A Governance Framework to Integrate Longitudinal Clinical and Community Data in a Distributed Data Network: The Childhood Obesity Data Initiative.

CONTEXT: Integrating longitudinal data from community-based organizations (eg, physical activity programs) with electronic health record information can improve capacity for childhood obesity research. OBJECTIVE: A governance framework that protects individual privacy, accommodates organizational data stewardship requirements, and complies with laws and regulations was developed and implemented to support the harmonization of data from disparate clinical and community information systems. PARTICIPANTS AND SETTING: Through the Childhood Obesity Data Initiative (CODI), 5 Colorado-based organizations collaborated to expand an existing distributed health data network (DHDN) to include community-generated data and assemble longitudinal patient records for research. DESIGN: A governance work group expanded an existing DHDN governance infrastructure with CODI-specific data use and exchange policies and procedures that were codified in a governance plan and a delegated-authority, multiparty, reciprocal agreement. RESULTS: A CODI governance work group met from January 2019 to March 2020 to conceive an approach, develop documentation, and coordinate activities. Governance requirements were synthesized from the CODI use case, and a customized governance approach was constructed to address governance gaps in record linkage, a procedure to request data, and harmonizing community and clinical data. A Master Sharing and Use Agreement (MSUA) and Memorandum of Understanding were drafted and executed to support creation of linked longitudinal records of clinical- and community-derived childhood obesity data. Furthermore, a multiparty infrastructure protocol was approved by the local institutional review board (IRB) to expedite future CODI research by simplifying IRB research applications. CONCLUSION: CODI implemented a clinical-community governance strategy that built trust between organizations and allowed efficient data exchange within a DHDN. A thorough discovery process allowed CODI stakeholders to assess governance capacity and reveal regulatory and organizational obstacles so that the governance infrastructure could effectively leverage existing knowledge and address challenges. The MSUA and complementary governance documents can inform similar efforts.

The Childhood Obesity Data Initiative: A Case Study in Implementing Clinical-Community Infrastructure Enhancements to Support Health Services Research and Public Health.

CONTEXT: We describe a participatory framework that enhanced and implemented innovative changes to an existing distributed health data network (DHDN) infrastructure to support linkage across sectors and systems. Our processes and lessons learned provide a potential framework for other multidisciplinary infrastructure development projects that engage in a participatory decision-making process. PROGRAM: The Childhood Obesity Data Initiative (CODI) provides a potential framework for local and national stakeholders with public health, clinical, health services research, community intervention, and information technology expertise to collaboratively develop a DHDN infrastructure that enhances data capacity for patient-centered outcomes research and public health surveillance. CODI utilizes a participatory approach to guide decision making among clinical and community partners. IMPLEMENTATION: CODI's multidisciplinary group of public health and clinical scientists and information technology experts collectively defined key components of CODI's infrastructure and selected and enhanced existing tools and data models. We conducted a pilot implementation with 3 health care systems and 2 community partners in the greater Denver Metro Area during 2018-2020. EVALUATION: We developed an evaluation plan based primarily on the Good Evaluation Practice in Health Informatics guideline. An independent third party implemented the evaluation plan for the CODI development phase by conducting interviews to identify lessons learned from the participatory decision-making processes. DISCUSSION: We demonstrate the feasibility of rapid innovation based upon an iterative and collaborative process and existing infrastructure. Collaborative engagement of stakeholders early and iteratively was critical to ensure a common understanding of the research and project objectives, current state of technological capacity, intended use, and the desired future state of CODI architecture. Integration of community partners' data with clinical data may require the use of a trusted third party's infrastructure. Lessons learned from our process may help others develop or improve similar DHDNs.

Simultaneous Kinematic and Contact Force Modeling of a Human Finger Tendon System Using Bond Graphs and Robotic Validation.

