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Refereed/Peer-reviewed The Job Demands-Resources (JD-R) model is a well-recognized theoretical framework assessing the impact of job demands and resources on well-being. Though the model conceptualises job demands and resources in terms of how jobs are both objectively designed and subjectively experienced, most studies have relied only on subjective self-reported data. In a comprehensive test of the model, our study investigates how objective job characteristics at the occupation level are associated with employees’ perceptions of job demands and resources in their role, and examines the indirect effect of objective characteristics on employee outcomes via perceived characteristics. Multilevel analyses of multisource and lagged data from 2,049 employees in97 jobs indicated that perceived job characteristics mediate the effects of objective job characteristics on employee outcomes. Specifically, the objective requirement for positive emotional displays is positively related to exhaustion through perceived emotional demands. Second, objective job hazard exposure is positively related to physical health problems through perceived physical demands. Finally, objective job complexity has a significant positive indirect relationship with work engagement through perceived skill discretion. The results suggest that risk identification and enrichment processes should consider the nature of the job itself instead of merely focusing on employees’ cognitive appraisals.

Impacts of exposure are generally monitored and recorded after injuries or illness occur. Yet, absence of conventional after-the-effect impacts (i.e., lagging indicators), tend to focus on physical health and injuries, and fail to inform if workers are not exposed to safety and health hazards. In contrast to lagging indicators, leading indicators are proactive, preventive, and predictive indexes that offer insights how effective safety and health. The present study is to validate an extended Voluntary Protection Programs (VPP) that consists of six leading indicators.Questionnaires were distributed to 13 organizations (response rate = 93.1%, 1,439 responses) in Taiwan. Cronbach α, multiple linear regression and canonical correlation were used to test the reliability of the extended Voluntary Protection Programs (VPP) which consists of six leading indicators (safe climate, transformational leadership, organizational justice, organizational support, hazard prevention and control, and training). Criteria-related validation strategy was applied to examine relationships of six leading indicators with six criteria (perceived health, burnout, depression, job satisfaction, job performance, and life satisfaction).The results showed that the Cronbach's α of six leading indicators ranged from 0.87 to 0.92. The canonical correlation analysis indicated a positive correlation between the six leading indicators and criteria (1st canonical function: correlation = 0.647, square correlation = 0.419,The present study validates the extended VPP framework that focuses on promoting safety and physical and mental health. Results further provides applications of the extended VPP framework to promote workers' safety and health.

Adoption of hypofractionated whole breast irradiation (HWBI) for patients with early-stage, biologically high-risk breast cancer remains relatively low. We compared clinical outcomes of conventionally fractionated whole breast irradiation (CWBI) versus moderate HWBI in this patient population.We queried a prospectively maintained database for patients with early-stage (T1-2, N0, M0) breast cancer who received whole breast irradiation with either CWBI or moderate HWBI at a single institution. We included only patients with biologically high-risk tumors (defined as either estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2 negative, human epidermal growth factor receptor 2 amplified, and/or patients with a high-risk multigene assay) who received systemic chemotherapy. Inverse probability of treatment weighting was used to compare treatment cohorts and to estimate 5-year time to event endpoints. Hazard ratios (HR) and 95% confidence interval (CI) were determined based on Cox proportional hazards model.We identified 300 patients, of whom 171 received CWBI and 129 received HWBI. There was a statistically significant difference in median age at diagnosis, 59 years for CWBI versus 63 years for HWBI (P = .004), and in median follow-up time, 97 months for CWBI versus 55 months for HWBI (P.001). After accounting for differences in patient and tumor characteristics with inverse probability of treatment weighting, we found similar 5-year freedom from local recurrence (HR, 0.76; 95% CI, 0.14-4.1), freedom from regional recurrence (HR, 3.395% CI 0.15-69), freedom from distant metastasis (HR 3.9, 95% CI 0.86-17), and disease-free survival (HR 0.84; 95% CI, 0.3-2.4), between those treated with CWBI and those treated with HWBI. Results were similar among each of the 3 high-risk subtypes.Our data support the use of moderate HWBI in patients with early-stage, biologically high-risk breast cancer.

Although global heart dose has been associated with late cardiac toxic effects in patients who received radiation therapy for breast cancer, data detailing the clinical significance of cardiac substructure dosimetry are limited. We investigated whether dose to the left anterior descending artery (LAD) correlates with adverse cardiac events.We identified 375 consecutively treated female patients from 2012 to 2018 who received left-sided breast or chest wall irradiation (with or without regional nodal irradiation). Medical records were queried to identify cardiac events after radiation therapy. Mean and maximum LAD and heart doses (LAD DMedian follow-up time was 48 months. Thirty-six patients experienced a cardiac event, and 23 patients experienced a major cardiac event. On univariate and multivariable analyses, increased LAD DDose to the LAD correlated with adverse cardiac events in this cohort. Contouring and minimizing dose to the LAD should be considered for patients receiving radiation therapy for left-sided breast cancer.

Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research. (c) 2021 Elsevier Inc. All rights reserved.

