BACKGROUND Coronavirus patients demonstrate varying degrees of respiratory insufficiency; many will progress to respiratory failure with a severe version of acute respiratory distress syndrome refractory to traditional supportive strategies. Providers must consider alternative therapies to deter or prevent the cascade of decompensation to fulminant respiratory failure. METHODS This is a case-series of five COVID-19 positive patients who demonstrated severe hypoxemia, declining respiratory performance, and escalating oxygen requirements. Patients met the following criteria: COVID-19 positivity, worsening respiratory performance, severe hypoxemia (Pao 2 ≤ 80) despite traditional supportive measures, escalating supplemental oxygen requirements, and D-dimer greater than 1.5 μg/mL. All patients received protocol directed thrombolytic therapy with tissue plasminogen activator (tPA). RESULTS All five patients improved without deleterious effects of thrombolytic therapy. Patient one was on maximum ventilator support, paralytics, and prone positioning without improvement. During tPA administration his Pao 2/FIO2 ratio improved from 69 to 127. Ventilator support was weaned immediately on posttreatment day 1, and he was extubated on posttreatment day 12. Our second through fifth patients were not intubated at time of initiation of tPA therapy. These patients each required significant oxygen supplementation trending toward intubation. After tPA therapy, all patients demonstrated a noticeable increase in Pao 2 values overtime. Three of these patients avoided intubation due to COVID-19–associated respiratory failure. CONCLUSION Administration of thrombolytics was followed by overall improvement in patients' oxygen requirements, and in three cases, prevented progression to mechanical ventilation, without deleterious effects. Clinical trials of thrombolytic therapy would further serve to underscore the efficacy and utility of this therapy. LEVEL OF EVIDENCE Case series of therapeutic effect, Level V.
The COVID-19 pandemic presented a unique challenge for Medical systems worldwide. Initial response to the crisis situation for the pandemic closely mirrored plans for a mass casualty event. By leveraging resources including human and physical, and by dividing our surgeon workforce into micro teams we were able to create a flexible and responsive infrastructure to address the crisis as it unfolded. By adoption of virtual platforms and equal division of labor, surgical resident education was continued. Specific adjustments to the schedule and curriculum for medical students allowed them to continue their studies safely and on schedule. Our model serves as an example by which hospital systems of similar size may utilize principles of mass casualty preparedness to craft their own plan for a future contagion response strategy.
Purpose This study presents patient-specific quality assurance (QA) results from the first 395 clinical cases for the new helical TomoTherapy® platform (Radixact) coupled with dedicated Precision TPS. Methods The passing rate of the Gamma Index (GP%) of 395 helical QA of patient-specific tomotherapy, acquired with ArcCHECK, is presented, analysed and correlated to various parameters of the plan. Following TG-218 recommendations, the clinic specific action limit (ALcs) and tolerance limit (TLcs) were calculated for our clinic and monitored during the analysed period. Results The mean values (± 1 standard deviation) of GP% (3%/2 mm) (both global and local normalization) are: 97.6% and 90.9%, respectively. The proposed ALcs and TLcs, after a period of two years’ process monitoring are 89.4% and 91.1% respectively. Conclusions The phantom measurements closely match the planned dose distributions, demonstrating that the calculation accuracy of the new Precision TPS and the delivery accuracy of the Radixact unit are adequate, with respect to international guidelines and reports. Furthermore, a first correlation with the planning parameters was made. Action and tolerance limits have been set for the new Radixact Linac.
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