Assessing the functionality of a water-vending kiosk network with high-frequency instrumentation in Freetown, Sierra Leone.

Access to safe, reliable, and equitable water services in urban settings of low- and middle-income countries remains a critical challenge toward achieving Sustainable Development Goal 6.1, but progress has either slowed or stagnated in recent years. A pilot water kiosk network funded by the United States Millennium Challenge Corporation was implemented by the Sierra Leone Millennium Challenge Coordinating Unit into the intermittent piped water distribution network of Freetown, Sierra Leone, as a private-public partnership to improve water service provision for households without reliable piped water connections and to reduce non-revenue water. This study employs the use of high-frequency instrumentation to monitor, model, and assess the functionality of this water kiosk network over 2,947 kiosk-days. Functionality was defined via functionality levels on a daily basis through monitored stored water levels and modeled water withdrawals. The functionality levels across the kiosk network were found to be 34% operational, 30% offline, and 35% empty. Statistically significant (p<0.001) determinants of functionality were found for several predictors across the defined thresholds. Finally, modeling of water supply, water demand and withdrawal capacity, and water storage was conducted to further explain findings and provide additionally externally relevant support for kiosk operations.

Advancing Beyond the Hippocampus to Preserve Cognition for Patients With Brain Metastases: Dosimetric Results From a Phase 2 Trial of Memory-Avoidance Whole Brain Radiation Therapy.

Purpose: Recent advances to preserve neurocognitive function in patients treated for brain metastases include stereotactic radiosurgery, hippocampal avoidance whole brain radiation therapy (WBRT), and memantine administration. The hippocampus, corpus callosum, fornix, and amygdala are key neurocognitive substructures with a low propensity for brain metastases. Herein, we report our preliminary experience using a "memory-avoidance" WBRT (MA-WBRT) approach that spares these substructures for patients with >15 brain metastases. Methods and Materials: Ten consecutive patients treated with MA-WBRT on a phase 2 clinical trial were reviewed. In each patient, the hippocampi, amygdalae, corpus callosum, and fornix were contoured. Patients were not eligible for MA-WBRT if they had metastases in these substructures. A memory-avoidance region was created using a 5-mm volumetric expansion around these substructures. Hotspots were avoided in the hypothalamus and pituitary gland. Coverage of brain metastases was prioritized over memory avoidance dose constraints. Dose constraints for these avoidance structures included a D100% ≤ 9 Gy and D0.03 cm3 ≤ 16 Gy (variation acceptable to 20 Gy). LINAC-based volumetric modulated arc therapy plans were generated for a prescription dose of 30 Gy in 10 fractions. Results: On average, the memory avoidance structure volume was 37.1 cm3 (range, 25.2-44.6 cm3), occupying 2.5% of the entire whole brain target volume. All treatment plans met the D100% dose constraint, and 8 of 10 plans met the D0.03 cm3 constraint, with priority given to tumor coverage for the remaining 2 cases. Target coverage (D98% > 25 Gy) and homogeneity (D2% ≤ 37.5 Gy) were achieved for all plans. Conclusions: Modern volumetric modulated arc therapy techniques allow for sparing of the hippocampus, amygdala, corpus callosum, and fornix with good target coverage and homogeneity. After enrollment is completed, quality of life and cognitive data will be evaluated to assess the efficacy of MA-WBRT to mitigate declines in quality of life and cognition after whole brain radiation.

Volumetric Modulated Arc Therapy Craniospinal Irradiation Utilizing a Vertebral Body Sparing Approach: An Alternative Approach to Improve Access and Minimize Toxicity.