Objective To identify pretreatment variables associated with the development of acute vestibular symptoms after Gamma Knife (GK) treatment for Vestibular Schwannoma (VS). Study design Retrospective case series. Setting Tertiary neurotology referral center. Patients Patients treated with GK radiosurgery for VS between March 2007 and March 2017 were considered for this study. Patients with neurofibromatosis type II, previous VS surgery, follow-up less than 6 months, or the lack of T2 magnetic resonance imaging (MRI) sequences from the day of treatment were excluded. Main outcome measures The presence of acute vestibular symptoms arising within 6 months after GK was the main outcome variable. Tumor, patient, and treatment characteristics were gathered from the medical record. Results In total, 98 patients met inclusion criteria. The incidence of acute vestibular symptoms occurring within 6 months after GK treatment was 46.9%. Post-GK vestibular symptoms were reported at a significantly higher frequency among subjects who had reported vestibular symptoms before their treatment (p = 0.001). Tumor size was not associated with a propensity to develop acute vestibular symptoms (p = 0.397). The likelihood of receiving a referral to vestibular rehabilitation services was not significantly different among patients with larger versus smaller tumor size, as defined by 1.6 cm and 1.4 cm thresholds (p = 0.896, p = 0.654). Conclusions Inquiries aimed at revealing a history of vestibular complaints may prove useful in counseling patients on the likelihood of experiencing acute vestibular symptoms after treatment of Vestibular Schwannoma with Gamma Knife therapy.

Dose to the left anterior descending artery (LAD) may be significant in patients receiving left-sided irradiation for breast cancer. We investigated if prospective contouring and avoidance of the LAD during treatment planning were associated with lower LAD dose.We reviewed dosimetric plans for 323 patients who received left whole breast or chest wall irradiation with or without internal mammary node (IMLN) coverage between 1/2014 and 1/2019 at a single institution. The LAD was contoured prospectively for 155 cases, and techniques were utilized to minimize LAD dose. Dose-volume-histograms from these patients were compared to those of 168 patients for whom the LAD was contoured retrospectively after treatment completion. EQD2 was calculated to account for fractionation differences.Compared to cases where the LAD was contoured retrospectively (n = 126), prospective LAD contouring (n = 124) was associated with lower unadjusted median max and mean LAD doses for 250 patients receiving whole-breast irradiation (WBI) without IMLN coverage: 8.5 Gy vs 5.2 Gy (p0.0001) and 3.6 Gy vs 2.7 Gy (p0.0001), respectively. EQD2 median max and mean LAD doses were also lower with prospective LAD contouring: 5.2 Gy vs 3.0 Gy (p0.0001) and 1.9 Gy vs 1.5 Gy (p0.0001), respectively. Compared to cases where the LAD was contoured retrospectively (n = 42), prospective LAD contouring (n = 31) was associated with lower max LAD doses for 73 patients with IMLN coverage: 20.4 Gy vs 14.3 Gy (p = 0.042). There was a nonsignificant reduction in median mean LAD dose: 6.2 Gy vs 6.1 Gy (p = 0.33). LAD doses were reduced while maintaining IMLN coverage (mean V90%Prospective contouring and avoidance of the LAD were associated with lower max and mean LAD doses in patients receiving WBI and with lower max LAD doses in patients receiving IMLN treatment. Further reduction in LAD dose may require stricter optimization weighting or compromise in IMLN coverage.

OBJECTIVE Assess inner ear radiation dose magnitude as it relates to fundal cap length and hearing outcomes in the radiosurgical treatment of vestibular schwannoma. STUDY DESIGN Retrospective case series. SETTING Tertiary neurotology referral center. PATIENTS Patients treated with Gamma Knife radiosurgery for vestibular schwannoma between March 2007 and March 2017 were considered for this study. Exclusion criteria included pretreatment pure-tone average (PTA) >90 dB, neurofibromatosis type II, history of previous surgical resection, and follow-up less than 1 year. MAIN OUTCOME MEASURE (s): Hearing function was assessed by maintenance of class A/B hearing level and maintenance of baseline hearing (≤20 dB change in PTA following Gamma Knife radiosurgery). RESULTS Lower radiation doses delivered to the inner ear were associated with longer fundal cap lengths: mean cochlear dose (r = -0.130; p = 0.184), mean labyrinth dose (r = -0.406; p

Objective To evaluate the relationship between fundal fluid and hearing outcomes after treatment of vestibular schwannoma (VS) with Gamma Knife radiosurgery (GKRS). Study design Retrospective case series. Setting Tertiary neurotology referral center. Patients Patients treated with GKRS for vestibular schwannoma between March 2007 and March 2017 were considered for this study. Exclusion criteria included pretreatment pure-tone average (PTA) >90 dB, neurofibromatosis type II, history of previous surgical resection, and follow-up less than 1 year. Main outcome measure(s) Hearing function was assessed both by preservation of serviceable hearing and by preservation of baseline hearing (≤20 dB change in PTA) after GKRS. Hearing preservation comparisons were made between groups of patients with and without a fundal fluid cap. Results Patients with a fundal cap had significantly higher rates of baseline hearing preservation (≤20 dB change in PTA) according to Kaplan-Meier survival analysis of all 106 patients (p = 0.006). By the 3rd year posttreatment, 70.9% of patients with a fundal cap had maintained a ≤20 dB change in PTA, while only 43.6% of patients without a fundal fluid cap achieved this outcome (p = 0.004). Conclusions Fundal fluid present on pretreatment magnetic resonance imaging is predictive of improved baseline hearing preservation rates in patients undergoing GKRS for vestibular schwannoma when considering all patients with PTA ≤90 dB. Fundal fluid cap presence may serve as a favorable prognostic indicator to help set hearing expectations and guide patient selection efforts.

