The extent and nature of stress of conscience among healthcare workers: A scoping review.

BACKGROUND: Healthcare workers experience morally stressful situations during delivery of care which may trouble their conscience. Literature emerging in the context of global pandemics suggest increased frequency of morally stressful situations in healthcare and a link with negative outcomes such as attrition and burnout. Little is known about the emerging concept of stress of conscience which could provide a meaningful way to highlight and address these morally stressful situations in healthcare. AIM: The aim of this scoping review was to provide an overview of the literature on, (i) the extent, (ii) the factors associated, and (iii) the interventions to prevent or mitigate stress of conscience among healthcare workers. DESIGN: The study was guided by the framework provided by Arksey and O'Malley in 2005 and the PRISMA Guidelines. Relevant healthcare databases were searched in November 2020 to identify relevant studies. RESULTS: The search identified 24 studies for inclusion in the analysis, 19 of these were from Nordic countries, particularly Sweden. Across those studies, stress of conscience was prevalent among healthcare workers and the levels varied with demographic factors, individual personalities, perceptions of belonging and the workplace culture and environment. Stress of conscience was associated with negative outcomes such as burnout, moral burden, workplace stress, and low quality of care. Although there were few quality interventions studies, facilitating healthcare workers to provide person-centred care appears to be a promising intervention. CONCLUSIONS: The concept of stress of conscience provides a contemporary framework to assess, highlight and discuss the degree of the negative impact of perceived violations of professional and personal values in healthcare. However, the limited studies suggest that exploring stress of conscience, including trials of potential interventions, particularly beyond Nordic countries is essential to fill the gaps in the literature.

Social media support group: Implementation and evaluation.

Lack of social support and perceived HIV-related stigma increase the risk of negative health-related outcomes among people living with HIV (PLWH). This study examines the social media use of PLWH participating in a behavioral health treatment program, and the association of participation in a "secret" Facebook group with improved client social support, education, and overall behavioral health treatment experience. Eighteen individuals participated in a survey and eight individuals participated in a focus group regarding their familiarity with technology and experience with using social media. Mixed-method analysis revealed that the majority of "secret" Facebook group participants thought that participation in the group improved overall personal wellbeing and perceived social support. However, lack of technology and social media experience and privacy concerns may have contributed to lower levels of participation with the "secret" Facebook group. A majority of participants who found Facebook difficult to use and/or had less technology experience were over the age of 50. Incorporating additional technology training for individuals who lack technology experience has the potential to improve clients' overall proficiency with technology and social media, as well as build confidence that could translate into an increased willingness to participate in a social media-based intervention.

Excretion of urine extracellular vesicles bearing markers of activated immune cells and calcium/phosphorus physiology differ between calcium kidney stone formers and non-stone formers.

BACKGROUNDS: Previous studies have demonstrated that excretion of urinary extracellular vesicles (EVs) from different nephron segments differs between kidney stone formers and non-stone formers (NSFs), and could reflect pathogenic mechanisms of urinary stone disease. In this study we quantified selected populations of specific urinary EVs carrying protein markers of immune cells and calcium/phosphorus physiology in calcium oxalate stone formers (CSFs) compared to non-stone formers (NSFs). METHODS: Biobanked urine samples from CSFs (n = 24) undergoing stone removal surgery and age- and sex- matched NSFs (n = 21) were studied. Urinary EVs carrying proteins related to renal calcium/phosphorus physiology (phosphorus transporters (PiT1 and PiT2), Klotho, and fibroblast growth factor 23 (FGF23); markers associated with EV generation (anoctamin-4 (ANO4) and Huntington interacting protein 1 (HIP1)), and markers shed from activated immune cells were quantified by standardized and published method of digital flow cytometry. RESULTS: Urine excretion of calcium, oxalate, phosphorus, and calcium oxalate supersaturation (SS) were significantly higher in CSFs compared to NSFs (P < 0.05). Urinary excretion of EVs with markers of total leukocytes (CD45), neutrophils (CD15), macrophages (CD68), Klotho, FGF23, PiT1, PiT2, and ANO4 were each markedly lower in CSFs than NSFs (P < 0.05) whereas excretion of those with markers of monocytes (CD14), T-Lymphocytes (CD3), B-Lymphocytes (CD19), plasma cells (CD138 plus CD319 positive) were not different between the groups. Urinary excretion of EVs expressing PiT1 and PiT2 negatively (P < 0.05) correlated with urinary phosphorus excretion, whereas excretion of EVs expressing FGF23 negatively (P < 0.05) correlated with both urinary calcium and phosphorus excretion. Urinary EVs with markers of HIP1 and ANO4 correlated negatively (P < 0.05) with clinical stone events and basement membrane calcifications on papillary tip biopsies. CONCLUSIONS: Urinary excretion of EVs derived from specific types of activated immune cells and EVs with proteins related to calcium/phosphorus regulation differed between CSFs and NSFs. Further validation of these and other populations of urinary EVs in larger cohort could identify biomarkers that elucidate novel pathogenic mechanisms of calcium stone formation in specific subsets of patients.

