SAFESTEREO: phase II randomized trial to compare stereotactic radiosurgery with fractionated stereotactic radiosurgery for brain metastases.

BACKGROUND: Stereotactic radiosurgery (SRS) is a frequently chosen treatment for patients with brain metastases and the number of long-term survivors is increasing. Brain necrosis (e.g. radionecrosis) is the most important long-term side effect of the treatment. Retrospective studies show a lower risk of radionecrosis and local tumor recurrence after fractionated stereotactic radiosurgery (fSRS, e.g. five fractions) compared with stereotactic radiosurgery in one or three fractions. This is especially true for patients with large brain metastases. As such, the 2022 ASTRO guideline of radiotherapy for brain metastases recommends more research to fSRS to reduce the risk of radionecrosis. This multicenter prospective randomized study aims to determine whether the incidence of adverse local events (either local failure or radionecrosis) can be reduced using fSRS versus SRS in one or three fractions in patients with brain metastases. METHODS: Patients are eligible with one or more brain metastases from a solid primary tumor, age of 18 years or older, and a Karnofsky Performance Status ≥ 70. Exclusion criteria include patients with small cell lung cancer, germinoma or lymphoma, leptomeningeal metastases, a contraindication for MRI, prior inclusion in this study, prior surgery for brain metastases, prior radiotherapy for the same brain metastases (in-field re-irradiation). Participants will be randomized between SRS with a dose of 15-24 Gy in 1 or 3 fractions (standard arm) or fSRS 35 Gy in five fractions (experimental arm). The primary endpoint is the incidence of a local adverse event (local tumor failure or radionecrosis identified on MRI scans) at two years after treatment. Secondary endpoints are salvage treatment and the use of corticosteroids, bevacizumab, or antiepileptic drugs, survival, distant brain recurrences, toxicity, and quality of life. DISCUSSION: Currently, limiting the risk of adverse events such as radionecrosis is a major challenge in the treatment of brain metastases. fSRS potentially reduces this risk of radionecrosis and local tumor failure. TRIAL REGISTRATION: ClincalTrials.gov, trial registration number: NCT05346367 , trial registration date: 26 April 2022.

Estimating urban air pollution contribution to South Platte River nitrogen loads with National Atmospheric Deposition Program data and SPARROW model.

Air pollution is commonly disregarded as a source of nutrient loading to impaired surface waters managed under the Clean Water Act per states' 303(d) list programs. The contribution of air pollution to 2017-2018 South Platte River nitrogen (N) loads was estimated from the headwaters to the gage at Weldona, Colorado, USA (100 km downstream of Denver), using data from the National Atmospheric Deposition Program (NADP) and the SPAtially Referenced Regressions On Watershed attributes (SPARROW) model. The NADP offers wet-deposition raster created by spatial interpolation of data collected from regionally representative monitoring sites, excluding the influences from urban site data. For this study, NADP wet-deposition data obtained from sites within the Denver-Boulder, Colorado, urban corridor were included and excluded in new spatial interpolations of wet-deposition raster, which were used as input for SPARROW to model the influence of urban air pollution sources on South Platte River loads. Because urban air pollution is already incorporated into the NADP Total Deposition modeling methodology, dry N deposition was held constant for each SPARROW modeling scenario when dry deposition was included. By including the urban wet-deposition data in the model, estimated N loading to the South Platte River at Denver increased by 9-11 percent. Factoring in dry deposition at a 1:1.8 dry:wet ratio obtained from the results, urban air pollution was estimated to contribute as much as 20 percent of the nitrate Total Maximum Daily Load for Segment 14 of the South Platte River.

Acute toxicity of intraoperative radiotherapy and external beam-accelerated partial breast irradiation in elderly breast cancer patients.

