the lateral (1.52 vs 2.07 mm), longitudinal (1.59 vs 1.87 mm), vertical (1.00 vs 1.73 mm), pitch (0.99 vs 0.79°), roll (1.24 vs 0.68°), and yaw (1.58 vs 0.90°) directions were observed at a couch angle of 0°. Most of patient positioning errors were less than 1.0 mm or 1.0° after the couch was rotated to the planned angle for non-coplanar beams. The overall absolute values of the translational and rotational XV position errors with and without the surgical mask were less than 0.5 mm and 0.5°, respectively. This study showed that a thermoplastic mask with a surgical mask is a feasible immobilization technique for brain SRS/SRT patients using the ExacTrac system.

Intra-fractional patient setup error during fractionated intracranial stereotactic irradiation treatment of patients wearing medical masks: comparison with and without bite block during COVID-19 pandemic.

The immobilization of patients with a bite block (BB) carries the risk of interpersonal infection, particularly in the context of pandemics such as COVID-19. Here, we compared the intra-fractional patient setup error (intra-SE) with and without a BB during fractionated intracranial stereotactic irradiation (STI). Fifteen patients with brain metastases were immobilized using a BB without a medical mask, while 15 patients were immobilized without using a BB and with a medical mask. The intra-SEs in six directions (anterior-posterior (AP), superior-inferior (SI), left-right (LR), pitch, roll, and yaw) were calculated by using cone-beam computed tomography images acquired before and after the treatments. We analyzed a total of 53 and 67 treatment sessions for the with- and without-BB groups, respectively. A comparable absolute mean translational and rotational intra-SE was observed (P > 0.05) in the AP (0.19 vs 0.23 mm with- and without-BB, respectively), SI (0.30 vs 0.29 mm), LR (0.20 vs 0.29 mm), pitch (0.18 vs 0.27°), roll (0.23 vs 0.23°) and yaw (0.27 vs 22°) directions. The resultant planning target volume (PTV) margin to compensate for intra-SE was <1 mm. No statistically significant correlation was observed between the intra-SE and treatment times. A PTV margin of <1 mm was achieved even when patients were immobilized without a BB during STI dose delivery.

Effect of Surgical Mask on Setup Error in Head and Neck Radiotherapy.

PURPOSE: With the widespread prevalence of Corona Virus Disease 2019 (COVID-19), cancer patients are suggested to wear a surgical mask during radiation treatment. In this study, cone beam CT (CBCT) was used to investigate the effect of surgical mask on setup errors in head and neck radiotherapy. METHODS: A total of 91 patients with head and neck tumors were selected. CBCT was performed to localize target volume after patient set up. The images obtained by CBCT before treatment were automatically registered with CT images and manually fine-tuned. The setup errors of patients in 6 directions of Vrt, Lng, Lat, Pitch, Roll and Rotation were recorded. The patients were divided into groups according to whether they wore the surgical mask, the type of immobilization mask used and the location of the isocenter. The setup errors of patients were calculated. A t-test was performed to detect whether it was statistically significant. RESULTS: In the 4 groups, the standard deviation in the directions of Lng and Pitch of the with surgical mask group were all higher than that in the without surgical mask group. In the head-neck-shoulder mask group, the mean in the Lng direction of the with surgical mask group was larger than that of the without surgical mask group. In the lateral isocenter group, the mean in the Lng and Pitch directions of the with surgical mask group were larger than that of the without surgical mask group. The t-test results showed that there was significant difference in the setup error between the 2 groups (p = 0.043 and p = 0.013, respectively) only in the Lng and Pitch directions of the head-neck-shoulder mask group. In addition, the setup error of 6 patients with immobilization open masks exhibited no distinguished difference from that of the patients with regular immobilization masks. CONCLUSION: In the head and neck radiotherapy patients, the setup error was affected by wearing surgical mask. It is recommended that the immobilization open mask should be used when the patient cannot finish the whole treatment with a surgical mask.

Thrombotic Complications of COVID-19 Infection: A Review.

The novel coronavirus (severe acute respiratory syndrome CoV-2 [SARS-CoV-2]), also known as COVID-19, is a single-stranded enveloped RNA virus that created a Public Health Emergency of International Concern in January 2020, with a global case burden of over 15 million in just 7 months. Infected patients develop a wide range of clinical manifestations-typically presenting with fever, cough, myalgia, and fatigue. Severely ill patients may fall victim to acute respiratory distress syndrome, acute heart injuries, neurological manifestations, or complications due to secondary infections. These critically ill patients are also found to have disrupted coagulation function, predisposing them to consumptive coagulopathies, and both venous and thromboembolic complications. Common laboratory findings include thrombocytopenia, elevated D-dimer, fibrin degradation products, and fibrinogen, all of which have been associated with greater disease severity. Many cases of pulmonary embolism have been noted, along with deep vein thrombosis, ischemic stroke, myocardial infarction, and systemic arterial embolism. The pathogenesis of coronavirus has not been completely elucidated, but the virus is known to cause excessive inflammation, endothelial injury, hypoxia, and disseminated intravascular coagulation, all of which contribute to thrombosis formation. These patients are also faced with prolonged immobilization while staying in the hospital or intensive care unit. It is important to have a high degree of suspicion for thrombotic complications as patients may rapidly deteriorate in severe cases. Evidence suggests that prophylaxis with anticoagulation may lead to a lower risk of mortality, although it does not eliminate the possibility. The risks and benefits of anticoagulation treatment should be considered in each case. Patients should be regularly evaluated for bleeding risks and thrombotic complications.