Nurse practitioner led model of after-hours emergency care in an Australian rural urgent care Centre: health service stakeholder perceptions.

BACKGROUND: The challenges of providing and accessing quality health care in rural regions have long been identified. Innovative solutions are not only required but are also vital if effective, timely and equitable access to sustainable health care in rural communities is to be realised. Despite trial implementation of some alternative models of health care delivery, not all have been evaluated and their impacts are not well understood. The aim of this study was to explore the views of staff and stakeholders of a rural health service in relation to the implementation of an after-hours nurse practitioner model of health care delivery in its Urgent Care Centre. METHODS: This qualitative study included semi-structured individual and group interviews with professional stakeholders of a rural health service in Victoria, Australia and included hospital managers and hospital staff who worked directly or indirectly with the after-hours NPs in addition to local GPs, GP practice nurses, and paramedics. Thematic analysis was used to generate key themes from the data. RESULTS: Four themes emerged from the data analysis: transition to change; acceptance of the after-hours nurse practitioner role; workforce sustainability; and rural context. CONCLUSIONS: This study suggests that the nurse practitioner-led model is valued by rural health practitioners and could reduce the burden of excessive after-hour on-call duties for rural GPs while improving access to quality health care for community members. As pressure on rural urgent care centres further intensifies with the presence of the COVID-19 pandemic, serious consideration of the nurse practitioner-led model is recommended as a desirable and effective alternative.

Elucidating measures of systemic racism to mitigate racial disparities in kidney transplantation.

PURPOSE OF REVIEW: Given recent national attention to the role of racism in perpetuating racial inequities in society and health, this review provides a timely and relevant summary of key measures of systemic racism in kidney transplantation. More specifically, the review identifies current and promising interventions, whereas highlighting the need for more sustainable and impactful interventions. RECENT FINDINGS: Racial disparities persist in kidney transplantation. Black and Hispanic individuals are less likely to receive a kidney transplant than non-Hispanic Whites despite disproportionately higher rates of kidney failure. Studies demonstrate that socioeconomic factors do not fully explain existing racial disparities in transplantation. Systemic racism at all levels, individual, interpersonal, institutional, and structural, is at the core of racial disparities, and current interventions are insufficient in mitigating their effects. Thus, targeted and sustainable interventions must be implemented to mitigate systemic racism in kidney transplantation. SUMMARY: Systemic racism in all its forms continues to influence disparities at all stages of kidney transplantation. This paper highlights recent findings that shed light on how racism contributes to racial disparities in kidney transplantation. Using these findings to identify targets and strategies for mitigation, relevant interventions and policies that show promise are detailed.

The Relationship of HIV-related Stigma and Health Care Outcomes in the US Deep South.