BACKGROUND AND PURPOSE: We investigated the acute toxicity of accelerated partial breast irradiation using external beam (EB-APBI) or intraoperative radiotherapy (IORT) techniques in elderly breast cancer patients. MATERIALS AND METHODS: Women ≥ 60 years with unifocal breast tumors of ≤ 30 mm were eligible for this prospective multi-center cohort study. IORT was applied with electrons following lumpectomy (23.3 Gy). EB-APBI was delivered using 3D-CRT or IMRT in 10 daily fractions of 3.85 Gy within 6 weeks after surgery. Acute toxicity was scored using the CTCAE v3.0 at 3 months after treatment. Patient-reported symptoms were analyzed using visual analogue scales (VAS) for pain and fatigue (scale 0-10), and single items from the EORTC QLQ-C30 and Breast Cancer questionnaires. RESULTS: In total, 267 (IORT) and 206 (EB-APBI) patients were available for toxicity analysis. More patients experienced ≥ grade 2 CTCAE acute toxicity in the IORT group (10.4% IORT and 4.9% EB-APBI; p = 0.03); grade 3 toxicity was low (3.3% IORT and 1.5% EB-APBI; ns); and no grade 4 toxicity occurred. EB-APBI patients experienced less fatigue direct postoperatively (EORTC p < 0.00, VAS p < 0.00). After 3 months only pain, according to the VAS scale, was significantly worse in the EB-APBI group (p < 0.00). CONCLUSION: Acute toxicity after IORT and EB-APBI treatment is acceptable.

The at-wavelength metrology facility for UV- and XUV-reflection and diffraction optics at BESSY-II.

A technology center for the production of high-precision reflection gratings has been established. Within this project a new optics beamline and a versatile reflectometer for at-wavelength characterization of UV- and XUV-reflection gratings and other (nano-) optical elements has been set up at BESSY-II. The Plane Grating Monochromator beamline operated in collimated light (c-PGM) is equipped with an SX700 monochromator, of which the blazed gratings (600 and 1200 lines mm(-1)) have been recently exchanged for new ones of improved performance produced in-house. Over the operating range from 10 to 2000 eV this beamline has very high spectral purity achieved by (i) a four-mirror arrangement of different coatings which can be inserted into the beam at different angles and (ii) by absorber filters for high-order suppression. Stray light and scattered radiation is removed efficiently by double sets of in situ exchangeable apertures and slits. By use of in- and off-plane bending-magnet radiation the beamline can be adjusted to either linear or elliptical polarization. One of the main features of a novel 11-axes reflectometer is the possibility to incorporate real life-sized gratings. The samples are adjustable within six degrees of freedom by a newly developed UHV-tripod system carrying a load up to 4 kg, and the reflectivity can be measured between 0 and 90° incidence angle for both s- and p-polarization geometry. This novel powerful metrology facility has gone into operation recently and is now open for external users. First results on optical performance and measurements on multilayer gratings will be presented here.

Less increase of CT-based calcium scores of the coronary arteries : Effect three years after breast-conserving radiotherapy using breath-hold.

PURPOSE: The aim of this prospective longitudinal study was to compare coronary artery calcium (CAC) scores determined before the start of whole breast irradiation with those determined 3 years afterwards. PATIENTS AND METHODS: Changes in CAC scores were analysed in 99 breast cancer patients. Three groups were compared: patients receiving left- and right-sided radiotherapy, and those receiving left-sided radiotherapy with breath-hold. We analysed overall CAC scores and left anterior descending (LAD) and right coronary artery (RCA) CAC scores. Between the three groups, changes of the value of the LAD minus the RCA CAC scores of each individual patient were also compared. RESULTS: Three years after breath-hold-based whole breast irradiation, a less pronounced increase of CAC scores was noted. Furthermore, LAD minus RCA scores in patients treated for left-sided breast cancer without breath-hold were higher when compared to LAD minus RCA scores of patients with right-sided breast cancers and those with left-sided breast cancer treated with breath-hold. CONCLUSION: Breath-hold in breast-conserving radiotherapy leads to a less pronounced increase of CT-based CAC scores. Therefore, breath-hold probably prevents the development of radiation-induced coronary artery disease. However, the sample size of this study is limited and the follow-up period relatively short.

Effectiveness of insulin therapy in people with Type 2 diabetes in the Hoorn Diabetes Care System.