BackgroundPulsed radiation therapy (PRT) has shown effective tumor control and superior normal-tissue sparing ability compared with standard radiotherapy (SRT) in preclinical models and retrospective clinical series. This is the first prospective trial to investigate PRT in the treatment of patients with newly diagnosed glioblastoma (GBM).MethodsThis is a single-arm, prospective study. Patients with newly diagnosed GBM underwent surgery, followed by 60 Gy of PRT with concurrent temozolomide (TMZ). Each day, a 2-Gy fraction was divided into ten 0.2-Gy pulses, separated by 3-minute intervals. Patients received maintenance TMZ. Neurocognitive function (NCF) and quality of life (QoL) were monitored for 2 years using the Hopkins Verbal Learning Test‒Revised and the European Organisation for Research and Treatment of Cancer QLQ-C30 QoL questionnaire. Change in NCF was evaluated based on a minimal clinically important difference (MCID) threshold of 0.5 standard deviation.ResultsTwenty patients were enrolled with a median follow-up of 21 months. Median age was 60 years. Forty percent underwent subtotal resection, and 60% underwent gross total resection. One patient had an isocitrate dehydrogenase (IDH)–mutated tumor. Median progression-free survival (PFS) and overall survival (OS) were 10.7 and 20.9 months, respectively. In a post-hoc comparison, median OS for the prospective cohort was longer, compared with a matched cohort receiving SRT (20.9 vs 14 mo, P = 0.042). There was no decline in QoL, and changes in NCF scores did not meet the threshold of an MCID.ConclusionsTreatment of newly diagnosed GBM with PRT is feasible and produces promising effectiveness while maintaining neurocognitive function and QoL. Validation of our results in a larger prospective trial warrants consideration.

With an increase in gender equality policies and gender balance targets within traditionally male professions, organisations such as the police service are experiencing changing demographics. How these shifts influence the construction of professional identity is unclear. Drawing on focus group data, this study aimed to explore identity construction of police officers across gender using a thematic analysis method. Two themes related to identity construction were found to be common to both male and female police officers: ‘Working within a blue family’ and ‘Being a copper is a job for life’. However, the way in which these themes were articulated differed between male and female officers, with male officers experiencing more difficulty than female officers in terms of positioning their identity within the evolving police culture. The findings from this study have implications for gender policies in the workforce as they suggest that men may experience more difficulty than women in adjusting to a gender-diverse workforce, and that professional identity within traditionally male professions is more complex and nuanced than what was previously assumed.

There is limited retrospective evidence addressing the utility of post-mastectomy radiotherapy (PMRT) in patients with T3N0 breast cancer. We performed a retrospective analysis of the National Cancer Database (NCDB) comparing overall survival (OS) in T3N0 patients treated with mastectomy alone (MTX) or with PMRT.We performed a matched-cohort analysis of NCDB breast cancer patients with pT3N0 disease who did not receive NAC, or cT3N0 patients who received NAC treated between 2006 and 2014. Patients were matched for all available baseline characteristics using propensity scores with inverse probability of treatment weighting (IPTW) with stabilized weights.We identified 13,901 eligible patients. In the pT3N0 cohort, median follow-up was 47 months for the MTX group and 50 months for the PMRT group. In the cT3N0 cohort, median follow-up was 44 months for the MTX group and 46 months for the PMRT group. OS was higher in pT3N0 patients treated with PMRT compared to MTX: 7-year OS of 74% vs. 65% (P 0.001). Doubly robust multivariable analysis showed an association between PMRT and improved OS (HR 0.78, 95% CI 0.68-0.89, P 0.001). There was no benefit to PMRT in patients who received adjuvant chemotherapy (AC). In the NAC cohort, PMRT did not change OS, with 7-year OS of 78% with MTX and 79% with PMRT. There was a trend of improved OS with PMRT in patients with residual disease in the breast and lymph nodes (HR 0.70, 95% CI 0.46-1.07).PMRT improves OS in patients with pT3N0 disease, but the benefit appears limited to those who do not receive AC. PMRT does not improve OS in patients with cT3N0 disease who receive NAC, but there might be a benefit in patients with a poor response to chemotherapy. However, longer follow-up may be needed to make a definitive conclusion about the benefit of PMRT in patients who receive chemotherapy.