This paper aims to use bond graph modeling to create the most comprehensive finger tendon model and simulation to date. Current models are limited to either free motion without external contact or fixed finger force transmission between tendons and fingertip. The forward dynamics model, presented in this work, simultaneously simulates the kinematics of tendon-finger motion and contact forces of a central finger given finger tendon inputs. The model equations derived from bond graphs are accompanied by nonlinear relationships modeling the anatomical complexities of moment arms, tendon slacking, and joint range of motion (ROM). The structure of the model is validated using a robotic testbed, Utah's Anatomically correct Robotic Testbed (UART) finger. Experimental motion of the UART finger during free motion (no external contact) and surface contact are simulated using the bond graph model. The contact forces during the surface contact experiments are also simulated. On average, the model was able to predict the steady-state pose of the finger with joint angle errors less than 6 deg across both free motion and surface contact experiments. The static contact forces were accurately predicted with an average of 11.5% force magnitude error and average direction error of 12 deg.

A Community Health Record: Improving Health Through Multisector Collaboration, Information Sharing, and Technology.

We present a framework for developing a community health record to bring stakeholders, information, and technology together to collectively improve the health of a community. It is both social and technical in nature and presents an iterative and participatory process for achieving multisector collaboration and information sharing. It proposes a methodology and infrastructure for bringing multisector stakeholders and their information together to inform, target, monitor, and evaluate community health initiatives. The community health record is defined as both the proposed framework and a tool or system for integrating and transforming multisector data into actionable information. It is informed by the electronic health record, personal health record, and County Health Ranking systems but differs in its social complexity, communal ownership, and provision of information to multisector partners at scales ranging from address to zip code.

Impact of target degradation on the 6FFF output of a Varian TrueBeam Linac.

The dosimetric output of a 6FFF beam, produced from a Varian TrueBeam linac exhibited an unexpected downward trend over time that was contrary to well-established expectations. To elucidate the cause of this uncharacteristic trend, a review of the linac's quality control results over its lifetime was performed, including, constancy checks of the dosimetric output, beam energy, flatness and symmetry, and percentage depth dose characteristics. These results were supplemented with a comprehensive series of measurements including flatness and symmetry measurements with a 1D-diode array, high-resolution measurements of the photon beam's build-up region with a parallel-plate chamber and measurement of the beam's output as a function of the x-ray target position. The review of the linac's QC results and supplemental tests identified no deviations in the linac's performance from its commissioning and baseline measurements. However, the 6FFF beam output exhibited a significant dependence on the target location relative to its default position, increasing by 5.43 % with a 0.5 mm target translation, indicating that target degradation was the cause of the atypical output trend. The change in output behaviour was believed to be the result of primary electrons escaping the degraded target and interacting with the linac's monitor chamber. Replacement of the x-ray target caused the 6FFF output to realign with expected trends. Target degradation was uncovered due to a robust quality control trending database and awareness of typical output behaviour. These results demonstrate the importance of data trending to identify component failure and provide centres with knowledge to recognise this potential fault.

Using Real-World Electronic Health Record Data to Assess Chronic Disease Screening in Children: A Case Study of Non-Alcoholic Fatty Liver Disease.

Background: Data sources for assessing pediatric chronic diseases and associated screening practices are rare. One example is non-alcoholic fatty liver disease (NAFLD), a common chronic liver disease prevalent among children with overweight and obesity. If undetected, NAFLD can cause liver damage. Guidelines recommend screening for NAFLD using alanine aminotransferase (ALT) tests in children ≥9 years with obesity or those with overweight and cardiometabolic risk factors. This study explores how real-world data from electronic health records (EHRs) can be used to study NAFLD screening and ALT elevation. Research Design: Using IQVIA's Ambulatory Electronic Medical Record database, we studied patients 2-19 years of age with body mass index ≥85th percentile. Using a 3-year observation period (January 1, 2019 to December 31, 2021), ALT results were extracted and assessed for elevation (≥1 ALT result ≥22.1 U/L for females and ≥25.8 U/L for males). Patients with liver disease (including NAFLD) or receiving hepatotoxic medications during 2017-2018 were excluded. Results: Among 919,203 patients 9-19 years of age, only 13% had ≥1 ALT result, including 14% of patients with obesity and 17% of patients with severe obesity. ALT results were identified for 5% of patients 2-8 years of age. Of patients with ALT results, 34% of patients 2-8 years of age and 38% of patients 9-19 years of age had ALT elevation. Males 9-19 years of age had a higher prevalence of ALT elevation than females (49% vs. 29%). Conclusions: EHR data offered novel insights into NAFLD screening: despite screening recommendations, ALT results among children with excess weight were infrequent. Among those with ALT results, ALT elevation was common, underscoring the importance of screening for early disease detection.