AIMS: To identify HbA1c trajectories after the start of insulin treatment and to identify clinically applicable predictors of the response to insulin therapy. METHODS: The study population comprised 1203 people with Type 2 diabetes included in the Hoorn Diabetes Care System (n = 9849). Inclusion criteria were: age ≥ 40 years; initiation of insulin during follow-up after failure to reach HbA1c levels ≤ 53 mmol/mol (7%) with oral glucose-lowering agents; and a follow up ≥ 2 years after initiating insulin. Latent class growth modelling was used to identify trajectories of HbA1c . Subjects considered to be 'off target' had HbA1c levels ≥ 53 mmol/mol (7.0%) during one-third or more of the follow-up time, and those considered to be 'on target' had HbA1c levels ≥ 53 mmol/mol (7.0%) during less than one-third of the follow-up time. RESULTS: Four HbA1c trajectories were identified. Most people (88.7%) were classified as having a stable HbA1c trajectory of ~57 mmol/mol (7.4%). Only 24.4% of the people were on target in response to insulin; this was associated with lower HbA1c levels and a higher age at the start of insulin treatment. CONCLUSIONS: Using latent class growth modelling, four HbA1c trajectories were identified. A quarter of the people starting insulin were on target. Low HbA1c levels and advanced age at the start of insulin therapy were associated with better response to insulin therapy. Initiating insulin earlier improves the likelihood of achieving and sustaining glycaemic control.

Links between N deposition and nitrate export from a high-elevation watershed in the Colorado Front Range.

Long-term patterns of stream nitrate export and atmospheric N deposition were evaluated over three decades in Loch Vale, a high-elevation watershed in the Colorado Front Range. Stream nitrate concentrations increased in the early 1990 s, peaked in the mid-2000s, and have since declined by over 40%, coincident with trends in nitrogen oxide emissions over the past decade. Similarities in the timing and magnitude of N deposition provide evidence that stream chemistry is responding to changes in atmospheric deposition. The response to deposition was complicated by a drought in the early 2000s that enhanced N export for several years. Other possible explanations, including forest disturbance, snow depth, or permafrost melting, could not explain patterns in N export. Our results show that stream chemistry responds rapidly to changes in N deposition in high-elevation watersheds, similar to the response observed to changes in sulfur deposition.

Dosimetric Analyses of the Three Radiation Techniques Used in the EORTC 22922/10925 IM-MS Breast Cancer Trial.

PURPOSE: The aim of the current study is to compare the dosimetry of 3 radiation therapy (RT) techniques used in the EORTC 22922/10925 trial for irradiating the internal mammary (IM) and medial supraclavicular nodes (MS) using a treatment planning system available nowadays for dose calculation. METHODS: We performed a retrospective dosimetry analysis of anonymised data; thus, ethics approval was not required. Ten cases of left-sided breast were randomly selected for RT planning to a total dose of 50 Gy in 25 fractions. The treatment planning was done according to the trial's protocol and under the supervision of the EORTC trial's coordinators. Doses to planning target volumes (PTV) and to organs at risk (OARs) are reported. Data is presented in descriptive statistics. RESULTS: A total of 10 cases and 40 treatment plans (4 plans per case: standard-plan A, modified standard-plan B, individualised-plan C and breast-only-plan D). For all planning techniques, the mean dose to the PTV of the left breast (plan A-D) and the PTV-MS (plan A-C) exceeded 95% of the prescribed dose (>47.5 Gy). The individualised technique (plan C) had a lower coverage for PTV-IM, with a mean of 87% of the prescribed dose compared to ∼102% for plans A and B. The dose to OARs varied between techniques, with the mean heart dose being higher in the standard and modified standard techniques (18.3 and 16.6 Gy, respectively) compared to the individualised technique (9.5 Gy). CONCLUSIONS: The 3 RT techniques used in the trial varied in target coverage and OARs dose. Our results may help to understand the observed larger absolute benefit of individualised IM-MS treatment planning in terms of breast cancer outcomes.

Evaluation of stream chemistry trends in US Geological Survey reference watersheds, 1970-2010.

