With COVID Comes Complexity: Assessing the Implementation of Family Visitation Programs in Long-Term Care.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) pandemic visitor restrictions to long-term care facilities have demonstrated that eliminating opportunities for family-resident contact has devastating consequences for residents' quality of life. Our study aimed to understand how public health directives to support family visitations during the pandemic were navigated, managed, and implemented by staff. RESEARCH DESIGN AND METHODS: Guided by the Consolidated Framework for Implementation Research, we conducted video/telephone interviews with 54 direct care and implementation staff in six long-term care homes in two Canadian provinces to assess implementation barriers and facilitators of visitation programs. Equity and inclusion issues were examined in the program's implementation. RESULTS: Despite similar public health directives, implementation varied by facility, largely influenced by the existing culture and processes of the facility and the staff understanding of the program; differences resulted in how designated family members were chosen and restrictions around visitations (e.g., scheduling and location). Facilitators of implementation were good communication networks, leadership, and intentional planning to develop the visitor designation processes. However, the lack of consultation with direct care staff led to logistical challenges around visitation and ignited conflict around visitation rules and procedures. DISCUSSION AND IMPLICATIONS: Insights into the complexities of implementing family visitation programs during a pandemic are discussed, and opportunities for improvement are identified. Our results reveal the importance of proactively including direct care staff and family in planning for future outbreaks.

Do Residential Long-Term Care Policies Support Family Involvement in Residents' Quality of Life in Four Canadian Provinces?

Family members are essential contributors to the quality of life (QoL) of persons living in residential long-term care (RLTC). This paper analyzes how the system enables or inhibits family involvement with residents in RLTC. Our analysis of 21 policies that regulate long-term care in four Canadian Provinces reveal differences in their portrayal of residents' families. Family roles are characterized procedurally (task-oriented) or relationally (interactive). Operational standards linked to licensing of RLTC homes employ more formal terminology, while RLTC program guidelines, use facilitative language to engage families and build relationships. Examples of orientation procedures, care protocols, living at risk, and end-of-life care reveal inter-provincial variations. We argue that there are opportunities to further engage families within the current regulatory framework and improve their continued contributions in the post-pandemic era.

Practical needle selection for Vienna-style applicators: improving therapeutic ratio in hybrid intracavitary-interstitial brachytherapy.

PURPOSE: Hybrid intracavitary and interstitial (IC/IS) applicators improve dose distribution compared to traditional IC applicators in cervical high-dose-rate (HDR) brachytherapy. There is a learning curve to these applicators, and initial standard needle insertion patterns have not been well-established. In this study, we quantified dosimetric benefits of IC/IS applicators, and offer practical initial interstitial needle-selection, insertion depths, and dwell position recommendations. MATERIAL AND METHODS: Fifteen patients previously treated with a tandem and ring IC applicator and magnetic resonance (MR)-guidance were re-planned at first fraction using a digital template of Vienna-style interstitial needles. IC/IS plans maintained identical high-risk clinical target volume (HR-CTV) D90% while reducing dose to organs at risk (OARs). To assess the validity of planning using virtual needles, virtual needle templates were overlaid on twelve clinical IC/IS plans, and the displacements between 40 physical and virtual needles were measured at 3 cm depth. RESULTS: The median HR-CTV volume in the present study was 19.6 cc (range, 6.6-60.5 cc). HR-CTV D90% was maintained in all re-plans. Median bladder D2cc decreased from 5.4 Gy per fraction to 4.8 Gy (p = 0.003); median rectum D2cc decreased from 2.4 Gy per fraction to 2.0 Gy (p = 0.007). We suggest that a standard loading pattern should include needles in lateral channels 4, 5, and 9, 10 inserted 3 cm deep, with dwell times < 20% of the combined tandem and ring dwells. The mean displacement between planned and physical needles was 1.8 mm. All needles but three deviated less than 3.3 mm, demonstrating the validity of re-planning with virtual needles. CONCLUSIONS: Hybrid IC/IS applicators maintain excellent D90% coverage while improving dose to OARs compared to IC-only applicators, even in non-bulky HR-CTVs. We offer practical recommendations for needle selection, insertion depth, and relative weighting for Vienna-style applicators in small HR-CTVs. These results support previous publications, offering practical recommendations for users of Vienna-style hybrid applicators.

Virtual reality-based simulation improves gynecologic brachytherapy proficiency, engagement, and trainee self-confidence.