HIV-related stigma is prevalent in the US Deep South; however, information regarding the types of stigma and their effects on HIV-related outcomes is limited. This study examined the prevalence of different forms of stigma and the association of stigma with medication and medical visit adherence in the Deep South. Survey participants included 201 individuals living with HIV recruited from Infectious Diseases Clinics (ID) and AIDS Service Organizations (ASOs) in four Deep South states. Study participants reported high levels of experienced, perceived, and internalized stigma. Multivariable analysis revealed that internalized stigma and recent stigmatizing experiences were significantly associated with poorer HIV medication adherence. Internalized stigma was also associated with having missed an HIV medical care visit in the last 6 months. These findings suggest the need to identify and develop effective interventions to address internalized HIV-related stigma and to address community HIV stigma to improve outcomes for individuals living with HIV.

The impact of route of diagnosis on survival in patients with glioblastoma.

INTRODUCTION: The standard of care for glioblastoma is maximal debulking surgery followed by chemo-radiotherapy (CRT). Published data show worse outcomes for patients who present with GBM as an emergency. This study investigates prognostic factors in a cohort of GBM patients treated with postoperative CRT, and compares outcomes in patients who present via emergency pathways with those who present through outpatient clinics. METHODS: Patients with GBM operated on between 1 April 2010 and 5 October 2015 and then treated with postoperative CRT were included in the study. Data were collected from electronic patient records and radiotherapy planning systems. Survival data were censored on 22 March 2016. Univariate and multivariate analyses of prognostic factors were performed. RESULTS: 104 patients were studied; mean age 51.6 years (range 19 to 70 years). Median overall survival (OS) was 16.5 months, with 68.2% and 37.8% alive at 12 and 24 months respectively. On multivariate analysis, improved OS was associated with ECOG Performance Status of 0 (vs ≥1; p = .012), patient age <60 years (vs ≥60 years; p < .001), and surgical debulking or macroscopic complete resection (vs biopsy; p < .001). Patients who presented through emergency medical pathways had worse survival (p = .005). CONCLUSION: This study supports published data that initial presentation through emergency pathways is associated with worse outcomes in GBM, even in patients who remain fit enough to receive post-operative CRT.

Ethical Challenges in Community-Based Participatory Research: A Scoping Review.

Ethical challenges in community-based participatory research (CBPR) are of increasing interest to researchers; however, it is not known how widespread these challenges are or how extensively the topic has been explored. Using Arksey and O'Malley's scoping review method, studies on ethical challenges in CBPR were mapped. Findings indicate that researchers continue to raise questions about ethics associated with CBPR. Our purpose in this article is to present a thematic summary of international ethical challenges as a guide for researchers interested in community participatory approaches and to better prepare them for qualitative health research with communities.

Rural health services and the task of community participation at the local community level: a case study.

Community participation in health service decision making is entrenched in health policy, with a strong directive to develop sustainable, effective, locally responsive services. However, it is recognised that community participation is challenging to achieve. The aim of the present study was to explore how a rural health service in Victoria enacts community participation at the local level. Using case study methodology, the findings indicate that enactment of community participation is desired by the health service, but a lack of understanding of the concept and how to enact associated policy are barriers that are exacerbated by a lack of resources and community capacity. The findings reveal a disconnect between community participation policy and practice.

Meningeal haemangiopericytoma and solitary fibrous tumour: a retrospective bi centre study for outcome and prognostic factor assessment.