Though workplace bullying is conceptualized as an organizational problem, there remains a gap in understanding the contexts in which bullying manifests-knowledge vital for addressing bullying in practice. In three studies, we leverage the rich content contained within workplace bullying complaint records to explore this issue then, based on our discoveries, investigate people management practices linked to bullying. First, through content analysis of 342 official complaints lodged with a state health and safety regulator (over 5,500 pages), we discovered that the risk of bullying primarily arises from ineffective people management in 11 different contexts (e.g., managing underperformance, coordinating working hours, and entitlements). Next, we developed a behaviorally anchored rating scale to measure people management practices within a refined set of nine risk contexts. Effective and ineffective behavioral indicators were identified through content analysis of the complaints data and data from 44 critical incident interviews with subject matter experts; indicators were then sorted and rated by two independent samples to form a risk audit tool. Finally, data from a multilevel multisource study of 145 clinical healthcare staff nested in 25 hospital wards showed that the effectiveness of people management practices predicts concurrent exposure to workplace bullying at individual level beyond established organizational antecedents, and at the team level beyond leading indicator psychosocial safety climate. Overall, our findings highlight where the greatest risk of bullying lies within organizational systems and identifies effective ways of managing people within those contexts to reduce the risk, opening new avenues for bullying intervention research and practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Recent retrospective studies suggest improved overall survival (OS) with breast conserving therapy (BCT), including breast conserving surgery and adjuvant whole breast radiotherapy, compared to mastectomy in the modern era. The patient subset most likely to benefit from BCT remains unclear, and the role of Oncotype DX Recurrence Score (RS) in this context is unknown. We compared BCT to mastectomy in early-stage, node-negative breast cancer. We further explored outcomes after stratification by RS and age.We performed a matched-cohort analysis of National Cancer Database (NCDB) patients with pT1-2, pN0, cM0 breast cancer treated between 2006 and 2014 with BCT or mastectomy. Patients were matched for all available baseline characteristics using propensity scores with inverse probability of treatment weighting (IPTW) with stabilized weights.We identified 144,263 eligible patients treated with BCT and 87,379 patients treated with mastectomy. After IPTW-matching, OS was higher with BCT compared to mastectomy: 5-year OS of 94.4% vs. 91.8% (P 0.001) and 7-year OS of 90% vs. 85.2% (P 0.001). Doubly robust multivariable analysis showed an association between BCT and improved OS (HR 0.66, 95% CI, 0.64-0.69, P 0.001). In a subset analysis, BCT was associated with improved OS in patients with RS25, but not patients with RS ≤25. When stratified by age, only patients50 years had improved OS with BCT.BCT is associated with improved OS compared to mastectomy in women with early-stage, node-negative breast cancer. The improvement in OS with BCT appears to be most pronounced in patients with high RS and50 years of age. Prospective validation of these findings is required.

Background The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. Methods Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. Results A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. Conclusions In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.

Purpose Drawing on the transaction theory of stress, the purpose of this paper is to conceptualize customer mistreatment as a stressor and examine how job routinization and proactive personality help employees cope with the effects of customer mistreatment on emotional exhaustion and work engagement. The interaction of job routinization and proactive personality was also tested. Design/methodology/approach In total, 128 hundred nurses were recruited to participate in the current study, which was a daily survey for two consecutive weeks (10 working days). Findings The results revealed that job routinization and proactive personality attenuated the effects of customer mistreatment on emotional exhaustion and work engagement. The analyses also showed that, with more proactive personality and high job routinization, the effects of customer mistreatment were minimized. Originality/value Job routinization is a type of job resources that attenuates the negative influence of customer mistreatment. Proactive personality strengthens job routinization’s function, when proactive personality and job routinization are both high, the ill effect of customer mistreatment will be minimized.

Purpose To construct a tumor voxel dose response matrix ( DRM ) and dose prescription function (DPF) for adaptive dose painting by number (DPbN) based on treatment feedback of fluoro-2-deoxyglucose (FGD) positron emission tomography (PET)/computed tomography (CT) imaging. Methods and Materials FDG-PET/CT images obtained before and after chemoradiation therapy and at weekly chemoradiation therapy sessions for each of 18 patients with head and neck cancer, as well as the treatment outcomes, were used in the modeling. All weekly and posttreatment PET/CT images were registered voxel-to-voxel to the corresponding pretreatment baseline PET/CT image. Tumor voxel DRM was created using serial FDG-PET imaging of each patient with respect to the baseline standardized uptake value ( SUV 0 ). A tumor voxel control probability (TVCP) lookup table was created using the maximum likelihood estimation on the tumor voxel ( SUV 0 , DRM ) domain of all tumors. Tumor voxel DPF was created from the TVCP lookup table and used as the objective function for DPbN-based inverse planning optimization. Results Large intertumoral and intratumoral variations on both tumor voxels ( SUV 0 , DRM ) were identified. Tumor voxel dose resistance did not show correlation with its baseline SUV 0 value and was the major cause of the tumor local failures. Tumor voxel DPF as the function of tumor voxel ( SUV 0 , DRM ) values also showed a very large intertumoral and intratumoral heterogeneity. Most human papillomavirus–negative tumors require a treatment dose >100 Gy to certain local tumor regions. These treatment doses, which are most unlikely to be implementable in conventional radiation therapy, can be achieved using adaptive DPbN treatment. Clinical feasibility was evaluated by comparing the adaptive DPbN treatment plan with the conventional intensity modulated radiation therapy plan. Conclusions Tumor voxel ( SUV 0 , DRM ) provides an intratumoral prognostic map to target tumor locoregional-resistant regions. The corresponding TVCP or DPF provides a quantitative objective to optimize the intratumoral dose distribution for the individuals. The adaptive DPbN with FDG-PET/CT imaging feedback is feasible to implement in clinics.