Privacy preserving record linkage for public health action: opportunities and challenges.

OBJECTIVES: To understand the landscape of privacy preserving record linkage (PPRL) applications in public health, assess estimates of PPRL accuracy and privacy, and evaluate factors for PPRL adoption. MATERIALS AND METHODS: A literature scan examined the accuracy, data privacy, and scalability of PPRL in public health. Twelve interviews with subject matter experts were conducted and coded using an inductive approach to identify factors related to PPRL adoption. RESULTS: PPRL has a high level of linkage quality and accuracy. PPRL linkage quality was comparable to that of clear text linkage methods (requiring direct personally identifiable information [PII]) for linkage across various settings and research questions. Accuracy of PPRL depended on several components, such as PPRL technique, and the proportion of missingness and errors in underlying data. Strategies to increase adoption include increasing understanding of PPRL, improving data owner buy-in, establishing governance structure and oversight, and developing a public health implementation strategy for PPRL. DISCUSSION: PPRL protects privacy by eliminating the need to share PII for linkage, but the accuracy and linkage quality depend on factors including the choice of PPRL technique and specific PII used to create encrypted identifiers. Large-scale implementations of PPRL linking millions of observations-including PCORnet, National Institutes for Health N3C, and the Centers for Disease Control and Prevention COVID-19 project have demonstrated the scalability of PPRL for public health applications. CONCLUSIONS: Applications of PPRL in public health have demonstrated their value for the public health community. Although gaps must be addressed before wide implementation, PPRL is a promising solution to data linkage challenges faced by the public health ecosystem.

Evaluation of a novel phantom for the quality assurance of a six-degree-of-freedom couch 3D-printed at multiple centres.

This study aimed to validate a bespoke 3D-printed phantom for use in quality assurance (QA) of a 6 degrees-of-freedom (6DoF) treatment couch. A novel phantom design comprising a main body with internal cube structures, was fabricated at five centres using Polylactic Acid (PLA) material, with an additional phantom produced incorporating a PLA-stone hybrid material. Correctional setup shifts were determined using image registration by 3D-3D matching of high HU cube structures between obtained cone-beam computer tomography (CBCT) images to reference CTs, containing cubes with fabricated rotational offsets of 3.5°, 1.5° and -2.5° in rotation, pitch, and roll, respectively. Average rotational setup shifts were obtained for each phantom. The reproducibility of 3D-printing was probed by comparing the internal cube size as well as Hounsfield Units between each of the uniquely produced phantoms. For the five PLA phantoms, the average rot, pitch and roll correctional differences from the fabricated offsets were -0.3 ± 0.2°, -0.2 ± 0.5° and 0.2 ± 0.3° respectively, and for the PLA hybrid these differences were -0.09 ± 0.14°, 0.30 ± 0.00° and 0.03 ± 0.10°. There was found to be no statistically significant difference in average cube size between the five PLA printed phantoms, with the significant difference (P < 0.05) in HU of one phantom compared to the others attributed to setup choice and material density. This work demonstrated the capability producing a novel 3D-printed 6DoF couch QA phantom design, at multiple centres, with each unique model capable of sub-degree couch correction.

Femtosecond lasers for mass spectrometry: proposed application to catalytic hydrogenation of butadiene.