Introduction: Craniospinal irradiation (CSI) is indicated for adult patients diagnosed with leptomeningeal disease (LMD). Proton-based vertebral body sparing (VBS) CSI has been explored with pediatric patients to minimize hematologic toxicity; however, utilization of VBS in an adult population is limited. A recent phase II trial has shown efficacy of proton-based CSI to treat non-small cell lung and breast cancer with LMD. We hypothesize that VBS CSI using volumetric modulated arc therapy (VMAT) could also effectively reduce dose to vertebral bodies and surrounding organs at risk, minimizing toxicity for adult patients with LMD and comparing favorably to proton-based CSI. Methods and Materials: Consecutive patients with LMD received VMAT VBS CSI, 30 Gy in 10 fractions, as a part of a prospective registry. Full VMAT arcs for the brain fields matched to 2 spine isocenters for the upper and lower spine were created using limited posterior arcs. To further decrease the vertebral body dose, an avoid entry and exit contour was created. Acute toxicity data were collected using Common Terminology Criteria for Adverse Events v5. Results: Ten adult patients were treated in this cohort. One patient experienced grade 2 neutropenia with the remaining 9 experiencing grade 1 hematologic toxicity. Three patients experienced grade 2 gastrointestinal toxicity with the remaining 7 experiencing grade 1 nausea. No patient experienced grade 3+ toxicities in this cohort. One patient experienced a 5-day delay in systemic therapy initiation due to neutropenia; otherwise, all patients planned for systemic therapy started without delay. Conclusions: In this study, VMAT VBS CSI led to acceptable toxicity compared with patients treated with proton CSI on a phase 2 clinical trial. Given its promising early results, future prospective evaluation of the technique is warranted.

Vertebral Compression Fracture After Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate Disruption.

BACKGROUND AND OBJECTIVES: Vertebral compression fracture (VCF) is a common, but serious toxicity of spinal stereotactic body radiotherapy (SBRT). Several variables that place patients at high risk of VCF have previously been identified, including advanced Spinal Instability Neoplastic Score (SINS), a widely adopted clinical decision criterion to assess spinal instability. We examine the role of tumoral endplate (EP) disruption in the risk of VCF and attempt to incorporate it into a simple risk stratification system. METHODS: This study was a retrospective cohort study from a single institution. Demographic and treatment information was collected for patients who received spinal SBRT between 2013 and 2019. EP disruption was noted on pre-SBRT computed tomography scan. The primary end point of 1-year cumulative incidence of VCF was assessed on follow-up MRI and computed tomography scans at 3-month intervals after treatment. RESULTS: A total of 111 patients were included. The median follow-up was 18 months. Approximately 48 patients (43%) had at least one EP disruption. Twenty patients (18%) experienced a VCF at a median of 5.2 months from SBRT. Patients with at least one EP disruption were more likely to experience VCF than those with no EP disruption (29% vs 6%, P < .001). A nomogram was created using the variables of EP disruption, a SINS of ≥7, and adverse histology. Patients were stratified into groups at low and high risk of VCF, which were associated with 2% and 38% risk of VCF ( P < .001). CONCLUSION: EP disruption is a novel risk factor for VCF in patients who will undergo spinal SBRT. A simple nomogram incorporating EP disruption, adverse histology, and SINS score is effective for quickly assessing risk of VCF. These data require validation in prospective studies and could be helpful in counseling patients regarding VCF risk and referring for prophylactic interventions in high-risk populations.

A Prospective Registry Study of 68Ga-DOTATATE PET/CT Incorporation Into Treatment Planning of Intracranial Meningiomas.