The Hydrologic Benchmark Network (HBN) is a long-term monitoring program established by the US Geological Survey in the 1960s to track changes in the streamflow and stream chemistry in undeveloped watersheds across the USA. Trends in stream chemistry were tested at 15 HBN stations over two periods (1970-2010 and 1990-2010) using the parametric Load Estimator (LOADEST) model and the nonparametric seasonal Kendall test. Trends in annual streamflow and precipitation chemistry also were tested to help identify likely drivers of changes in stream chemistry. At stations in the northeastern USA, there were significant declines in stream sulfate, which were consistent with declines in sulfate deposition resulting from the reductions in SO2 emissions mandated under the Clean Air Act Amendments. Sulfate declines in stream water were smaller than declines in deposition suggesting sulfate may be accumulating in watershed soils and thereby delaying the stream response to improvements in deposition. Trends in stream chemistry at stations in other part of the country generally were attributed to climate variability or land disturbance. Despite declines in sulfate deposition, increasing stream sulfate was observed at several stations and appeared to be linked to periods of drought or declining streamflow. Falling water tables might have enhanced oxidation of organic matter in wetlands or pyrite in mineralized bedrock thereby increasing sulfate export in surface water. Increasing sulfate and nitrate at a station in the western USA were attributed to release of soluble salts and nutrients from soils following a large wildfire in the watershed.

Effect of power plant emission reductions on a nearby wilderness area: a case study in northwestern Colorado.

This study evaluates the effect of emission reductions at two coal-fired power plants in northwestern Colorado on a nearby wilderness area. Control equipment was installed at both plants during 1999-2004 to reduce SO2 and NOx emissions. One challenge was separating the effects of local from regional emissions, which also declined during the study period. The long-term datasets examined confirm that emission reductions had a beneficial effect on air and water quality in the wilderness. Despite a 75 % reduction in SO2 emissions, sulfate aerosols measured in the wilderness decreased by only 20 %. Because the site is relatively close to the power plants (<75 km), the slow rate of conversion of SO2 to sulfate, particularly under conditions of low relative humidity, might account for this less than one-to-one response. On the clearest days, emissions controls appeared to improve visibility by about 1 deciview, which is a small but perceptible improvement. On the haziest days, however, there was little improvement perhaps reflecting the dominance of regional haze and other components of visibility degradation particularly organic carbon and dust. Sulfate and acidity in atmospheric deposition decreased by 50 % near the southern end of the wilderness of which 60 % was attributed to power plant controls and the remainder to reductions in regional sources. Lake water sulfate responded rapidly to trends in deposition declining at 28 lakes monitored in and near the wilderness. Although no change in the acid-base status was observed, few of the lakes appear to be at risk from chronic or episodic acidification.

Local progression and pseudo progression after single fraction or fractionated stereotactic radiotherapy for large brain metastases. A single centre study.

PURPOSE: The 1-year local control rates after single-fraction stereotactic radiotherapy (SRT) for brain metastases > 3 cm diameter are less than 70%, but with fractionated SRT (FSRT) higher local control rates have been reported. The purpose of this study was to compare our treatment results with SRT and FSRT for large brain metastases. MATERIALS AND METHODS: In two consecutive periods, 41 patients with 46 brain metastases received SRT with 1 fraction of 15 Gy, while 51 patients with 65 brain metastases received FSRT with 3 fractions of 8 Gy. We included patients with brain metastases with a planning target volume of > 13 cm(3) or metastases in the brainstem. RESULTS: The minimum follow-up of patients still alive was 22 months. Comparing 1 fraction of 15 Gy with 3 fractions of 8 Gy, the 1-year rates of freedom from any local progression (54% and 61%, p = 0.93) and pseudo progression (85% and 75%, p = 0.25) were not significantly different. Overall survival rates were also not different. CONCLUSION: The 1-year local progression and pseudo progression rates after 1 fraction of 15 Gy or 3 fractions of 8 Gy for large brain metastases and metastases in the brainstem are similar. For better local control rates, FSRT schemes with a higher biological equivalent dose may be necessary.

Indications for cone-beam computed tomography in the area of oral and maxillofacial surgery.