Work environment hypothesis, a predominant theoretical framework in workplace bullying literature, postulates that job characteristics may trigger workplace bullying. Yet, these characteristics are often assessed by employees based on their experience of the job. This study aims to assess how job characteristics, independently assessed via Occupational Information Network (O*NET), are related to perceived job characteristics reported by employees, which, in turn, are associated with self-reported workplace bullying. Multilevel mediation analyses from 3,829 employees in 209 occupations confirmed that employees, whose work schedules are more irregular and whose work involves a higher level of conflictual contact (as assessed by O*NET), report experiencing higher job demands, which are associated with higher exposure to bullying. Moreover, employees working in jobs structured to allow for more discretion in decision-making (as assessed by O*NET) report experiencing more job autonomy and are less likely to experience bullying. The results offer some clues as to how the way in which a job is structured is related to how that job is perceived, which in turn is associated with exposure to bullying. Our findings also suggest that a job design perspective to redesign certain job characteristics may offer an additional viable approach to prevent workplace bullying. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose To quantify inter/intra-tumoral variations of baseline metabolic activity and dose response. To evaluate their impact on tumor control and treatment dose prescription strategies. Methods and materials Tumor voxel baseline metabolic activity, SUV0, and dose response matrix, DRM, quantified using the pre-treatment and weekly FDG-PET/CT imaging feedback for each of 34 HNSCC patients (25 HPV+ and 9 HVP−) were evaluated. Inter/intra-tumoral variations of tumor voxel (SUV0, DRM) for each of the HPV− and HPV+ tumor groups were quantified and used to evaluate the variations of individual tumor control probabilities and the efficiency of uniform vs non-uniform treatment dose prescription strategies. Results Tumor voxel dose response variation of all tumor voxels assessed using FDG-PET/CT imaging feedback had the mean(CV) = 0.47(47%), which was consistent with those of previously published in vitro tumor clonogenic assay. The HPV− tumors had the mean(CV) dose response, 0.53(49%), significantly larger than those of the HPV+ tumors, 0.45(43%). However, their baseline SUVs were opposite, 6.5(56%) vs 7.7(65%). Comparing to the inter-tumoral variations, both HPV−/+ tumor groups showed larger intra-tumoral variations, (53%, 58%) vs (20%, 31%) for the baseline SUV and (38%, 37%) vs (31%, 21%) for the dose response. Due to the large dose response variations, treatment dose to control the tumor voxels has very broad range with CV of TCD50 = 97% for the HPV− and 67% for the HPV+ tumor group respectively. As a consequence, heterogeneous prescription dose could potentially reduce the treatment integral dose for 92% of the HPV+ tumors and 78% of the HPV− tumors. Conclusions The study demonstrates that tumor dose response assessed using FDG-PET/CT feedback images had a similar distribution to those assessed conventionally using in vitro tumor clonogenic assay. Inter-tumoral dose response variation seems larger for HPV− tumors, but intra-tumoral dose response variations are similar for both HPV groups. These variations cause very large variation on the individual tumor control probability and limit the efficacy of dose escalation and de-escalation in conventional clinical practice. On the other hand, heterogeneous dose prescription guided by metabolic imaging feedback has a potential advantage in radiotherapy.

