The Radiation Therapist profession through the lens of new technology: A practice development paper based on the ESTRO Radiation Therapist Workshops.

Technological advances in radiation therapy impact on the role and scope of practice of the radiation therapist. The European Society of Radiotherapy and Oncology (ESTRO) recently held two workshops on this topic and this position paper reflects the outcome of this workshop, which included radiation therapists from all global regions. Workflows, quality assurance, research, IGRT and ART as well as clinical decision making are the areas of radiation therapist practice that will be highly influenced by advancing technology in the near future. This position paper captures the opportunities that this will bring to the radiation therapist profession, to the practice of radiation therapy and ultimately to patient care.

The Use of Lavender Aromatherapy for Pain After Total Hip and Total Knee Arthroplasty: A Randomized Trial.

A randomized clinical trial was conducted over a threemonth period with 102 participants undergoing a total hip arthroplasty (THA) or total knee arthroplasty (TKA). The study purpose was to assess whether there was a reduction in the use of opioids in the postoperative period for THA or TKA participants that utilized lavender aromatherapy as an adjunct to pain medication. The participants in the control and intervention group were administered nonopioid pain medication around the clock and opioids as needed after surgery. However, the intervention group also received a pre-packaged lavender essential oil inhaler. Total oral morphine equivalents (OME) were calculated for each participant to determine opioid usage. Although the total OME was similar for the groups overall, the total OME was slightly lower for THA patients that were enrolled in the intervention group (median 22.5) compared to THA patients that were enrolled in the control group (median 31.2). In the intervention group, 58% of participants reported that the lavender inhaler was a useful tool for pain management and 76% indicated they would continue to use the lavender inhaler after discharge.

The QuADRANT study: Current status and recommendations for improving uptake and implementation of clinical audit of medical radiological procedures in Europe. The radiotherapy perspective.

BACKGROUND: QuADRANT was a research project funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive). AIM: Focusing on the QuADRANT objectives - to obtain an overview of European clinical audit activity; identify good practices, resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety focusing on the field of radiotherapy. RESULTS: A pan-European survey, expert interviews and a literature review conducted within the framework of the QuADRANT project indicated that developments in national clinical audit infrastructure are required. While in radiotherapy, there is a strong tradition and high level of experience of dosimetry audits and well-established practice through the IAEA's QUATRO audits, few countries have a well-established comprehensive clinical audit programme or international/national initiatives on tumour specific clinical audits. Even if sparse, the experience from countries with established system of quality audits can be used as role-models for national professional societies to promote clinical audit implementation. However, resource allocation and national prioritisation of clinical audit are needed in many countries. National and international societies should take the initiative to promote and facilitate training and resources (guidelines, experts, courses) for clinical audits. Enablers used to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. Because there is a persisting variation in European awareness of BSSD clinical audit requirements, work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes. The aim is to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation. CONCLUSION: QuADRANT provided an overarching view of clinical audit practice in Europe, with all its related aspects. Unfortunately, it showed that the awareness of the BSSD requirements for clinical audit are highly variable. Therefore, there is an urgent need to dedicate efforts towards ensuring that regulatory inspections also incorporate an assessment of clinical audit program(s), affecting all aspects of clinical work and specialties involved in patient exposure to ionising radiation.

QuADRANT: a study on uptake and implementation of clinical audit of medical radiological procedures in Europe-expert recommendations for improvement, endorsed by the ESR.

BACKGROUND: QuADRANT was a study funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive). AIMS: QuADRANT objectives-obtain an overview of European clinical audit activity; identify good practices and resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety in the three core project specialties, radiology, radiotherapy and nuclear medicine. FINDINGS AND RECOMMENDATIONS: QuADRANT identified that developments in national clinical audit infrastructure are required. National professional societies can be pivotal in improving clinical audit implementation, but resource allocation and national prioritisation of clinical audit are needed in many countries. Lack of staff time and expertise are also barriers. Enablers to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. There is persisting variation in European awareness of BSSD clinical audit requirements. Work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation. CONCLUSION: QuADRANT provides an important step towards enhancing clinical audit uptake and implementation across Europe and improving patient safety and outcomes.

Association of Body Mass Index With the Safety Profile of Nivolumab With or Without Ipilimumab.