PURPOSE: The current standard for meningioma treatment planning involves magnetic resonance imaging-based guidance. Somatostatin receptor ligands such as 68Ga-DOTATATE are being explored for meningioma treatment planning due to near-universal expression of somatostatin receptors 1 and 2 in meningioma tissue. We hypothesized that 68Ga-DOTATATE positron emission tomography (PET)-guided treatment management for patients with meningiomas is safe and effective and can identify which patients benefit most from adjuvant radiation therapy. METHODS AND MATERIALS: A single-institution prospective registry study was created for inclusion of patients with intracranial meningiomas who received a 68Ga-DOTATATE PET/CT to assist with radiation oncologist decision making. Patients who received a PET scan from January 1, 2018, to February 25, 2022, were eligible for inclusion. RESULTS: Of the 60 patients included, 40%, 47%, and 5% had World Health Organization grades 1, 2, and 3 meningiomas, respectively, and 8% (5 patients) had no grade assigned. According to Radiation Therapy Oncology Group 0539 criteria, 22%, 72%, and 7% were categorized as high, intermediate, and low risk, respectively. After completing their PET scans, 48 patients, 11 patients, and 1 patient proceeded with radiation therapy, observation, and redo craniotomy, respectively. The median follow-up for the entire cohort was 19.5 months. Of the 3 patients (5%) who experienced local failure between 9.2 and 28.5 months after diagnosis, 2 had PET-avid disease in their postoperative cavity and elected for observation before recurrence, and 1 high-risk patient with multifocal disease experienced local failure 2 years after a second radiation course and multiple previous recurrences. Notably, 5 patients did not have any local PET uptake and were observed; none of these patients experienced recurrence. Only 1 grade 3 toxicity was attributed to PET-guided radiation. CONCLUSIONS: This study examined one of the largest known populations of patients with intracranial meningiomas followed by physicians who used 68Ga-DOTATATE PET-guided therapy. Incorporating 68Ga-DOTATATE PET into future trials may assist with clinician decision making and improve patient outcomes.

Mesenchymal Wnts are required for morphogenetic movements of calvarial osteoblasts during apical expansion.

Apical expansion of calvarial osteoblast progenitors from the cranial mesenchyme (CM) above the eye is integral for calvarial growth and enclosure of the brain. The cellular behaviors and signals underlying the morphogenetic process of calvarial expansion are unknown. During apical expansion, we found that mouse calvarial primordia have consistent cellular proliferation, density, and survival with complex tissue scale deformations, raising the possibility that morphogenetic movements underlie expansion. Time lapse light sheet imaging of mouse embryos revealed that calvarial progenitors intercalate in 3D to converge supraorbital arch mesenchyme mediolaterally and extend it apically. In contrast, progenitors located further apically exhibited protrusive and crawling activity. CM cells express non-canonical Wnt/Planar Cell Polarity (PCP) core components and calvarial osteoblasts are bidirectionally polarized. We found non-canonical ligand, Wnt5a-/- mutants have less dynamic cell rearrangements, protrusive activity, and a flattened head shape. Loss of cranial mesenchyme-restricted Wntless (CM-Wls), a gene required for secretion of all Wnt ligands, led to diminished apical expansion of OSX+ calvarial osteoblasts in the frontal bone primordia in a non-cell autonomous manner without perturbing proliferation or survival. Calvarial osteoblast polarization, progressive cell elongation and enrichment for actin cytoskeleton protein along the baso-apical axis were dependent on CM-Wnts. Thus, CM-Wnts regulate cellular behaviors during calvarial morphogenesis and provide tissue level cues for efficient apical expansion of calvarial osteoblasts. These findings also offer potential insights into the etiologies of calvarial dysplasias.

Shape-driven confluent rigidity transition in curved biological tissues.

Collective cell motions underlie structure formation during embryonic development. Tissues exhibit emergent multicellular characteristics such as jamming, rigidity transitions, and glassy dynamics, but there remain questions about how those tissue-scale dynamics derive from local cell-level properties. Specifically, there has been little consideration of the interplay between local tissue geometry and cellular properties influencing larger-scale tissue behaviors. Here, we consider a simple two-dimensional computational vertex model for confluent tissue monolayers, which exhibits a rigidity phase transition controlled by the shape index (ratio of perimeter to square root area) of cells, on surfaces of constant curvature. We show that the critical point for the rigidity transition is a function of curvature such that positively curved systems are likely to be in a less rigid, more fluid, phase. Likewise, negatively curved systems (saddles) are likely to be in a more rigid, less fluid, phase. A phase diagram we generate for the curvature and shape index constitutes a testable prediction from the model. The curvature dependence is interesting because it suggests a natural explanation for more dynamic tissue remodeling and facile growth in regions of higher surface curvature. Conversely, we would predict stability at the base of saddle-shaped budding structures without invoking the need for biochemical or other physical differences. This concept has potential ramifications for our understanding of morphogenesis of budding and branching structures.