PURPOSE: Intracavitary brachytherapy is critical in treatment of cervical cancer with the highest rates of local control and survival. Only about 50% of graduating residents express confidence to develop a brachytherapy practice with caseload as the greatest barrier. We hypothesize that virtual reality (VR)-based intracavitary brachytherapy simulation will improve resident confidence, engagement, and proficiency. METHODS: We created a VR training video of an intracavitary brachytherapy case performed by a board-certified gynecologic radiation oncologist and medical physicist. Residents performed a timed intracavitary procedure on a pelvic simulator before and after viewing the VR simulation module on a commercially available VR headset while five objective measures of implant quality were recorded. The residents completed a pre- and postsimulation questionnaire assessing self-confidence, procedural knowledge, and perceived usefulness of the session. RESULTS: There were 14 residents, including five postgraduate year (PGY)-2, three PGY-3, four PGY-4, and two PGY-5, who participated in the VR curriculum. There were improvements in resident confidence (1.43-3.36), and subjective technical skill in assembly (1.57-3.50) and insertion (1.64-3.21) after the simulation. Average time of implant decreased from 5:51 to 3:34 (p = 0.0016). Median technical proficiencies increased from 4/5 to 5/5. Overall, the residents found VR to be a useful learning tool and indicated increased willingness to perform the procedure again. CONCLUSIONS: VR intracavitary brachytherapy simulation improves residents' self-confidence, subjective and objective technical skills, and willingness to perform brachytherapy. Furthermore, VR is an immersive, engaging, time-efficient, inexpensive, and enjoyable tool that promotes residents interest in brachytherapy.

Per-fraction positional and dosimetric performance of prone breast tangential radiotherapy on Halcyon™ linear accelerator assessed with daily rapid kilo-voltage cone beam computed tomography: a single-institution pilot study.

BACKGROUND: This study investigates daily breast geometry and delivered dose to prone-positioned patients undergoing tangential whole breast radiation therapy (WBRT) on an O-ring linear accelerator with 6X flattening filter free mode (6X-FFF), planned with electronic compensation (ECOMP) method. Most practices rely on skin marks or daily planar image matching for prone breast WBRT. This system provides low dose daily CBCT, which was used to study daily robustness of delivered dose parameters for prone-positioned WBRT. METHODS: Eight patients treated with 16-fraction prone-breast WBRT were retrospectively studied. Planning CTs were deformed to daily CBCT to generate daily synthetic CTs, on which delivered dose distributions were calculated. A total of 8 × 16 = 128 synthetic CTs were generated. Consensus ASTRO definition was used to contour Breast PTV Eval for each daily deformed CT. Breast PTV Eval coverage (V90%) and hotspot (V105% and Dmax) were monitored daily to compare prescription dose with daily delivered dose. Various predictors including patient weight, breast width diameter (BWD), and Dice similarity coefficient (DSC) were fit into an analysis of covariance model predicting V90% and V105% deviation from prescribed (ΔV90%, ΔV105%). Statistical significance is indicated with asterisks (* for p < 0.05; ** for p < 0.001). RESULTS: Daily delivered Breast PTV Eval V90% was moderately smaller than prescribed (median ΔV90% = - 0.1%*), while V105% was much larger (median ΔV105% = + 10.1%** or + 92.4 cc**). Patient's weight loss correlated with significantly increased ΔV105% (+ 4.6%/ - 1% weight, R2 = 0.4**) and moderately decreased ΔV90% (- 0.071%/ - 1% wt., R2 = 0.2**). Comprehensive ANCOVA models indicated three factors affect ΔV90% and ΔV105% the most: (1) BWD decrease (- 0.09%* and + 10%**/ - 1 cm respectively), (2) PTV Eval volume decrease (- 0.4%** and + 9%**/ - 100 cc), and for ΔV105% only, (3) the extent of breast deformation (+ 10%**/ - 0.01 DSC). Breast PTV Eval volume also decreased with time (- 2.21*cc/fx), possibly indicating seroma resolution and increase in V105% over time. CONCLUSIONS: Daily CBCT revealed key delivered dose parameters vary significantly for patients undergoing tangential prone breast WBRT planned with ECOMP using 6X-FFF. Patient weight, BWD, and breast shape deformation could be used to predict dosimetric variations from prescribed. Preliminary findings suggest an adaptive plan based on daily CBCT could reduce excessive dose to the breast.

Geometric and dosimetric effects of image co-registration workflows for Gamma Knife frameless radiosurgery.

The Gamma Knife® Icon™ CBCT facilitates frameless radiosurgery. In the vendor-recommended workflow, MRI is co-registered directly to CBCT for planning. Alternatively, MRI is co-registered to a diagnostic CT, which is then co-registered to CBCT. Our objective is to evaluate if this additional CT is necessary for more accurate registrations. Nine small spherical targets were generated onto 14 patient data-sets. Single-shot treatment plans were created. Geometric and dosimetric differences between the two workflows were determined. Mean target displacement was 0.5±0.3mm; average PTV coverage loss was 4.3±5.0%. For 19 clinical targets in 14 patients, the mean displacement and coverage change was 0.6±0.4mm and 1.3±1.6%. Eleven surrogate landmarks were contoured on a phantom MRI and registered to the CBCT using both workflows. The registration uncertainty was 0.50±0.65mm and 0.32±0.47mm for the MRI-CT-CBCT and MRI-CBCT respectively. As neither workflow was significantly more accurate, the additional CT is unnecessary for most cases.