Importance: Increased survival with immune checkpoint inhibitors has been reported for patients with obesity vs a normal body mass index (BMI). However, the association of obesity with the safety of immune checkpoint inhibitors warrants study. Objective: To investigate associations between BMI and immune-related adverse events (irAEs) among patients with advanced cancers treated with nivolumab monotherapy and nivolumab plus ipilimumab combination therapy. Design, Setting, and Participants: This study was a retrospective pooled analysis of 3772 patients from 14 multicenter CheckMate clinical trials across 8 tumor types. Patients with advanced cancers received nivolumab, 3 mg/kg (n = 2746); nivolumab, 3 mg/kg, plus ipilimumab, 1 mg/kg (n = 713); or nivolumab, 1 mg/kg, plus ipilimumab, 3 mg/kg (n = 313). Baseline BMI was categorized as normal weight or underweight (<25), overweight (25 to <30), or obese (≥30) according to World Health Organization criteria. The studies began patient enrollment between February 9, 2012, and May 21, 2015, and patients were followed up to database lock on May 1, 2019. Data analysis was conducted from May 1 to September 1, 2019. Interventions: Nivolumab, 3 mg/kg; nivolumab, 3 mg/kg, plus ipilimumab, 1 mg/kg; and nivolumab, 1 mg/kg, plus ipilimumab, 3 mg/kg. Main Outcomes and Measures: Odds ratios (ORs) and 95% CIs for incidence of any-grade and grade 3 or 4 irAEs were calculated for patients with obesity vs normal weight or underweight BMI in the overall cohort and in subgroups based on patient and tumor characteristics. Analyses for nivolumab plus ipilimumab cohorts were exploratory. Results: A total of 3772 patients were included, 2600 were male (69%), and median age was 61 years (range, 18-90 years). For patients receiving monotherapy with nivolumab, 3 mg/kg (n = 2746), the incidence of any-grade irAEs was higher in patients with obesity (n = 543) vs those with normal weight or underweight BMI (n = 1266; OR, 1.71; 95% CI, 1.38-2.11). Incidence of grade 3 or 4 irAEs did not differ between patients with obesity and those with normal weight or underweight BMI (OR, 1.21; 95% CI, 0.92-1.61). Risk of any-grade and grade 3 or 4 irAEs appeared consistent with that in the overall population across all subgroups evaluated except for a higher likelihood of grade 3 or 4 irAEs among female patients with obesity vs normal weight or underweight BMI (OR, 1.73; 95% CI, 1.07-2.79). For patients receiving nivolumab plus ipilimumab, the incidence of irAEs appeared consistent across BMI categories. Conclusions and Relevance: Obesity appeared to be associated with an increased incidence of any-grade irAEs among patients treated with nivolumab monotherapy and with grade 3 or 4 irAEs among female patients only. These findings may inform the monitoring of patients at high risk of developing irAEs.

Exploring radiation therapist education and training.

Radiation therapy has become increasingly complex over time and is rapidly evolving. Radiation therapists play a key role within the interdisciplinary team and their education must prepare them to function effectively in the future in order to ensure a safe, high quality radiation therapy service. The aim of this research was to evaluate the current status of radiation therapist education to establish the duration of education programs, the percentage of radiation therapy-specific content and the professional title on graduation. A survey was developed, based on the questionnaire used for the ESTRO 3rd Revision of the Core Curriculum for Radiation Therapists. This was piloted by colleagues to verify the validity of the survey and also its use outside of the European context. The final survey was distributed purposively through Survey Monkey via a local gatekeeper to key radiation therapy personnel covering all of Europe and Australia, New Zealand, USA and South Korea in January 2021 who distributed it to educational institutes and clinical departments in their respective countries. 101 responses were received of which 58 were fully complete and available for analysis representing 30 countries, 26 European and 4 beyond Europe. The duration and radiation therapy-specific content of education programs varied considerably with dedicated radiation therapy programs from the respondents offered only in Ireland, Australia, New Zealand, and the U.S.A. 17 countries in the survey offer 'combined' programs with the majority dedicating less than 20% of their content to radiation therapy. Of note is that several respondents were unable to state the percentage of content related to radiation therapy and there was a variation in content and duration of programs, even within a single country. This survey has demonstrated that there remains a significant deficit in the educational programs of radiation therapists in many regions.

A National Cyberattack Affecting Radiation Therapy: The Irish Experience.