Mass spectra from the interaction of intense, femtosecond laser pulses with 1,3-butadiene, 1-butene, and n-butane have been obtained. The proportion of the fragment ions produced as a function of intensity, pulse length, and wavelength was investigated. Potential mass spectrometry applications, for example in the analysis of catalytic reaction products, are discussed.

Static Weight Perception Through Skin Stretch and Kinesthetic Information: Detection Thresholds, JNDs, and PSEs.

We examined the contributions of kinesthetic and skin stretch cues to static weight perception. In three psychophysical experiments, several aspects of static weight perception were assessed by asking participants either to detect on which hand a weight was presented or to compare between two weight cues. Two closed-loop controlled haptic devices were used to present cutaneous and kinesthetic weights, in isolation and together, with a precision of 0.05 g. Our results show that combining skin stretch and kinesthetic information leads to better weight detection thresholds than presenting uni-sensory cues does. For supra-threshold stimuli, Weber fractions were 22-44%. Kinesthetic information was less reliable for lighter weights, while both sources of information were equally reliable for weights up to 300 g. Weight was perceived as equally heavy regardless of whether skin stretch and kinesthetic cues were presented together or alone. Data for lighter weights complied with an Optimal Integration model, while for heavier weights, measurements were closer to predictions from a Sensory Capture model. The presence of correlated noise might explain this discrepancy, since that would shift predictions from the Optimal Integration model towards our measurements. Our experiments provide device-independent perceptual measures, and can be used to inform, for instance, skin stretch device design.

The Relation of Adiposity Rebound to Subsequent BMI in a Large Electronic Health Record Database.

Objective: The beginning of postinfancy increase in BMI has been termed the adiposity rebound, and an early rebound increases the risk for obesity in adolescence and adulthood. We examined whether the relation of the age at BMI rebound (agerebound) to subsequent BMI is independent of childhood BMI. Design: From the electronic health records of 2.8 million children, we selected 17,077 children examined at least once each year between ages 2 and <8 years, and who were reexamined between age 10 and <16 years. The mean age at the last visit was 12 years (SD = 1). We identified agerebound for each child using lowess, a smoothing technique. Results: Children who had an agerebound <3 years were, on average, 6.8 kg/m2 heavier after age 10 years than were children with an agerebound >7 years. However, BMI after age 10 years was more strongly associated with BMI at the rebound (BMIrebound) than with agerebound (r = 0.63 vs. -0.49). Although the relation of agerebound to BMI at the last visit was mostly independent of the BMIrebound, adjustment for age-5 BMI reduced the association's magnitude by about 55%. Conclusions: Both agerebound and the BMIrebound are independently related to BMI and obesity after age 10 years. However, a child's BMIrebound and at ages 5 and 7 years accounts for more of the variability in BMI levels after age 10 years than does agerebound.

3D-printed patient-specific pelvis phantom for dosimetry measurements for prostate stereotactic radiotherapy with dominant intraprostatic lesion boost.

AIM: Developing and assessing the feasibility of using a three-dimensional (3D) printed patient-specific anthropomorphic pelvis phantom for dose calculation and verification for stereotactic ablative radiation therapy (SABR) with dose escalation to the dominant intraprostatic lesions. MATERIAL AND METHODS: A 3D-printed pelvis phantom, including bone-mimicking material, was fabricated based on the computed tomography (CT) images of a prostate cancer patient. To compare the extent to which patient and phantom body and bones overlapped, the similarity Dice coefficient was calculated. Modular cylindrical inserts were created to encapsulate radiochromic films and ionization chamber for absolute dosimetry measurements at the location of prostate and at the boost region. Gamma analysis evaluation with 2%/2mm criteria was performed to compare treatment planning system calculations and measured dose when delivering a 10 flattening filter free (FFF) SABR plan and a 10FFF boost SABR plan. RESULTS: Dice coefficients of 0.98 and 0.91 were measured for body and bones, respectively, demonstrating agreement between patient and phantom outlines. For the boost plans the gamma analysis yielded 97.0% of pixels passing 2%/2mm criteria and these results were supported by the chamber average dose difference of 0.47 ± 0.03%. These results were further improved when overriding the bone relative electron density: 97.3% for the 2%/2mm gamma analysis, and 0.05 ± 0.03% for the ionization chamber average dose difference. CONCLUSIONS: The modular patient-specific 3D-printed pelvis phantom has proven to be a highly attractive and versatile tool to validate prostate SABR boost plans using multiple detectors.