Background This study investigated the feasibility and potential clinical benefit of utilizing a new proton treatment technique: Spot-scanning Proton Arc (SPArc) therapy for left-sided breast cancer irradiation to further reduce radiation dose to healthy tissue and mitigate the probability of normal tissue complications compared to conventional Intensity Modulated Proton Therapy(IMPT). Methods Eight patients diagnosed with left-sided breast cancer and treated with breast-preserving surgery followed by whole breast irradiation without regional nodal irradiation were included in this retrospective planning. Two proton treatment plans were generated for each patient: vertical intensity-modulated proton therapy used for clinical treatment (vIMPT, gantry angle 10°-30°) and SPArc for comparison purpose. Both SPArc and vIMPT plans were optimized using the robust optimization of ± 3.5% range and 5 mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used for plan robustness evaluation. All dosimetric results were evaluated based on dose-volume histograms (DVH), and the interplay effect was evaluated based on the accumulation of single-fraction 4D dynamic dose on CT50. The treatment beam delivery time was simulated based on a gantry rotation with energy-layer-switching-time (ELST) from 0.2 to 5 s. Results The average D1 to the heart and LAD were reduced to 53.63 cGy and 82.25 cGy compared with vIMPT 110.38 cGy (p = 0.001) and 170.38 cGy (p = 0.001), respectively. The average V5Gy and V20Gy of ipsilateral lung was reduced to 16.77% and 3.07% compared to vIMPT 25.56% (p = 0.001) and 4.68% (p = 0.003). Skin3mm mean and maximum dose was reduced to 3999.38 cGy and 4395.63 cGy compared to vIMPT 4104.25 cGy (p = 0.039) and 4411.63 cGy (p = 0.043), respectively. A significant relative risk reduction (RNTCP = NTCPSPArc / NTCPvIMPT) for organs at risk (OARs) was obtained with SPArc ranging from 0.61 to 0.86 depending on the clinical endpoint. The RMSD Volume Histogram(RVH) analysis shows SPArc provided better plan robustness in OARs sparing, including the heart, LAD, ipsilateral lung, and skin. The average estimated treatment beam delivery times were comparable to vIMPT plans when the ELST is about 0.5 s. Conclusion SPArc technique can further reduce dose delivered to OARs and the probability of normal tissue complications in patients treated for left-sided breast cancer.

The appropriateness of substituting sentinel lymph node dissection (SLND) and regional nodal irradiation (RNI) for axillary lymph node dissection (ALND) in patients with residual lymph node (LN) disease following neoadjuvant chemotherapy (NAC) is unknown. We used the National Cancer Database (NCDB) to compare survival following SLND and ALND in breast cancer patients with residual LN disease. We analyzed NCDB patients, treated between 2006 and 2014, with cT1–3, cN1, cM0 breast cancer and residual disease in 1–3 axillary LNs (ypN1) following NAC. Patients were grouped into those who received SLND (defined as removal of ≤ 4 LNs) and RNI, or ALND and RNI. Patients were matched for all patient, tumor, and treatment characteristics. We identified 1313 eligible patients in the ALND group and 304 patients in the SLND group. For the matched cohorts, SLND was associated with significantly lower survival in both univariate and doubly robust multivariable analyses (MVA) (HR 1.7, 95% CI 1.3–2.2, P

Purpose The purpose of this paper is to investigate safety goal commitment as a potential mediator of the relationship between safety-specific transformational leadership and safety performance. Design/methodology/approach A field study was conducted in a sample of municipal utilities workers. All workers were asked to take a survey during work time. Findings The results suggest that safety-specific transformational leadership is positively related to safety performance and safety goal commitment, safety goal commitment is positively related to safety performance, and goal commitment is a significant mediator of the relationship between transformational leadership and safety performance. Practical implications Goal-setting theory and subsequent research has suggested a variety of strategies that can be employed to enhance the goal commitment of employees, and this study suggests that some of these strategies could be explored in the occupational safety realm. Future research could explore what transformational behaviors might be taught which would aid in setting safety goals with employees and motivating them to commit to those goals. Originality/value These findings add to existing research which supports connections between transformational leadership and job behaviors. Furthermore, they add to the limited research which has explored possible explanatory mechanisms and underscores the importance of safety goal commitment as the focus of future research and/or organizational interventions.

Purpose/Objective(s) Though microsurgery remains the most common method for management of acoustic neuromas (ANs), stereotactic radiosurgery continues to be a promising alternative. This study assesses long-term quality of life (QOL) outcomes and changes in hearing acuity in patents who have undergone single fraction Gamma Knife stereotactic radiosurgery (GKSRS) for AN. Materials/Methods Prospective QOL outcomes were collected and analyzed to include Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), Tinnitus Handicap Inventory (THI), and 36-Item Short-Form Survey (SF-36) scores. Likewise, audiometric outcomes including speech discrimination (SD) and pure-tone average (PTA) were assessed. These data points were collected prior to and following GKSRS at regular intervals up to 5 years post-treatment. A mixed effects model for repeated measures was employed to assess QOL data for statistical significance. Results A total of 235 patients underwent GKSRS for AN at our institution from January 2007 to January 2017. Of these, 130 patients had available QOL and audiometric follow-up data and were included in this study. Median age was 60 y and median follow-up time was 36 mo. Median tumor size was 1.6 cm (0.1 - 3.6 cm), with median tumor volume of 0.552 cm3 (0.028 - 11.31 cm3), while median cochlear mean dose was 2.4 Gy (0 - 9.7 Gy). Baseline mean (median) HHI, DHI, THI, and SF-36 scores were 31.7 (28), 19.3 (12), 18.2 (12), and 70.0 (73.4) respectively. For each of these QOL metrics, mixed effects analysis indicated no statistically significant decline at any time point out to 5 years post-treatment. Indeed, 87% of patients had baseline SD and PTA scores available; 70% had follow-up SD and PTA available. Of these, 59% had baseline serviceable hearing (Gardner-Robertson score of I or II). Serviceable hearing was preserved in 71% of patients at 1 month, 79% at 6 months, 79% at 12 months, 62% at 18 months, 67% at 24 months, and 68% at 36 months. Conclusion GKSRS provides long-term maintenance of QOL in the treatment of AN. HHI, DHI, THI, and SF-36 scores showed no significant decline up to 5 years post-radiosurgery. Patients with baseline serviceable hearing exhibited adequate hearing preservation. Author Disclosure J.S. Lee: None. K.C. Lee: Royalty; Regents of the University of Michigan. Patent/License Fees/Copyright; Regents of the University of Michigan. D. Bojrab: None. P.Y. Chen: Stock; Greater Michigan Gamma Knife (GMGK). J. Jacob: None. I.S. Grills: Greater Michigan Gamma Knife.

