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Prospective Plan of Care ("Peer") Review (PPCR) has been shown to catch major issues such as changes to target volumes, organs-at-risk (OAR) contours, the prescription, and overall treatment appropriateness (PMID: 36706911). Typically, when PPCR is employed, radiotherapy planning is held until the review is complete which can result in lengthened time-to-treatment (TTT). In effort to minimize the TTT for those undergoing PPCR we developed a PPCR process that does not hold treatment planning unless a major change is identified. We review our overall PPCR experience of over 5 years. A weekly online departmental PPCR meeting was developed whereby a selection of definitive cases were chosen at random or submitted for review from across our Department of Radiation Oncology comprised of 32 physicians across various locations. Head and neck (H&N), stereotactic body radiation therapy (SBRT), and brachytherapy (brachy) PPCR became separate online meetings over time due to the level of expertise needed. An offline (independent) PPCR review option was also developed to reduce meeting time constraints. From 7/2018 to 12/2023, 1670 definitive cases across a wide variety of diagnoses were prospectively reviewed at our weekly meeting. In addition to general appropriateness of treatment, cases were evaluated with respect to simulation, target volumes, OAR, and prescription (dose and fractionation). Consensus outcomes were recorded as either "agreed", "minor suggestion" or "major suggestion" for each evaluation. When accounting for the cases reviewed through all of our prospective PPCR processes (i.e. offline, H&N, SBRT, brachy PPCR) 2813 total cases were reviewed in 2023 alone, representing 30% of our departmental cases. Table 1 shows the rate of minor and major changes recorded during our weekly PPCR meeting. When looking specifically at offline PPCR, we note a 17% "major" change for targets and 6% "major" change for prescription. In 2023 TTT (the interval from simulation to chart check) for all IMRT and SBRT cases through our department was 7.2 and 8.2 business days, respectively. PPCR continues to evolve at our institution. Offline PPCR may lead to an increased rate of "major" change outcomes perhaps due to its one-on-one nature (no group consensus) or perhaps these cases are inherently challenging or complex prompting colleagues to seek peer review before proceeding with treatment. We feel it valuable to continue weekly online and offline PPCR and are also in the process of creating disease specific PPCR or "office hours" in efforts to continue to have group consensus and solidify practice patterns within our department. Parallel PPCR is feasible, allowing for case review in 30% or more without a detrimental impact on departmental TTT metrics. [ABSTRACT FROM AUTHOR]

Abstract: This study discusses the fabric development in naturally sheared quartz aggregates in comparison to results from texture modeling according to the polycrystalline plasticity theory with particular emphasis on the formation of a single c-axis maximum. The investigated natural shear zone samples were deformed at about 650 ± 50 °C with increasing strain up to γ ≈ 14 and show dynamic recrystallization microstructures of grain boundary migration recrystallization. Neutron diffraction texture analysis results in c-axis pole figures with a single maximum at the periphery of the pole figure. This maximum does not align with the shear plane normal towards higher strain, but rotates towards an inclined orientation in accordance with the sense of shear. Such a rotation is inconsistent with the single-slip hypothesis and suggests that the formation of this c-axis pattern is controlled by multi-slip on several slip systems. Based on the polycrystalline plasticity theory, this quartz fabric can develop if combined {r}, {z} and prism slip dominates and must not be related to the commonly proposed basal slip. The multi-slip texture development is in agreement with the shear sense interpretation from the asymmetry between well-defined quartz fabrics and the foliation. For dominant basal slip in quartz and γ > 2, numerical simulations predict a single peripheral maximum perpendicular to the shear plane and two a-maxima with a ∼30°-inward position parallel to the shear plane. This simulation corresponds to naturally observed CPO patterns of quartz formed at different deformation conditions and it is in agreement with the single-slip hypothesis. Hence, our combined natural and numerical data suggest that the single-slip hypothesis is a possible explanation for a single c(0001)-maximum but not universally true. [Copyright &y& Elsevier]

Variation in process and documentation cause gaps that lead to decreased patient safety and department efficiency. Safety risk can increase as enterprises grow and add regional centers. Implementation of an Intradepartmental Survey Program provides an opportunity to improve standardization of documentation and technique, review appropriateness of care, provide staff psychological safety and remain accreditation ready with the ultimate goal of providing the safest place for patients to receive treatment throughout the enterprise. Our Intradepartmental Survey Program has been in place for 5 years and has performed 10 different department audits with the goal of surveying every center once between the three-year American College of Radiology (ACR) survey interval. Survey standards from the ACR and the American Association of Physicists in Medicine (AAPM) were utilized for this program. A voluntary survey team from both main and regional centers was assembled from the following groups: physician, physicist, dosimetrist, and therapist. The survey consisted of three parts: 1) an anonymous pre-site survey, which was sent to each department member asking 5 quality related questions such as commitment to quality and safety, just culture, and needed changes 2) a random sample of 8 charts per radiation oncologist, which are reviewed by surveyors and 3) an onsite survey with opportunities for question-and-answer conference and observation. A final report is presented to the medical director of each center and manager. The report included feedback from each surveyor including a narrative of overall department function, strengths and recommendations, and findings of each chart reviewed. From our ten surveys completed to date, the physician and therapist groups have the most recommendations as noted in the table below. Based on the report, an action plan is generated by the surveyed center, listing improvement projects to address the recommendations from the report. Creation of our Intradepartmental Survey Program, which is one of our Continuous Quality Improvement (CQI) projects, has unified main and regional sites to share best practices through standardization, which facilitates efficient safe practices. This program has also improved our just culture, a culture where individuals feel safe reporting and speaking about deviations and working together on opportunities of shared accountability. [ABSTRACT FROM AUTHOR]