On Friday, May 14, 2021, the Health Service Executive, the organization providing public health services in the Republic of Ireland, was the victim of a significant cyberattack on its information technology systems. All systems were subsequently shut down to prevent further damage and to allow cybersecurity experts to investigate the attack. As a result, oncology services were severely disrupted, with the cessation of radiation therapy treatments in all public radiation therapy departments. Ireland has 5 large public and 6 smaller private radiation therapy centers in total. Because of the widespread adoption of electronic medical records in radiation therapy departments, it wasn't possible to retrieve patient details of those who were undergoing radiation therapy at the time of the cyberattack. In total, 513 patients nationally had their radiation therapy interrupted. A national radiation therapy cyberattack response team was formed immediately to oversee the response to the attack. The immediate concerns were radiation therapy emergencies and category 1 patients where gaps in treatment would have an adverse effect on outcome. Communication with patients and the public was also established as a priority and agreements were reached with the private sector for the treatment of patients affected by the cyberattack. The national media was used to alert patients of the need to communicate with their radiation therapy department. Dedicated phone lines were established. Locally, radiation therapy departments held daily crisis meetings with key staff members, including information technology personnel. Individual centers employed different technologies for treatment planning and data storage, so local solutions to the cyberattack to reestablish radiation therapy for patients were developed. In addition, national documentation on prioritization of patients to resume treatment was produced and a national approach was made to compensate for gaps in treatment caused by the attack. All 5 centers had reestablished radiation therapy by May 30, although there has been a long aftermath to the cyberattack. In this article, we provide an overview of the effects of the cyberattack on our national radiation therapy service and our strategy to resume patient treatment in a timely fashion.

Outcomes and Material Cost Comparison of Transosseous Versus Suture Anchor Fixation of the Achilles Tendon: A Retrospective Study.

Insertional Achilles tendinopathy is a common pathology that may be resistant to conservative treatment requiring surgical intervention. Treatment often involves partial to complete detachment of the Achilles tendon, debridement, and reattachment. Although 50% of the tendon may be safely resected without significantly compromising strength, the addition of a lengthening procedure requires further reinforcement. We conducted a retrospective review of 43 procedures comparing outcomes of 16 single suture anchor procedures with 27 transosseous fixation procedures for reattachment of the Achilles. The suture anchor group utilized one of 2 different industry anchors while the transosseous group utilized sutures ranging in size from 2-0 to #2. Female patients contributed 67% of the procedures with 53% occurring on the left side. For each group the median preoperative pain score (scale 0-10) was 8 and the median of the lowest reported postoperative pain score was 0. The typical time to lowest postoperative pain was 10 weeks for the suture anchor group and 4 weeks for the transosseous group. Tourniquet time averaged 59.3 (12.9) minutes for the suture anchor group and 65.1 (16.4) for the transosseous group. There was a large difference in material costs between the suture anchor and transosseous groups which ranged from $364.51 to $448.51 and $99.80 to $104.00 respectively. With similar results on postoperative pain and adverse event rate to suture anchor fixation and lower material costs than anchor fixation, transosseous fixation remains a viable option for fixating the Achilles tendon to bone in treatment of insertional Achilles tendinopathy.

Future-proof Radiation therapist (RTT) practice in a pandemic - Lessons learnt from COVID-19.

BACKGROUND AND PURPOSE: The European SocieTy for Radiotherapy and Oncology Radiation Therapist Committee (ESTRO RTTC) published a guidance document and infographic providing recommendations to minimise risk of COVID-19 transmission in radiotherapy (RT) departments. The purpose of this study was to investigate the changes embedded in RT practice in the COVID-19 era and to recommend proactive measures to protect RT practice in future pandemics. MATERIALS AND METHODS: The study was initiated by the ESTRO Radiation Oncology Safety and Quality Committee (ROSQC). A survey consisting of multiple choice, open ended and Likert scale questions was created to analyse the extent of changes embedded in RT practice in response to the COVID-19 pandemic under the four domains: patient care, RTT workflow, remote working and RT practice. This online survey was distributed globally in May 2020. RESULTS: 229 respondents across 27 countries completed the survey. 60% of respondents reported continuing/commencing RT in COVID-19 patients. Routine testing of patients and RTTs was not common. Split teams' procedures, hot linacs and separate entrances were implemented by 50% of respondents. Remote working was implemented for RT team members where face to face patient contact was not essential. Lack of staff, connectivity issues and lack of confirmed positive cases in the department were the main reasons cited for not implementing recommended measures. CONCLUSION: It is suggested that RT departments have responded to the COVID-19 pandemic and implemented certain changes in RT practice. RT departments should act now to implement recommended proactive measures to protect patients and RTTs - frontline healthcare workers.