Purpose/Objective(s) Accelerated partial breast irradiation (APBI) can reduce treatment time and spare normal breast tissue. Techniques for APBI include applicator-based, external beam radiotherapy (EBRT), intra-operative radiotherapy (IORT), and interstitial implant-based. Data comparing these various APBI modalities and associated outcomes are lacking in the literature. We conducted a single-institution retrospective analysis of patients treated with APBI to compare treatment techniques and report outcomes. Materials/Methods Patients treated with APBI between 1990 and 2019 were included. Baseline patient characteristics, clinical and pathological features, treatment details, and clinical outcomes were retrospectively reviewed using a single-institution database. Outcomes were updated through August 2020. Statistical methods included Kruskal-Wallis test, Fisher's exact test, chi-square test of independence, and Kaplan-Meier analysis. Results A total of 926 APBI cases were analyzed, a majority of which were invasive ductal carcinoma (50.6%). Comparing applicator-based to EBRT, IORT, and implant-based, there was no difference in overall survival, freedom from local recurrence, or freedom from mastectomy (Table 1). 5-, 10-, and 25-year cumulative incidence of ipsilateral breast tumor recurrence (IBTR) was 1.5% (0.87-2.5%), 3.3% (2.3-4.7%), and 5.2% (3.9-6.7%), with no difference between treatment techniques. The median follow-up time was 121.6 months (66-165.7 months). Cosmesis was good/excellent in 91%, 84%, and 93%, for applicator, EBRT, and interstitial techniques, respectively. Late toxicities assessed included pigmentary changes, telangiectasias, induration/fibrosis, and fat necrosis. The majority of late toxicities were none or Grade 1, with less than 10% of patients experiencing Grade 2 or greater toxicity. Conclusion With our 30-year single-institution APBI experience using various treatment techniques, long term outcomes of both disease control and local morbidity demonstrate that the various APBI techniques are equally effective for suitable early-stage breast cancer patients. As evolving radiotherapy paradigms incorporate more shortened time-course treatments, these results affirm that APBI remains a viable alternative for such favorable patients.

PURPOSE/OBJECTIVE(S) Definitive chemoradiation for HPV-positive oropharyngeal squamous cell carcinoma (HPV+ OPC) is associated with high cure rates, but also with significant patient morbidity. Using previously described techniques to create heterogenous radiotherapy dose level selection, combined with data from patients followed by serial FDG-PET/CT during definitive chemoradiation, we generated hypothetical adaptive radiation plans with the goal of decreasing dose to normal tissues while maintaining equivalent local control. MATERIALS/METHODS Five patients with HPV+ OPC enrolled on a prospective single-institution protocol with serial FDG-PET/CT imaging during the course of definitive chemoradiation were analyzed. Two radiotherapy plans were then generated for each patient: one in which gross disease was prescribed a uniform dose of 60 Gy, and a second using adaptive tumor response to progressively reduce the prescription dose to gross disease in a heterogenous fashion. Voxel-level changes in FDG avidity were combined with a previously described tumor voxel control probability model to guide dose de-escalation in radiosensitive regions of tumor while maintaining equivalent local control. Dose accumulation to nearby organs at risk (OARs), incorporating changes due to progressive de-escalation, were then compared for the two sets of plans using the paired samples Wilcoxon test. RESULTS The de-escalated plans created using voxel-level tumor response resulted in treatment plans with significantly reduced dose to all evaluated OARs. Significant improvements included a decreased spinal cord maximum dose, brainstem maximum dose, parotoid gland mean dose, constrictor muscle mean and maximum dose, and mandible maximum dose (P = 0.03). Projected tumor control probability remained high, despite de-escalation of dose in PET-sensitive areas of gross disease. CONCLUSION Adaptive FDG-PET response can be used to guide de-escalation to reduce dose to nearby OARs. Using a novel technique for dose selection based on voxel-level tumor response, heterogeneous de-escalation can further reduce toxicity while maintaining optimal local control in most patients with HPV+ OPC. This concept will be used to design a non-randomized prospective trial investigating the role of heterogeneous de-escalation in this patient population.