The aim of this study was to identify specific indications for dental cone-beam computed tomography (CBCT) in the field of oral and maxillofacial surgery. To this end, we compared the efficacy of CBCT to that of panoramic radiography, the standard imaging modality, for the evaluation of different surgical questions in the oral and maxillofacial region. Dentall CBCT proved to be particularly useful in cases where visualization of a second plane is necessary for implant planning or for pre-surgical evaluation of retained and displaced teeth posing a risk to adjacent structures. It is also indicated for precise localization of luxated teeth and dental implants dislocated into surrounding areas, localization of the mandibular canal to assess its anatomical relationship to overfilled root canal filling materials, assessment ofthe extent of osseous lesions, and evaluation of patients with suspected mandibular or condylar fractures. The main advantages of CBCT are reduction of the risks of surgery due to the free selection of imaging planes, maindibular canal marking, 1:1 magnification, and the ability to use DICOM data in other implant or surgical planning software. Adequate user experience is important for proper evaluation of dental CBCT scans, as is the diagnosis of incidental findings falling into areas not primarily related to dentistry and therefore requiring additional investigation.

Target Volume Coverage and Organ at Risk Doses for Left-sided Whole-breast Irradiation With or Without Internal Mammary Chain Irradiation: A Comparison Between Three Techniques Representing the Past and the Present.

AIMS: The 15-year results of the EORTC 229922-10925 phase III trial showed a significant reduction in breast cancer mortality and breast cancer recurrences after internal mammary chain (IMC) and medio-supraclavicular irradiation. Unexpectedly, cardiac death was not increased, and the incidence of cardiac events did not differ between left- and right-sided cases, although target volume coverages and organ at risk doses were unknown. Therefore, a planning study was carried out comparing the past and the present, to eventually enable, thereafter, an increased therapeutic ratio of IMC irradiation. MATERIALS AND METHODS: A planning study was carried out on target volume coverage and organ at risk doses for whole-breast irradiation (WBI) ± IMC comparing the results between two-dimensional radiotherapy (free-breathing), hybrid intensity-modulated radiotherapy (IMRT; breath-hold) and robust intensity-modulated proton therapy (IMPT; free-breathing) for 10 left-sided breast cancer cases. Two-dimensional radiotherapy consisted of two tangential wedged photon breast fields and mixed electron/photon beams for the IMC. Hybrid IMRT included two tangential photon breast fields (70%) complemented with IMRT (30%). IMPT plans were created using multi-field robust optimisation (5 mm set-up and 3% range uncertainties) with two (WBI) or three (WBI + IMC) beams. RESULTS: Target volume dose objectives were met for hybrid IMRT and IMPT. For two-dimensional radiotherapy, target coverage was 97% and 83% for breast and IMC, respectively. The mean heart dose for WBI only was <2 Gy for all techniques. For WBI + IMC, heart doses (mean heart dose, mean left anterior descending region, volume of the heart receiving 5 Gy (V5) were significantly higher for two-dimensional radiotherapy when compared with contemporary techniques. The V5 left anterior descending region reduced from 100% (two-dimensional radiotherapy) to 70% and 20% for hybrid IMRT and IMPT, respectively. CONCLUSION: Contemporary radiotherapy techniques result in improved target volume coverage and significantly decreased heart doses for WBI + IMC radiotherapy. Hence, nowadays an increased therapeutic ratio of elective IMC irradiation may be anticipated.

Impaired Geriatric 8 Score is Associated with Worse Survival after Radiotherapy in Older Patients with Cancer.

AIMS: To investigate whether the Geriatric 8 (G8) score and the Timed Get Up and Go Test (TGUGT), together with clinical and demographic patient characteristics, are associated with survival and late toxicity after (chemo)radiation therapy, administered with curative intent in older patients with cancer. MATERIALS AND METHODS: Four hundred and two patients aged ≥65 years (median age 72 years, range 65-96 years), diagnosed with either breast, non-small cell lung, prostate, head and neck, rectal or oesophageal cancer, and referred for curative (chemo)radiation therapy, took part in a multicentre prospective cohort study in eight radiotherapy centres in the Netherlands. The G8 and TGUGT scores were assessed before starting treatment. Other potential predictors and late toxicity were also recorded. Survival status and date of death, if applicable, were ascertained at the Dutch national death registry. RESULTS: After 2.5 years, the overall survival was 83%. Survival was 87% for patients with high G8 scores and 55% for patients with low G8 scores (Log-rank P value < 0.0001). Survival was 77% for patients with good TGUGT results and 50% for patients with poor TGUGT results (Log-rank P value < 0.001). In multivariable analysis, in addition to age and type of primary tumour, the association of the G8 score with overall survival remained, with a hazard ratio of 2.1 (95% confidence interval 1.2-3.8) for low versus high scores. CONCLUSIONS: G8 was associated with overall survival in older patients with cancer irradiated with curative intent. This association was independent of the predictive value of age and primary tumour.