Polycrystalline Diamond Micro-Hotplates.

Micro-hotplate structures are increasingly being investigated for use in a host of applications ranging from broadband infra-red sources within absorption-based gas sensors to in situ heater stages for ultra-high-resolution imaging. With devices usually fabricated from a conductive electrode placed on top of a freestanding radiator element, coefficient of thermal expansion (CTE) mismatches between layers and electro-migration within the heating element typically lead to failure upon exceeding temperatures of 1600 K. In an attempt to mitigate such issues, a series of hotplates of varying geometry have been fabricated from a single layer of mechanically robust, high thermal conductivity, and low CTE boron-doped polycrystalline diamond. Upon testing under high vacuum conditions and characterization of the emission spectra, the resulting devices are shown to exhibit a grey-body like emission response and reach temperatures vastly in excess of conventional geometries of up to 2731 K at applied powers of ⩽100 mW. Characterization of the thermalization time meanwhile demonstrates rapid millisecond response times, while Raman spectroscopy reveals the performance of the devices is dictated by cumulative graphitization at elevated temperatures. As such, both diamond and sp2 carbon are shown to be promising materials for the fabrication of next-generation micro-hotplates.

Monitoring of the Initial Stages of Diamond Growth on Aluminum Nitride Using In Situ Spectroscopic Ellipsometry.

The high thermal conductivity of polycrystalline diamond makes it ideally suited for thermal management solutions for gallium nitride (GaN) devices, with a diamond layer grown on an aluminum nitride (AlN) interlayer atop the GaN stack. However, this application is limited by the thermal barrier at the interface between diamond and substrate, which has been associated with the transition region formed in the initial phases of growth. In this work, in situ spectroscopic ellipsometry (SE) is employed to monitor early-stage microwave plasma-enhanced chemical vapor deposition diamond growth on AlN. An optical model was developed from ex situ spectra and applied to spectra taken in situ during growth. Coalescence of separate islands into a single film was marked by a reduction in bulk void fraction prior to a spike in sp2 fraction due to grain boundary formation. Parameters determined by the SE model were corroborated using Raman spectroscopy and atomic force microscopy.

Novel Intrafraction Motion Tracking During Postoperative Spine Stereotactic Irradiation for a Patient With Carbon Fiber Fixation Hardware.

Carbon-fiber reinforced (CFR) polyetheretherketone hardware is an alternative to traditional metal hardware used for spinal fixation surgeries before postoperative radiation therapy for patients with spinal metastases. CFR hardware's radiolucency decreases metal artifact, improving visualization and accuracy of treatment planning. We present the first clinical use and proof of principle of CFR spinal hardware with tantalum markers used for successful tracking of intrafraction motion (IM) using Varian TrueBeam IMR (Intrafraction Motion Review) software module during postoperative spine stereotactic radiation. A 63-year-old woman with history of endometrial cancer presented with acute back pain. Imaging demonstrated pathologic T12 vertebral fracture with cord compression. She underwent T12 vertebrectomy with circumferential decompression and posterior instrumented T10-L2 fusion at our facility using CFR-polyetheretherketone hardware with tantalum screw markers followed by postoperative stereotactic body radiation therapy to 3000 cGy in 5 fractions delivered to T11-T12. Tantalum screw markers were used for IMR tracking. During irradiation, 260 kV images were acquired, and IMR software was able to identify and track markers. During the entire treatment, the IM motions were less than 3 mm. This is the first presented case of CFR spinal hardware with tantalum markers used for successful IMR tracking of IM during daily spine stereotactic treatment. Future work will be needed to improve workflow and create a spine-specific IMR protocol.

