Comparative Evaluation of Proton Therapy and Volumetric Modulated Arc Therapy for Brachial Plexus Sparing in the Comprehensive Reirradiation of High-Risk Recurrent Breast Cancer.

Purpose: Recurrent or new primary breast cancer requiring comprehensive regional nodal irradiation after prior radiation therapy (RT) to the supraclavicular area and upper axilla is challenging due to cumulative brachial plexus (BP) dose tolerance. We assessed BP dose sparing achieved with pencil beam scanning proton therapy (PBS-PT) and photon volumetric modulated arc therapy (VMAT). Methods and Materials: In an institutional review board-approved planning study, all patients with ipsilateral recurrent breast cancer treated with PBS-PT re-RT (PBT1) with at least partial BP overlap from prior photon RT were identified. Comparative VMAT plans (XRT1) using matched BP dose constraints were developed. A second pair of proton (PBT2) and VMAT (XRT2) plans using standardized target volumes were created, applying uniform prescription dose of 50.4 per 1.8 Gy and a maximum BP constraint <25 Gy. Incidence of brachial plexopathy was also assessed. Results: Ten consecutive patients were identified. Median time between RT courses was 48 months (15-276). Median first, second, and cumulative RT doses were 50.4 Gy (range, 42.6-60.0), 50.4 Gy relative biologic effectiveness (RBE) (45.0-64.4), and 102.4 Gy (RBE) (95.0-120.0), respectively. Median follow-up was 15 months (5-33) and 18 months for living patients (11-33) Mean BP max was 37.5 Gy (RBE) for PBT1 and 36.9 Gy for XRT1. Target volume coverage of V85% (volume receiving 85% of prescription dose), V90%, and V95% were numerically lower for XRT1 versus PBT1. Similarly, axilla I-III and supraclavicular area coverage were significantly higher for PBT2 than XRT2 at dose levels of V55%, V65%, V75%, V85%, and V95%. Only axilla I V55% did not reach significance (P = .06) favoring PBS-PT. Two patients with high cumulative BPmax (95.2 Gy [RBE], 101.6 Gy [RBE]) developed brachial plexopathy symptoms with ulnar nerve distribution neuropathy without pain or weakness (1 of 2 had symptom resolution after 6 months without intervention). Conclusions: PBS-PT improved BP sparing and target volume coverage versus VMAT. For patients requiring comprehensive re-RT for high-risk, nonmetastatic breast cancer recurrence with BP overlap and reasonable expectation for prolonged life expectancy, PBT may be the preferred treatment modality.

Virtual and online learning during COVID-19: the experience of community children's nursing students.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes to education delivery. For many university programmes this has included a move from face-to-face to virtual and online learning and teaching. AIM: To gain insight into the experiences of students undertaking the community children's nursing specialist practitioner programme during the academic year 2020-21, when most learning and teaching was delivered using virtual and online methods as a consequence of the COVID-19 pandemic. METHOD: A survey questionnaire containing qualitative and quantitative questions was distributed to 28 students by programme leaders at three universities in England. Seven questionnaires were returned, yielding a 25% response rate. FINDINGS: Respondents' experience of online and virtual learning was generally positive, with benefits for work-life balance and the opportunity to revisit recorded lectures being particularly well regarded. Loss of opportunity for face-to-face engagement with fellow students and the teaching team were identified as disadvantages. CONCLUSION: There was strong student support for the provision of more flexible approaches to learning and teaching. Universities should recognise that failure to offer such flexibility could potentially affect recruitment and the viability of courses in the future.

Using the 7 Habits programme to develop effective leadership.

This article discusses a short leadership programme for nurse and allied health professional leaders working in a community or community hospital environment in England. It describes the adoption, adaption, implementation, delivery and interim evaluation of the programme. The article sets out the background that led to adoption of the 7 Habits for Healthcare programme and discusses the concepts outlined. It also reflects on feedback from delegates between three and nine months after they completed the programme, to explore how it has influenced them professionally and personally.