Carotid dosimetry after re-irradiation with 131Cs permanent implant brachytherapy in recurrent, resected head and neck cancer.

PURPOSE: Permanent seed implant cesium-131 (131Cs) brachytherapy provides highly localized radiation for patients with recurrent head and neck cancer (HNC), who may be ineligible for external beam radiation therapy due to a high-risk of toxicity. As carotid blowout is a concern in the setting of re-irradiation, a dose to the carotid artery was examined for 131Cs brachytherapy implants. MATERIAL AND METHODS: Eleven patients were implanted with 131Cs adjacent to carotid at the time of resection for recurrent HNC. Vascularized tissue flaps were used in some patients. The carotid artery was contoured on the post-implant brachytherapy treatment plan, and the maximum carotid point dose and minimum carotid-seed distances are reported. The incidence of carotid blowout in the follow-up period was also measured. RESULTS: The maximum carotid dose was 77 ±52 Gy (range, 3-158 Gy). The closest seed to the carotid artery was 0.8 ±0.8 cm (range, 0.2-2.6 cm). One patient without a flap experienced carotid blowout, which was attributed to a non-healing wound rather than to high radiation doses. CONCLUSIONS: Carotid artery doses from 131Cs are reported. Vascularized tissue flaps should be considered when planning 131Cs brachytherapy.

Single institution implementation of permanent 131Cs interstitial brachytherapy for previously irradiated patients with resectable recurrent head and neck carcinoma.

PURPOSE: Permanent interstitial brachytherapy is an appealing treatment modality for patients with locoregional recurrent, resectable head and neck carcinoma (HNC), having previously received radiation. Cesium-131 (131Cs) is a permanent implant brachytherapy isotope, with a low average photon energy of 30 keV and a short half-life of 9.7 days. Exposure to medical staff and family members is low; patient isolation and patient room shielding are not required. This work presents a single institution's implementation process of utilizing an intraoperative, permanent 131Cs implant for patients with completely resected recurrent HNC. MATERIAL AND METHODS: Fifteen patients receiving 131Cs permanent seed brachytherapy were included in this analysis. The process of pre-planning, selecting the dose prescription, seed ordering, intraoperative procedures, post-implant planning, and radiation safety protocols are described. RESULTS: Tumor volumes were contoured on the available preoperative PET/CT scans and a pre-implant treatment plan was created using uniform source strength and uniform 1 cm seed spacing. Implants were performed intraoperatively, following tumor resection. In five of the fifteen cases, intraoperative findings necessitated a change from the planned number of seeds and recalculation of the pre-implant plan. The average prescription dose was 56.1 ±6.6 Gy (range, 40-60 Gy). The average seed strength used was 2.2 ±0.2 U (3.5 ±0.3 mCi). Patients returned to a recovery room on a standard surgical floor and remained inpatients, without radiation safety restrictions, based on standard surgical recovery protocols. A post-implant treatment plan was generated based on immediate post-operative CT imaging to verify the seed distribution and confirm delivery of the prescription dose. Patients were provided educational information regarding radiation safety recommendations. CONCLUSIONS: Cesium-131 interstitial brachytherapy is feasible and does not pose major radiation safety concerns; it should be considered as a treatment option for previously irradiated patients with recurrent, resectable HNC.

A nomogram to determine required seed air kerma strength in planar 131Cesium permanent seed implant brachytherapy.

PURPOSE: Intraoperatively implanted Cesium-131 (131Cs) permanent seed brachytherapy is used to deliver highly localized re-irradiation in recurrent head and neck cancers. A single planar implant of uniform air kerma strength (AKS) seeds and 10 mm seed-to-seed spacing is used to deliver the prescribed dose to a point 5 mm or 10 mm perpendicular to the center of the implant plane. Nomogram tables to quickly determine the required AKS for rectangular and irregularly shaped implants were created and dosimetrically verified. By eliminating the need for a full treatment planning system plan, nomogram tables allow for fast dose calculation for intraoperative re-planning and for a second check method. MATERIAL AND METHODS: TG-43U1 recommended parameters were used to create a point-source model in MATLAB. The dose delivered to the prescription point from a single 1 U seed at each possible location in the implant plane was calculated. Implant tables were verified using an independent seed model in MIM Symphony LDR™. Implant tables were used to retrospectively determine seed AKS for previous cases: three rectangular and three irregular. RESULTS: For rectangular implants, the percent difference between required seed AKS calculated using MATLAB and MIM was at most 0.6%. For irregular implants, the percent difference between MATLAB and MIM calculations for individual seed locations was within 1.5% with outliers of less than 3.1% at two distal locations (10.6 cm and 8.8 cm), which have minimal dose contribution to the prescription point. The retrospectively determined AKS for patient implants using nomogram tables agreed with previous calculations within 5% for all six cases. CONCLUSIONS: Nomogram tables were created to determine required AKS per seed for planar uniform AKS 131Cs implants. Comparison with the treatment planning system confirms dosimetric accuracy that is acceptable for use as a second check or for dose calculation in cases of intraoperative re-planning.