Understanding the Effect of Prescription Isodose in Single-Fraction Stereotactic Radiosurgery on Plan Quality and Clinical Outcomes for Solid Brain Metastases.

BACKGROUND AND OBJECTIVES: There is wide variation in treatment planning strategy for central nervous system (CNS) stereotactic radiosurgery. We sought to understand what relationships exist between intratumor maximum dose and local control (LC) or CNS toxicity, and dosimetric effects of constraining hotspots on plan quality of multiple metastases volumetric modulated arc therapy radiosurgery plans. METHODS: We captured brain metastases from 2015 to 2017 treated with single-isocenter volumetric modulated arc therapy radiosurgery. Included tumors received single-fraction stereotactic radiosurgery, had no previous surgery or radiation, and available follow-up imaging. Our criterion for local failure was 25% increase in tumor diameter on follow-up MRI or pathologic confirmation of tumor recurrence. We defined significant CNS toxicity as Radiation Therapy Oncology Group irreversible Grade 3 or higher. We performed univariate and multivariate analyses evaluating factors affecting LC. We examined 10 stereotactic radiosurgery plans with prescriptions of 18 Gy to all targets originally planned without constraints on the maximum dose within the tumor. We replanned each with a constraint of Dmax 120%. We compared V50%, mean brain dose, and Dmax between plans. RESULTS: Five hundred and thirty tumors in 116 patients were available for analysis. Median prescription dose was 18 Gy, and median prescription isodose line (IDL) was 73%. Kaplan-Meier estimate of 12-month LC only tumor volume (HR 1.43 [1.22-1.68] P < .001) was predictive of local failure on univariate analysis; prescription IDL and histology were not. In multivariate analysis, tumor volume impacted local failure (HR 1.43 [1.22-1.69] P < .001) but prescription IDL did not (HR 0.95 [0.86-1.05] P = .288). Only a single grade 3 and 2 grade 4 toxicities were observed; tumor volume was predictive of CNS toxicity (HR 1.58 [1.25-2.00]; P < .001), whereas prescription IDL was not (HR 1.01 [0.87-1.17] P = .940). CONCLUSION: The prescription isodose line had no impact on local tumor control or CNS toxicity. Penalizing radiosurgery hotspots resulted in worse radiosurgery plans with poorer gradient. Limiting maximum dose in gross tumor causes increased collateral exposure to surrounding tissue and should be avoided.

Advances in Radiotherapy for Brain Metastases.

Radiotherapy remains a cornerstone treatment of brain metastases. With new treatment advances, patients with brain metastases are living longer, and finding solutions for mitigating treatment-related neurotoxicity and improving quality of life is important. Historically, whole-brain radiation therapy (WBRT) was widely used but treatment options such as hippocampal sparing WBRT and stereotactic radiosurgery (SRS) have emerged as promising alternatives. Herein, we discuss the recent advances in radiotherapy for brain metastases including the sparing of critical structures that may improve long-term neurocognitive outcomes (eg, hippocampus, fornix) that may improve long-term neurocognitive outcome, evidence supporting preoperative and fractionated-SRS, and treatment strategies for managing radiation necrosis.

Study design and baseline to evaluate water service provision among peri-urban communities in Kasai Oriental, Democratic Republic of the Congo.

We present a study design and baseline results to establish the impact of interventions on peri-urban water access, security and quality in Kasai Oriental province of the Democratic Republic of the Congo. In standard development practice, program performance is tracked via monitoring and evaluation frameworks of varying sophistication and rigor. Monitoring and evaluation, while usually occurring nearly concurrently with program delivery, may or may not measure parameters that can identify performance with respect to the project's overall goals. Impact evaluations, often using tightly controlled trial designs and conducted over years, challenge iterative program evolution. This study will pilot an implementation science impact evaluation approach in the areas immediately surrounding 14 water service providers, at each surveying 100 randomly-selected households and conducting water quality assessments at 25 randomly-selected households and five water points every three months. We present preliminary point-of-collection and point-of-use baseline data. This study is utilizing a variety of short- and medium-term monitoring and impact evaluation methods to provide feedback at multiple points during the intervention. Rapid feedback monitoring will assess the continuity of water services, point-of-consumption and point-of-collection microbial water quality, household water security, household measures of health status, ability and willingness to pay for water and sanitation service provision, and service performance monitoring. Long-term evaluation will focus on the use of qualitative comparative analysis whereby we will investigate the combination of factors that lead to improved water access, security and quality.