To describe the outcome of patients diagnosed with central nervous system haemangiopericytoma (HPC) or solitary fibrous tumour (SFT) and identify factors that may influence recurrence and survival. Between January 2000 and September 2016, a retrospective search identified 55 HPCs/SFTs. The patients underwent a total of 101 surgical resections and 56.9% received radiation therapy. Median follow-up was 7.8 years. 28 patients (50.9%) were re-operated for tumour recurrence. At the end of the study, 21 patients (42%) had no residual tumour on the last scan. Surgical recurrence-free survival at 5 years was 75.2%, 95% CI [63.3-89.3] and, the median surgical recurrence-free survival was 7.4 years. In the adjusted analysis, venous sinus invasion (present vs. absent) (HR 3.39, 95% CI [1.16, 9.93], p = 0.026), completeness of resection (HR 0.38, 95% CI [0.15-0.97], p = 0.042) and tumour subtype (SFT vs. HPC) (HR 3.02, 95% CI[1.02, 8.91], p = 0.045) were established as independent prognostic factors. At the end of the study, 25 patients were deceased (45.5%). and only 15 patients (27.3%) had no residual tumour on the last scan and were alive. Overall survival at 5 years was 80.2, 95% CI [69.3-92.8] and the median overall survival was 13.1 years. None of the investigated variables was associated with overall survival. Patients who received radiation therapy demonstrated neither a reduced risk of surgical recurrence (p = 0.370) nor a longer overall survival (p = 1.000). SFTs/HPCs are associated with a significant risk of recurrence that may reduce the survival of the patients. Total tumour resection upon initial surgery is associated with a lower risk of relapse but not with a prolonged survival. We did not observe a significant improvement in any of the clinical outcomes after radiation therapy.

State of HIV in the US Deep South.

The Southern United States has been disproportionately affected by HIV diagnoses and mortality. To inform efforts to effectively address HIV in the South, this manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV. The manuscript focuses on a specific Southern region, the Deep South, which has been particularly affected by HIV. Epidemiologic data from the Centers from Disease Control and Prevention indicate that the Deep South had the highest HIV diagnosis rate and the highest number of individuals diagnosed with HIV (18,087) in 2014. The percentage of new HIV diagnoses that were female has decreased over time (2008-2014) while increasing among minority MSM. The Deep South also had the highest death rates with HIV as an underlying cause of any US region in 2014. Despite higher diagnosis and death rates, the Deep South received less federal government and private foundation funding per person living with HIV than the US overall. Factors that have been identified as contributors to the disproportionate effects of HIV in the Deep South include pervasive HIV-related stigma, poverty, higher levels of sexually transmitted infections, racial inequality and bias, and laws that further HIV-related stigma and fear. Interventions that address and abate the contributors to the spread of HIV disease and the poorer HIV-related outcomes in the Deep South are warranted. Funding inequalities by region must also be examined and addressed to reduce the regional disparities in HIV incidence and mortality.

WHO grade II meningioma: a retrospective study for outcome and prognostic factor assessment.

To analyse the outcome of patients with WHO grade II meningioma and identify factors that may influence recurrence and survival. Between January 2007 and September 2015, a retrospective search identified 194 WHO grade II meningiomas at the National Hospital for Neurology and Neurosurgery, London. Survival methods were implemented. 31 patients (16 %) had a previous history of grade I meningioma. The patients underwent a total of 344 surgical resections and 43.3 % received radiotherapy. 55 patients (28.4 %) had been re-operated on for a WHO grade II meningioma relapse. Median follow-up was 4.4 years. At the end of the study, 75 patients (40.1 %) had no residual tumour on the last scan. Surgical recurrence free survival at 5 years was 71.6, 95 % CI [63.5, 80.8]. Secondary grade II meningioma (HR = 2.29, p = 0.010), and, Simpson resection grade 1, 2 and 3 vs. 4 and 5 (HR = 0.57, p = 0.050) were associated with the surgical recurrence-free survival. 32 died from meningioma (16.5 %). Overall survival probability at 5 years was 83.2, 95 % CI [76.6, 90.4]. Age at diagnosis (HR = 0.22, p < 0.001), WHO grade I meningioma progressing into grade II (HR = 3.2, p = 0.001), tumour location (HR = 0.19, p < 0.001), and mitosis count (HR = 0.36, p = 0.010) were independently associated with the overall survival. Patients who received radiotherapy demonstrated neither a reduced risk of recurrence nor a longer overall survival (p = 0.310). In our series shorter survival correlated with older age, increased mitoses, progression from grade I to II and location. We were not able to demonstrate a significant improvement in any of the clinical outcomes after radiotherapy.

Use and Safety of Erythromycin and Metoclopramide in Hospitalized Infants.