[Gender-specific aspects of the physician-patient interaction]. / Geschlechtsspezifische Aspekte des Gesprächs zwischen Arzt und Patient.

This article aims at shedding light on the role of physician and patient gender in the medical consultation. Because of the scarce amount of studies concentrating on gender aspects of the physician-patient interaction in rehabilitation or chronic disease, mostly results from general medicine are reported. Female physicians have a more emotional and less dominant communication style. Female patients bring up more psychosocial topics and disclose more information about themselves in general. Both female and male physicians give more information and apply a more partnership-oriented communication style when seeing a female patient. Female and male patients communicate more partnership-oriented with female physicians and share more psychosocial and medical information with them. Same-gender dyads seem beneficial most of the time for physician-patient communication. Mixed-gender dyads are more difficult, especially when a younger female physician sees a male patient. There is no single good communication style recommendable for all physicians. Rather, the research results presented should be applied to communication trainings for physicians. This could provide physicians with a flexible choice of communication styles to apply according to different situations.

A multi-level approach of evaluating crew resource management training: a laboratory-based study examining communication skills as a function of team congruence.

The article proposes a multi-level approach for evaluating communication skills training (CST) as an important element of crew resource management (CRM) training. Within this methodological framework, the present work examined the effectiveness of CST in matching or mismatching team compositions with regard to hierarchical status and competence. There is little experimental research that evaluated the effectiveness of CRM training at multiple levels (i.e. reaction, learning, behaviour) and in teams composed of members of different status and competence. An experiment with a two (CST: with vs. without) by two (competence/hierarchical status: congruent vs. incongruent) design was carried out. A total of 64 participants were trained for 2.5 h on a simulated process control environment, with the experimental group being given 45 min of training on receptiveness and influencing skills. Prior to the 1-h experimental session, participants were assigned to two-person teams. The results showed overall support for the use of such a multi-level approach of training evaluation. Stronger positive effects of CST were found for subjective measures than for objective performance measures. STATEMENT OF RELEVANCE: This work provides some guidance for the use of a multi-level evaluation of CRM training. It also emphasises the need to collect objective performance data for training evaluation in addition to subjective measures with a view to gain a more accurate picture of the benefits of such training approaches.

[Interactions between patients and physicians: why should we care about gender issues?]. / Les médecins hommes et femmes interagissent de manière différente avec leurs patients: pourquoi s'en préoccuper?

This article presents the major findings of research on medical interactions from a gender perspective. Male and female physicians give the same amount of medical informations to their patients, but male physicians discuss less the psychosocial aspects of the illness. Male physicians ask less medical and psychosocial questions, and patients provide them with less information. Female physicians adopt more partnership-behaviors and display more affiliative nonverbal behaviors. Patients behave less dominantly with male than with female physicians. Finally, male patients are given less signs of empathy and receive less information, whatever the gender of the physician.

Reduced increase of calcium scores using breath-hold in left-sided whole breast irradiation.