Tracking of obesity among 2- to 9-year-olds in an electronic heath record database from 2006 to 2018.

BACKGROUND AND OBJECTIVE: As obesity among children and adolescents is associated with major health risks, including the persistence of obesity into adulthood, there has been interest in targeting prevention efforts at children and adolescent. The longitudinal tracking of BMI and obesity, as well as the effects of initial age and duration of follow-up on this tracking, were examined in a large electronic health record (EHR) database. METHODS: The data consisted of 2.04 million children who were examined from 2006 through 2018. These children were initially examined between ages 2 and 9 years and had a final examination, on average, 4 years later. RESULTS: Overall, children with obesity at one examination were 7.7 times more likely to have obesity at a subsequent examination than children with a BMI ≤ 95th percentile. Further, 71% of children with obesity at one examination continued to have obesity at re-examination. Although 2-year-olds had a relative risk of 5.5 and a positive predictive value of 54%, then sensitivity of obesity at younger ages was low. Of the children who were re-examined after age 10 y and found to have obesity, only 22% had a BMI ≥ 95th percentile at age 2 years. CONCLUSIONS: Despite the tracking of obesity at all ages, these results agree with previous reports that have found that an elevated BMI at a very young age will identify only a small proportion of older children with obesity.

The Longitudinal Relation of Childhood Height to Subsequent Obesity in a Large Electronic Health Record Database.

OBJECTIVE: Several cross-sectional studies have shown that height in childhood is correlated with BMI and with body fatness, and two longitudinal studies have reported that childhood height is associated with adult BMI. This study explored this longitudinal association in an electronic health record database of 2.8 million children. METHODS: Children were initially examined between the ages of 2 and 13.9 years and, on average, were reexamined 4 years later. RESULTS: As expected, there was a cross-sectional correlation between height-for-age z score and BMI that increased from r = -0.06 (age of 2 years) to r = 0.37 (age of 9-10 years). In addition, height-for-age at the first visit was related to subsequent BMI and obesity, with the prevalence of subsequent obesity increasing about fourfold over six categories of height-for-age at the first visit. About 40% of this longitudinal association was independent of initial BMI, but its magnitude decreased with initial age. For example, the initial height-for-age of children who were 12 years of age or older was only weakly associated with subsequent BMI. CONCLUSIONS: Health professionals should recognize that greater childhood height-for-age before 12 years of age may be a marker for increased risk of subsequent obesity.

An evaluation of techniques for dose calculation on cone beam computed tomography.

OBJECTIVE:: To assess the accuracy and efficiency of four different techniques, thus determining the optimum method for recalculating dose on cone beam CT (CBCT) images acquired during radiotherapy treatments. METHODS:: Four established techniques were investigated and their accuracy assessed via dose calculations: (1) applying a standard planning CT (pCT) calibration curve, (2) applying a CBCT site-specific calibration curve, (3) performing a density override and (4) using deformable registration. Each technique was applied to 15 patients receiving volumetric modulated arc therapy to one of three treatment sites, head and neck, lung and prostate. Differences between pCT and CBCT recalculations were determined with dose volume histogram metrics and 2.0%/0.1 mm gamma analysis using the pCT dose distribution as a reference. RESULTS:: Dose volume histogram analysis indicated that all techniques yielded differences from expected results between 0.0 and 2.3% for both target volumes and organs at risk. With volumetric gamma analysis, the dose recalculation on deformed images yielded the highest pass-rates. The median pass-rate ranges at 50% threshold were 99.6-99.9%, 94.6-96.0%, and 94.8.0-96.0% for prostate, head and neck and lung patients, respectively. CONCLUSION:: Deformable registration, HU override and site-specific calibration curves were all identified as dosimetrically accurate and efficient methods for dose calculation on CBCT images. ADVANCES IN KNOWLEDGE:: With the increasing adoption of CBCT, this study provides clinical radiotherapy departments with invaluable information regarding the comparison of dose reconstruction methods, enabling a more accurate representation of a patient's treatment. It can also integrate studies in which CBCT is used in image-guided radiation therapy and for adaptive radiotherapy planning processes.