OBJECTIVE: Prokinetic medications are used in premature infants to promote motility and decrease time to full enteral feeding. Erythromycin and metoclopramide are the most commonly used prokinetic medications in the neonatal intensive care unit (NICU), but their safety profile is not well defined. METHODS: We conducted a large retrospective cohort study using data from 348 NICUs managed by the Pediatrix Medical Group. All of the infants exposed to ≥1 dose of erythromycin, metoclopramide, or both, from a cohort of 8,87,910 infants discharged between 1997 and 2012 were included. We collected laboratory and clinical information while infants were exposed to erythromycin or metoclopramide and described the frequency of laboratory abnormalities and clinical adverse events (AEs). RESULTS: Metoclopramide use increased from 1997 to 2005 and decreased from 2005 to 2012, whereas erythromycin use remained stable. Erythromycin use was most often associated with a diagnosis of feeding problem (40%), whereas metoclopramide was most often associated with a diagnosis of gastroesophageal reflux (59%). The most common laboratory AE during exposure to erythromycin or metoclopramide was hyperkalemia (8.6/1000 infant days on erythromycin and 11.0/1000 infant days on metoclopramide). Incidence of pyloric stenosis was greater with erythromycin than with metoclopramide (10/1095, 0.9% vs 76/19,001, 0.4%; P = 0.01), but odds were not significantly increased after adjusting for covariates (odds ratio 0.52, 95% confidence interval [CI] 0.26-1.02, P = 0.06). More infants experienced an AE while treated with metoclopramide than with erythromycin (odds ratio 1.21, 95% CI 1.03-1.43). CONCLUSIONS: Metoclopramide was associated with increased risk of AEs compared with erythromycin. Studies are needed to confirm safety and effectiveness of both the drugs in infants.

HIV Diagnoses, Prevalence and Outcomes in Nine Southern States.

A group of nine states in the Southern United States, hereafter referred to as the targeted states, has experienced particularly high HIV diagnosis and case fatality rates. To provide additional information about the HIV burden in this region, we used CDC HIV surveillance data to examine characteristics of individuals diagnosed with HIV in the targeted states (2011), 5-year HIV and AIDS survival, and deaths among persons living with HIV (2010). We used multivariable analyses to explore the influence of residing in the targeted states at diagnosis on deaths among persons living with HIV after adjustment for demographics and transmission risk. In 2011, the targeted states had a higher HIV diagnosis rate (24.5/100,000 population) than the US overall (18.0/100,000) and higher proportions than other regions of individuals diagnosed with HIV who were black, female, younger, and living in suburban and rural areas. Furthermore, the targeted states had lower HIV and AIDS survival proportions (0.85, 0.73, respectively) than the US overall (0.86, 0.77, respectively) and the highest death rate among persons living with HIV of any US region. Regional differences in demographics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted states indicating that other factors contribute to this disparity. Differences in characteristics and outcomes of individuals with HIV in the targeted states are critical to consider when creating strategies to address HIV in the region, as are other factors identified in previous research to be prominent in the region including poverty and stigma.

World Health Organization grade III meningiomas. A retrospective study for outcome and prognostic factors assessment.

BACKGROUND: Anaplastic meningiomas are uncommon primary intracranial tumours associated with high level of recurrence and low life expectancy. Through three institutions experience, we analysed the clinical characteristics of patients with malignant meningiomas to determine their outcome and identify prognostic factors that may influence recurrence and survival. MATERIAL AND METHODS: A retrospective search identified 62 cases of WHO grade III meningiomas, of whom 9 (14.5%) were not considered in the survival analysis as no follow-up data were available. Thirty patients (48.4%) had a previous history of non-malignant meningioma surgery. The patients underwent a total of 139 surgical resections and 42 courses of radiotherapy of which 27 were given after the WHO grade III meningioma diagnosis. RESULTS: Eighteen patients (29.5%) were re-operated for a relapse of their anaplastic meningioma. Median time between the first and the second surgery was 1.3 years. Median overall survival time was 3.5 years. Overall survival probabilities at 1, 2 and 5 years were 74.6%, 95% confidence interval (CI) [63.8, 87.1], 58.7%, 95% CI [46.4, 74.3] and 37.7%, 95% CI [25, 56.8], respectively. Extent of resection was associated with the survival. DISCUSSION: This retrospective series highlights the poor prognosis associated with the diagnosis of malignant meningioma. Complete or subtotal resection may prolong the patients' survival. We could not confirm the usefulness of postoperative radiotherapy.