Neoadjuvant Arterial Embolization of Spine Metastases Associated With Improved Local Control in Patients Receiving Surgical Decompression and Stereotactic Body Radiotherapy.

BACKGROUND: Spine metastases often cause significant pain, instability, and/or neurological morbidity. Local control (LC) of spine metastases has been augmented with advances in systemic therapies, radiation, and surgical technique. Prior reports suggest an association between preoperative arterial embolization and improved LC and palliative pain control. OBJECTIVE: To further elucidate the role of neoadjuvant embolization on LC of spine metastases and the potential for improved pain control in patients receiving surgery and stereotactic body radiotherapy (SBRT). METHOD: A retrospective single-center review between 2012 and 2020 identified 117 patients with spinal metastases from various solid tumor malignancies managed with surgery and adjuvant SBRT with or without preoperative spinal arterial embolization. Demographic information, radiographic studies, treatment characteristics, Karnofsky Performance Score, Defensive Veterans Pain Rating Scale, and mean daily doses of analgesic medications were reviewed. LC was assessed using magnetic resonance imaging obtained at a median 3-month interval and defined as progression at the surgically treated vertebral level. RESULTS: Of 117 patients, 47 (40.2%) underwent preoperative embolization, followed by surgery and SBRT and 70 (59.8%) underwent surgery and SBRT alone. Within the embolization cohort, the median LC was 14.2 months compared with 6.3 months among the nonembolization cohort ( P = .0434). Receiver operating characteristic analysis suggests ≥82.5% embolization predicted significantly improved LC (area under the curve = 0.808; P < .0001). Defensive Veterans Pain Rating Scale mean and maximum scores significantly decreased immediately after embolization ( P < .001). CONCLUSION: Preoperative embolization was associated with improved LC and pain control suggesting a novel role for its use. Additional prospective study is warranted.

Implementation of triggered kilovoltage imaging for stereotactic radiotherapy of the spine for patients with spinal fixation hardware.

Background and purpose: Mitigation of intrafraction motion (IM) is valuable in stereotactic radiotherapy (SRT) radiotherapy where submillimeter accuracy is desired. The purpose of this study was to investigate the application of triggered kilovoltage (kV) imaging for spine SRT patients with hardware by correlating kV imaging with patient motion and summarizing implications of tolerance for IM based on calculated dose. Materials and methods: Ten plans (33 fractions) were studied, correlating kV imaging during treatment with pre- and post-treatment cone beam computed tomography (CBCT). Images were taken at 20-degree gantry angle intervals during the arc-based treatment. The contour of the hardware with a 1 mm expansion was displayed at the treatment console to manually pause treatment delivery if the hardware was visually detected outside the contour. The treatment CBCTs were compared using retrospective image registration to assess the validity of contour-based method for pausing treatment. Finally, plans were generated to estimate dose volume objective differences in case of 1 mm deviation. Results: When kV imaging during treatment was used with the 1 mm contour, 100 % of the post-treatment CBCTs reported consistent results. One patient in the cohort exhibited motion greater than 1 mm during treatment which allowed intervention and re-setup during treatment. The average translational motion was 0.35 mm. Treatment plan comparison at 1 mm deviation showed little differences in calculated dose for the target and cord. Conclusions: Utilizing kV imaging during treatment is an effective method of assessing IM for SRT spine patients with hardware without increasing treatment time.

Effectiveness of a water-vending kiosk intervention toward household water quality and surveyed water security in Freetown, Sierra Leone.