Fiducial markers visibility and artefacts in prostate cancer radiotherapy multi-modality imaging.

BACKGROUND: In this study, a novel pelvic phantom was developed and used to assess the visibility and presence of artefacts from different types of commercial fiducial markers (FMs) on multi-modality imaging relevant to prostate cancer. METHODS AND MATERIALS: The phantom was designed with 3D printed hollow cubes in the centre. These cubes were filled with gel to mimic the prostate gland and two parallel PVC rods were used to mimic bones in the pelvic region. Each cube was filled with gelatine and three unique FMs were positioned with a clinically-relevant spatial distribution. The FMs investigated were; Gold Marker (GM) CIVCO, GM RiverPoint, GM Gold Anchor (GA) line and ball shape, and polymer marker (PM) from CIVCO. The phantom was scanned using several imaging modalities typically used to image prostate cancer patients; MRI, CT, CBCT, planar kV-pair, ExacTrac, 6MV, 2.5MV and integrated EPID imaging. The visibility of the markers and any observed artefacts in the phantom were compared to in-vivo scans of prostate cancer patients with FMs. RESULTS: All GMs were visible in volumetric scans, however, they also had the most visible artefacts on CT and CBCT scans, with the magnitude of artefacts increasing with FM size. PM FMs had the least visible artefacts in volumetric scans but they were not visible on portal images and had poor visibility on lateral kV images. The smallest diameter GMs (GA) were the most difficult GMs to identify on lateral kV images. CONCLUSION: The choice between different FMs is also dependent on the adopted IGRT strategy. PM was found to be superior to investigated gold markers in the most commonly used modalities in the management of prostate cancer; CT, CBCT and MRI imaging.

Improved military air traffic controller selection methods as measured by subsequent training performance.

INTRODUCTION: Over the past decade, the U.S. military has conducted several studies to evaluate determinants of enlisted air traffic controller (ATC) performance. Research has focused on validation of the Armed Services Vocational Aptitude Battery (ASVAB) and has shown it to be a good predictor of training performance. Despite this, enlisted ATC training and post-training attrition is higher than desirable, prompting interest in alternate selection methods to augment current procedures. The current study examined the utility of the FAA Air Traffic Selection and Training (AT-SAT) battery for incrementing the predictiveness of the ASVAB versus several enlisted ATC training criteria. METHOD: Subjects were 448 USAF enlisted ATC students who were administered the ASVAB and FAA AT-SAT subtests and subsequently graduated or were eliminated from apprentice-level training. Training criteria were a dichotomous graduation/elimination training score, average ATC fundamentals course score, and FAA certified tower operator test score. RESULTS: Results confirmed the predictive validity of the ASVAB and showed that one of the AT-SAT subtests resembling a low-fidelity ATC work sample significantly improved prediction of training performance beyond the ASVAB alone. DISCUSSION: Results suggested training attrition could be reduced by raising the current ASVAB minimum qualifying score. However, this approach may make it difficult to identify sufficient numbers of trainees and lead to adverse impact. Although the AT-SAT ATC work sample subtest showed incremental validity to the ASVAB, its length (95 min) may be problematic in operational testing. Recommendations are made for additional studies to address issues affecting operational implementation.

National Burden of Heart Failure Events in the United States, 2006 to 2014.