PURPOSE: In this prospective longitudinal study, Coronary Artery Calcium (CAC) scores determined before the start of whole breast irradiation were compared with those determined 7 years afterwards. The aim was to examine whether the use of a breath-hold (BH) technique is associated with less increase of CAC scores. METHODS AND MATERIALS: Changes in CAC scores were analysed in 87 breast cancer patients. The results of the following groups were compared: patients receiving right (R) or left-sided radiotherapy using free breathing (L-FB) with those receiving left-sided radiotherapy with BH (L-BH). We compared the changes of CAC scores between these groups over time, testing the hypothesis that a significantly reduced increase of calcium scores is observed when using BH. RESULTS: For L-BH cases, when compared with L-FB cases, for overall as well as for Left Anterior Descending coronary artery (LAD) CAC scores, we noted significantly less increased CAC scores (p < 0.01). This effect of BH was even more striking in the group with CAC scores >0 at baseline. The attenuated increase over time of CAC scores in the L-BH group was robust to correction for age and statin use (p < 0.05). CONCLUSION: After a median follow-up of 7.4 years, we found significantly less increased CAC scores when using BH. This is a relevant finding since higher levels of CAC scores are associated with higher probabilities of coronary artery events. Moreover, it underlines the rationale for the use of BH in left-sided whole breast irradiation.

Health-related quality of life of breast cancer patients after accelerated partial breast irradiation using intraoperative or external beam radiotherapy technique.

PURPOSE: To compare health-related quality of life (HRQL) in elderly breast cancer patients between two types of Accelerated Partial Breast Irradiation: intraoperative radiotherapy (IORT) and external beam APBI (EB-APBI). METHODS: Between 2011 and 2016 women ≥60 years undergoing breast conserving therapy for early stage breast cancer were included in a prospective multi-centre cohort study. Patients were treated with electron IORT (1 × 23.3 Gy) or photon EB-APBI (10 × 3.85 Gy daily). HRQL was measured by the EORTC-QLQ C30 and BR23 questionnaires before surgery and at several time points until 1 year. RESULTS: HRQoL data was available of 204 IORT and 158 EB-APBI patients. In longitudinal analyses emotional functioning and future perspective were significantly, but not clinically relevantly, worse in IORT-treated patients, and improved significantly during follow-up in both groups. All other aspects of HRQL slightly worsened after treatment and recovered within 3 months with an improvement until 1 year. Cross-sectional analysis showed that postoperatively fatigue and role functioning were significantly worse in IORT patients compared to EB-APBI patients who were not yet irradiated, but the difference was not clinically relevant. At other timepoints there were no significant differences. Multivariable analysis at 1 year identified comorbidity and systemic therapy as risk factors for a worse global health score (GHS). CONCLUSIONS: EB-APBI and IORT were well tolerated. Despite a temporary deterioration after treatment, all HRQL scales recovered within 3 months resulting in no clinically relevant differences until 1 year between groups nor compared to baseline levels.

Toward the improvement of total nitrogen deposition budgets in the United States.

Frameworks for limiting ecosystem exposure to excess nutrients and acidity require accurate and complete deposition budgets of reactive nitrogen (Nr). While much progress has been made in developing total Nr deposition budgets for the U.S., current budgets remain limited by key data and knowledge gaps. Analysis of National Atmospheric Deposition Program Total Deposition (NADP/TDep) data illustrates several aspects of current Nr deposition that motivate additional research. Averaged across the continental U.S., dry deposition contributes slightly more (55%) to total deposition than wet deposition and is the dominant process (>90%) over broad areas of the Southwest and other arid regions of the West. Lack of dry deposition measurements imposes a reliance on models, resulting in a much higher degree of uncertainty relative to wet deposition which is routinely measured. As nitrogen oxide (NOx) emissions continue to decline, reduced forms of inorganic nitrogen (NHx = NH3 + NH4+) now contribute >50% of total Nr deposition over large areas of the U.S. Expanded monitoring and additional process-level research are needed to better understand NHx deposition, its contribution to total Nr deposition budgets, and the processes by which reduced N deposits to ecosystems. Urban and suburban areas are hotspots where routine monitoring of oxidized and reduced Nr deposition is needed. Finally, deposition budgets have incomplete information about the speciation of atmospheric nitrogen; monitoring networks do not capture important forms of Nr such as organic nitrogen. Building on these themes, we detail the state of the science of Nr deposition budgets in the U.S. and highlight research priorities to improve deposition budgets in terms of monitoring and flux measurements, leaf- to regional-scale modeling, source apportionment, and characterization of deposition trends and patterns.