Low-income urban residents of Freetown, Sierra Leone, have limited access to safely managed piped drinking water services. The Government of Sierra Leone, in partnership with the United States Millennium Challenge Corporation, implemented a demonstration project of ten water kiosks providing distributed, stored, treated water among two neighborhoods in Freetown. This study quantifies the impact of the water kiosk intervention by utilizing a quasi-experimental propensity score matched difference-in-differences study design. Results indicate a 0.6 % improvement in household microbial water quality and an 8.2 % improvement in surveyed water security within the treatment group. Furthermore, low functionality and adoption of the water kiosks were observed.

Applying climate reparative finance toward water security.

Water insecurity is increasing globally as one of the first perceivable effects of climate change. While water management is typically a local challenge, climate finance mechanisms offer the potential to switch climate-damaging capital toward climate reparative water infrastructure and create a sustainable, performance-based funding stream to incentivize safe water services globally.

Improving bleeding disorder treatment log adherence: An application of the information-motivation-behavioral skills model.

INTRODUCTION: For people with severe bleeding disorders (PwBD) who are prescribed home treatment, treatment logs are an important part of the management of their care. Treatment logs provide a clinical picture of the home treatment regimen and can serve as a communication tool between the medical team and the person with a bleeding disorder. Most importantly, treatment logs allow for the adjustment of the treatment dose and frequency to prevent bleeding episodes. Yet, a large number of PwBD do not complete treatment logs. AIMS: We aimed to develop and implement interventions to increase adherence rates of treatment log completion in PwBD on a home treatment regimen by at least 20% over 2 years. METHODS: We conducted a quality improvement initiative from 2019-2022 involving developing and implementing interventions that were guided by the application of the Information-Motivation-Behavioural Skills Model. Examples of interventions included: the development of educational materials on the different methods of log completion and interactive discussions that involved a patient-driven decision of selecting a treatment log method. Data on the implementation of the theoretically-based interventions as well as outcome data on the success of treatment log completion was reviewed monthly. RESULTS: Following the application of the Information-Motivation-Behavioural Skills Model on the designed and implemented interventions, there was a 20% increase in individuals' adherence with treatment logs completion (N = 68). CONCLUSION: Treatment logs are an important piece of a PwBDs' prescribed home treatment regimen. Quality improvement interventions promoted increased treatment log adherence for PwBDs'prescribed prophylactic home treatment.

Comparing pre-operative versus post-operative single and multi-fraction stereotactic radiotherapy for patients with resectable brain metastases.

Background: The standard treatment for patients with large brain metastases and limited intracranial disease is surgical resection and post-operative stereotactic radiosurgery (SRS). However, post-operative SRS still has elevated rates of local failure (LF) and is complicated by radiation necrosis (RN), and meningeal disease (MD). Pre-operative SRS may reduce the risk of RN and MD, while fractionated therapy may improve local control through delivering a higher biological effective dose. We hypothesize that pre-operative fractionated stereotactic radiation therapy (FSRT) will have less toxicity compared to patients who receive post-operative SRS or FSRT. Methods: A multi-institutional analysis was conducted and included patients who had surgical resection and stereotactic radiation therapy to treat at least one brain metastasis. Pertinent demographic, clinical, radiation, surgical, and follow up data were collected for each patient. The primary outcome was a composite endpoint defined as patients with one of the following adverse events: 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. Results: 279 patients were eligible for analysis. The median follow-up time was 9 months. 87 % of patients received fractionated treatment. 29 % of patients received pre-operative treatment. The composite endpoint incidences for post-operative SRS (n = 10), post-operative FSRT (n = 189), pre-operative SRS (n = 27), and pre-operative FSRT (n = 53) were 0 %, 17 %, 15 %, and 7.5 %, respectively. Conclusions: In our study, the composite endpoint of 7.5% for pre-operative FSRT compares favorably to our post-operative FSRT rate of 17%. Pre-operative FSRT was observed to have low rates of LF, MD, and RN. Prospective validation is needed.