HIV/AIDS in the Southern USA: a disproportionate epidemic.

This research synthesis examined HIV/AIDS surveillance and health care financing data and reviewed relevant research literature to describe HIV epidemiology, outcomes, funding, and contributing factors to the HIV epidemic in the Southern USA with particular focus on a group of Southern states with similar demographic and disease characteristics and comparable HIV epidemics (Alabama, Georgia, Florida, Los Angeles, Mississippi, North Carolina, South Carolina, Tennessee, and Texas). These states are hereafter referred to as "targeted Southern states." Eight of the 10 states with the highest HIV diagnosis rates in 2011 were in the Southern USA; six were targeted states. Forty-nine percent of HIV diagnoses were in the South in 2011, which contains only 37% of the US population. The targeted states region had the highest HIV diagnosis rate than any other US region in 2011. The South was also found to have the highest HIV-related mortality and morbidity rates in the USA. The high levels of poverty, HIV-related stigma, and STDs found in the South, particularly in the targeted Southern states, likely contribute to greater HIV incidence and mortality. The disproportionate impact of HIV in the South, particularly among targeted states, demonstrates a critical need to improve HIV prevention and care and address factors that contribute to HIV disease in this region.

Provider perspectives on screening and treatment for opioid use disorder and mental health in HIV care: A qualitative study.

BACKGROUND: HIV, opioid use disorder (OUD), and mental health challenges share multiple syndemic risk factors. Each can be effectively treated with routine outpatient appointments, medication management, and psychosocial support, leading implementers to consider integrated screening and treatment for OUD and mental health in HIV care. Provider perspectives are crucial to understanding barriers and strategies for treatment integration. METHODS: We conducted in-depth qualitative interviews with 21 HIV treatment providers and social services providers (12 individual interviews and 1 group interview with 9 participants) to understand the current landscape, goals, and priorities for integrated OUD, mental health, and HIV care. Providers were purposively recruited from known clinics in Mecklenburg County, North Carolina, U.S.A. Data were analyzed using applied thematic analysis in the NVivo 12 software program and evaluated for inter-coder agreement. RESULTS: Participants viewed substance use and mental health challenges as prominent barriers to engagement in HIV care. However, few organizations have integrated structured screening for substance use and mental health into their standard of care. Even fewer screen for opioid use. Although medication assisted treatment (MAT) is effective for mitigating OUD, providers struggle to connect patients with MAT due to limited referral options, social barriers such as housing and food insecurity, overburdened staff, stigma, and lack of provider training. Providers believed there would be clear benefit to integrating OUD and mental health treatment in HIV care but lacked resources for implementation. CONCLUSIONS: Integration of screening and treatment for substance use and mental health in HIV care could mitigate many current barriers to treatment for all three conditions. Efforts are needed to train HIV providers to provide MAT, expand resources, and implement best practices.

Isocitrate Dehydrogenase 1/2 Wildtype Adult Astrocytoma with WHO Grade 2/3 Histological Features: Molecular Re-Classification, Prognostic Factors, Clinical Outcomes.