BACKGROUND: Heart failure (HF)-a serious and costly condition-is increasingly prevalent. We estimated the US burden including emergency department (ED) visits, inpatient hospitalizations and associated costs, and mortality. METHODS AND RESULTS: We analyzed 2006 to 2014 data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample, the Healthcare Cost and Utilization Project National (nationwide) Inpatient Sample, and the National Vital Statistics System. International Classification of Disease codes identified HF and comorbidities. Burden was estimated separately for ED visits, hospitalizations, and mortality. In addition, criteria were applied to identify total unique acute events. Rates of primary HF (primary diagnosis or underlying cause of death) and comorbid HF (comorbid diagnosis or contributing cause of death) were calculated, age standardized to the 2010 US population. In 2014, there were an estimated 1 068 412 ED visits, 978 135 hospitalizations, and 83 705 deaths with primary HF. There were 4 071 546 ED visits, 3 370 856 hospitalizations, and 230 963 deaths with comorbid HF. Between 2006 and 2014, the total unique acute event rate for primary HF declined from 536 to 449 per 100 000 (relative percent change of -16%; P for trend, <0.001) but increased for comorbid HF from 1467 to 1689 per 100 000 (relative percentage change, 15%; P for trend, <0.001). HF-related mortality decreased significantly from 2006 to 2009 but did not change meaningfully after 2009. For hospitalizations with primary HF, the estimated mean cost was $11 552 in 2014, totaling an estimated $11 billion. CONCLUSIONS: Given substantial healthcare and mortality burden of HF, rising healthcare costs, and the aging US population, continued improvements in HF prevention, management, and surveillance are important.

Efficacy of a rectal spacer with prostate SABR-first UK experience.

OBJECTIVE: This study assessed the use of implanted hydrogel rectal spacers for stereotactic ablative radiotherapy-volumetric modulated arc therapy (SABR-VMAT) patients, investigating practicality, dosimetric impact, normal tissue complication probability (NTCP) and early toxicity. METHODS: Data from the first 6 patients treated within a prostate SABR and rectal spacer trial were examined to determine spacer insertion tolerability, resultant changes in treatment planning and dosimetry and early toxicity effects. CT scans acquired prior to spacer insertion were used to generate SABR plans which were compared to post-insertion plans. Plans were evaluated for target coverage, conformity, and organs at risk doses with NTCPs also determined from resultant dose fluences. Early toxicity data were also collected. RESULTS: All patients had successful spacer insertion under local anaesthetic with maximal Grade 1 toxicity. All plans were highly conformal, with no significant differences in clinical target volume dose coverage between pre- and post-spacer plans. Substantial improvements in rectal dose metrics were observed in post-spacer plans, e.g. rectal volume receiving 36 Gy reduced by ≥42% for all patients. Median NTCP for Grade 2 + rectal bleeding significantly decreased from 4.9 to 0.8% with the use of a rectal spacer (p = 0.031). To date, two episodes of acute Grade 1 proctitis have been reported following treatment. CONCLUSION: The spacer resulted in clinically and statistically significant reduction in rectal doses for all patients. Advances in knowledge: This is one of the first studies to investigate the efficacy of a hydrogel spacer in prostate SABR treatments. Observed dose sparing of the rectum is predicted to result in meaningful clinical benefit.

Combined sewage overflows (CSO) are major urban breeding sites for Culex quinquefasciatus in Atlanta, Georgia.

A longitudinal study of mosquito ecology in Tanyard Creek, an urban stream in Atlanta, GA, that receives combined storm and waste water effluent from the Atlanta combined sewage overflow system, was undertaken in 2006. Culex quinquefasciatus was the dominant species found, but Culex restuans was also abundant during the spring with limited numbers of Culex nigripalpis and Anopheles punctipennis also collected. Significant differences in mosquito densities were found with greater densities associated with side pools of water and stagnant water. Mosquito numbers are regulated largely by flooding of the stream by effluent discharges exceeding 15 kgal/min. These floods are associated with significant immediate reductions, but not complete elimination, of mosquitoes from Tanyard Creek. Mosquito numbers rebound within 5-10 days after such floods and rapidly reach high densities.