Avoidance sectors to reduce dosimetric impact of an irreproducible pannus on setup uncertainty in prostate SBRT VMAT: A case study.

This work investigates whether the use of an avoidance sector in a two-arc volumetric modulated arc therapy (VMAT) prostate stereotactic body radiotherapy (SBRT) plan reduces dosimetric variations due to an irreproducible pannus. A morbidly obese patient with favorable-risk prostate cancer elected treatment with SBRT. The patient was treated with the avoidance arcs across the pannus to eliminate reproducibility issues created by daily pannus variability in set up. For post-treatment assessment, the case was planned using Varian Eclipse™ treatment planning system (TPS) with two VMAT arcs with and without 100° avoidance sectors across the pannus. The dose was re-calculated using the external body contour from four daily treatment cone-beam computer tomography scans, and on two virtual body contours created by expanding the pannus region of the external contour by 5 and 10 mm. Dose differences between planned and re-calculated rectal wall mean dose and the V24Gy were numerically larger in the absence of the avoidance sector for all fractions and for both simulated pannus variations, with maximum changes of 2.6% and 1.3%. Maximum point dose variations in the PTV, CTV, rectum, bladder, and femoral heads were 105 cGy or less for all cases, with and without the avoidance sector. The use of an avoidance sector across this large, asymmetrical pannus did not inhibit achieving dose constraints and provided a reduction in dose variability which was nominal in this case for 10 mm variations. Avoidance sectors can be safely implemented in cases with obvious reproducibility concerns in the setting of prostate VMAT SBRT.

Technical Note: A novel quality assurance test to identify gantry angle inaccuracies in respiratory-gated VMAT treatments.

PURPOSE: During respiratory-gated volumetric-modulated arc therapy (VMAT), the radiation beam is turned off each time the target exits the gating window. At the same time, the gantry slows, stops, and rewinds before the beam is turned back on. A quality assurance (QA) test was developed to detect inaccuracies in the gantry angle position between beam-off and beam-on events during respiratory-gated VMAT. METHODS: Strips of Gafchromic™ EBT3 film were taped to the surface of a Capthan® 504 phantom mounted at isocenter. A homogeneous dose was delivered to the films through a 2 cm × 10 cm slit in the jaws using a respiratory-gated VMAT arc without the multileaf collimator. A periodic breathing cycle was used. Errors in gated delivery ranging from 0.5 to 5° were simulated by delivering nongated arcs with the same field size with over- and underlapping sections of 0.5-5°. The simulated errors were used to define QA levels to analyze the gated delivery. RESULTS: The QA test was capable of detecting errors as small as 0.5°. The test was delivered to three Varian TrueBeam™ linacs, and no gantry angle inaccuracies greater than or equal to 0.5° were detected on any of the films. CONCLUSIONS: A QA test capable of detecting gantry angle inaccuracies at beam-off and subsequent beam-on as small as 0.5° was developed and implemented for Varian TrueBeam™ linacs.

The influence of plan modulation on the interplay effect in VMAT liver SBRT treatments.

Volumetric modulated arc therapy (VMAT) uses multileaf collimator (MLC) leaves, gantry speed, and dose rate to modulate beam fluence, producing the highly conformal doses required for liver radiotherapy. When targets that move with respiration are treated with a dynamic fluence, there exists the possibility for interplay between the target and leaf motions. This study employs a novel motion simulation technique to determine if VMAT liver SBRT plans with an increase in MLC leaf modulation are more susceptible to dosimetric differences in the GTV due to interplay effects. For ten liver SBRT patients, two VMAT plans with different amounts of MLC leaf modulation were created. Motion was simulated using a random starting point in the respiratory cycle for each fraction. To isolate the interplay effect, motion was also simulated using four specific starting points in the respiratory cycle. The dosimetric differences caused by different starting points were examined by subtracting resultant dose distributions from each other. When motion was simulated using random starting points for each fraction, or with specific starting points, there were significantly more dose differences in the GTV (maximum 100cGy) for more highly modulated plans, but the overall plan quality was not adversely affected. Plans with more MLC leaf modulation are more susceptible to interplay effects, but dose differences in the GTV are clinically negligible in magnitude.