BACKGROUND: Isocitrate Dehydrogenase 1/2 (IDH 1/2)-wildtype (WT) astrocytomas constitute a heterogeneous group of tumors and have undergone a series of diagnostic reclassifications over time. This study aimed to investigate molecular markers, clinical, imaging, and treatment factors predictive of outcomes in WHO grade 2/3 IDH-WT astrocytomas ('early glioblastoma'). METHODOLOGY: Patients with WHO grade 2/3 IDH-WT astrocytomas were identified from the hospital archives. They were cross-referenced with the electronic medical records systems, including neuroimaging. The expert neuro-pathology team retrieved data on molecular markers-MGMT, TERT, IDH, and EGFR. Tumors with a TERT mutation and/or EGFR amplification were reclassified as glioblastoma. RESULTS: Fifty-four patients were identified. Sixty-three percent of the patients could be conclusively reclassified as glioblastoma based on either TERT mutation, EGFR amplification, or both. On imaging, 65% showed gadolinium enhancement on MRI. Thirty-nine patients (72%) received long-course radiotherapy, of whom 64% received concurrent chemotherapy. The median follow-up of the group was 16 months (range: 2-90), and the median overall survival (OS) was 17.3 months. The 2-year OS of the whole cohort was 31%. On univariate analysis, older age, worse performance status (PS), and presence versus absence of contrast enhancement on diagnostic MRI were statistically significant for poorer OS. CONCLUSION: IDH-WT WHO grade 2/3 astrocytomas are a heterogeneous group of tumors with poor clinical outcomes. The majority can be reclassified as glioblastoma, based on current WHO classification criteria, but further understanding of the underlying biology of these tumors and the discovery of novel targeted agents are needed for better outcomes.

Association between radiotherapy protocol variations and outcome in the CONVERT trial.

Background: Radiotherapy quality assurance (QA) is integral to radiotherapy delivery. Here we report comprehensive contouring, dosimetry, and treatment delivery QA, describe protocol compliance, and detail the impact of protocol variations on acute grade ≥3 toxicity, progression free survival (PFS), and overall survival (OS) in the phase III CONVERT trial. Materials/Methods: Radiotherapy planning data from one hundred randomly selected patients were requested. Members of the CONVERT Trial Management Group (TMG) recontoured the heart, lung, and spinal cord organs at risk (OAR) according to the trial guideline. The existing radiotherapy plan were re-applied to the new structures and the new dosimetric data were recollected. Compliance with radiotherapy QA components were recorded and radiotherapy QA components were pooled into protocol variations: acceptable, acceptable variation, and unacceptable variation. Univariable analysis with a Cox proportional hazards model established the relationship between protocol variations and patient outcome. Results: Ninety-three cases were submitted for retrospective radiotherapy QA review. Demographics of the radiotherapy QA cohort (n=93) matched the non-QA (n=450) cohort. 97.8% of gross tumour volume (GTV) contours were protocol compliant. OAR contours were non-compliant in 79.6% instances of the heart, 37.6% lung, and 75.3% spinal cord. Of the non-compliant heart contours, 86.5% and 2.7% had contours caudal and cranial to the protocol-defined heart borders. 10.8% did not include the pericardial sac and 2.7% did not include the anterior aspect of the pericardium. Eleven (11.8%) submissions exceeded protocol-defined dosimetric heart constraints; six of which were only noted on the application of protocol-compliant contours. Unacceptable variations were not associated with an increase in grade 3 toxicity (p=0.808), PFS (p=0.232), or OS (p=0.743). Conclusion: Non-protocol compliant heart contours were associated with increased dose delivered to the heart OAR, with 11.8 % of submitted heart structures exceeding protocol-defined constraints. In this QA cohort of patients with small cell lung cancer, unacceptable variations were not associated with acute grade ≥3 toxicity, PFS, or OS. Radiotherapy QA remains the cornerstone of high-quality radiotherapy delivery and should be embedded into clinical trial and non-clinical trial practice; clinical trials should report standardised radiotherapy QA parameters alongside trial outcomes.

Using Small Grants to SPARK! Substantial Reach to Reduce HIV-related Stigma.

Community-based organizations (CBOs) are well-positioned to address the negative effects of HIV stigma, which is prevalent in the U.S. South. This article describes a Gilead COMPASS-funded small grants and capacity-building program for CBOs to address stigma and describes the broad reach and positive outcomes associated with program implementation.