Purpose/Objective(s) Shorter courses of breast radiotherapy are offered as an alternative to 4-6 weeks of whole breast irradiation after lumpectomy, including brachytherapy. A prospective phase II multi-institution clinical trial to study 3-fraction accelerated partial breast irradiation (APBI) delivered by brachytherapy was conducted. Materials/Methods The trial treated selected breast cancers after breast-conserving surgery with brachytherapy applicators that delivered 22.5 Gy in 3 fractions of 7.5 Gy. The planning treatment volume was 1 to 2 cm beyond the surgical cavity. Eligible women were age ≥ 45 years with unicentric invasive or in situ tumors ≤ 3 cm excised with negative margins and with positive estrogen or progesterone receptors and no metastases to axillary nodes. Strict dosimetric parameters were required to be met and follow up information was collected from the participating sites. Results A total of 175 patients who were enrolled were followed for a median of 3.63 years. Three-fraction brachytherapy was associated with low chronic toxicity. There was excellent or good cosmesis in 95% of patients. There were no grade 4 toxicities. Grade 3 fibrosis at the treatment site was present in 1.7% and 32% percent had grades 1 or 2 fibrosis at the treatment site. There was 1 rib fracture. Other late toxicities included 7.4% grade 1 hyperpigmentation, 2% grade 1 telangiectasias, 1.7% symptomatic seromas, 1.7% abscessed cavities, and 1.1% symptomatic fat necrosis. There were 2 (1.1%) ipsilateral local recurrences, 2 (1.1%) nodal recurrences and no distant recurrences. Other incidents included one contralateral breast cancer and 2 second malignancies (lung). Conclusion Ultra-short breast brachytherapy is feasible and with acceptable late toxicity and could be an alternative to standard 5-day, 10 fraction APBI in eligible patients. Patients from this prospective trial will continue to be followed to evaluate long term outcomes.

Purpose/Objective(s) Moist desquamation (MD) and breast/chest wall (CW) pain are common, important acute toxicities associated with breast irradiation (RT). In this study, we correlate near-surface dose (NSD) with acute toxicity in patients receiving pencil beam scanning intensity modulated proton breast RT (PBSIMPT). Materials/Methods We reviewed thirty-one patients at a single institution who received PBSIMPT for breast cancer. All patients received PBSIMPT for the initial chest wall or whole breast treatment; all but two patients received regional nodal irradiation. 25 patients were treated to 50 Gy in 25 fractions and 6 patients were treated to 42.56 Gy in 16 fractions. Boosts to the lumpectomy cavity or mastectomy scar were delivered with proton, electron, or photon RT. A near-surface rind volume (SR3), which was bound by the skin surface and 3 mm and limited by the breast or chest wall PTV, was generated to be used prospectively during treatment planning to limit near-surface dose while maintaining appropriate PTV coverage. For this analysis, we retrospectively generated two additional near-surface rind volumes, bound by either the skin surface and 5 mm (SR5), or by 5 mm and 10 mm (SR10) from the skin surface. We determined mean SR doses of each patient's composite plan. Skin rind doses were converted to percent of pre-boost prescription dose to account for differences in prescription dose. The presence of any breast/CW MD, and grade 2/3 ("moderate" or "severe") breast/CW pain during RT and within the first two months of RT were recorded. Mann-Whitney U tests were performed to determine correlations between mean SR doses and toxicity endpoints. Results The mean composite SR3 dose was 4484 cGY (range 4030-5267) for conventionally fractionated patients and 3983 cGY (range 3568-4040) for hypofractionated patients. Five patients (16.1%) experienced MD, and 6 patients (19.3%) experienced grade 2/3 breast/CW pain. Mean composite SR3 dose converted to percent of prescription dose was 94.6% for patients with grade 2 or higher breast or CW pain, compared to 89.6% for those without (P = 0.036). This difference persisted for mean SR5 dose (96.1% versus 91.1%, P = 0.023) and mean SR10 dose (102.4% versus 99.9%, P = 0.012). Patients with MD had a mean SR3 dose of 93.5% versus 91.0% for those without (P = 0.7), and this trend weakened with mean SR5 dose (94.7% versus 92.9%, P = 0.78) and mean SR10 dose (100.7% versus 100.3%, P = 1.0). Conclusion Higher NSD significantly correlated with increased breast/CW pain. Further analysis with a larger sample size is warranted to explore correlations between NSD and other toxicity endpoints. Optimization of NSD may reduce toxicity in patients receiving PBS IMPT for breast cancer.

PURPOSE/OBJECTIVE(S) There is mixed and limited scientific evidence regarding radiotherapy (RT) tolerance in carriers of a pathogenic, germline ATM variant. The ASTRO-ASCO-SSO guidelines on management of hereditary breast cancer suggest offering RT to these patients if clinically indicated. We investigate RT toxicity for carriers of either a pathogenic ATM variant, or variant of unknown significance (VUS), in ATM. MATERIALS/METHODS Patients with a breast cancer history who had hereditary genetic testing and were found to carry either a pathogenic variant or VUS in ATM were identified. For those who received RT at our institution, toxicity metrics were recorded including dermatitis (scored per CTCAE version 4.0), moist desquamation, and cosmetic outcome (scored per Harvard scale). Fisher's exact test for count data was performed to compare toxicity between the two cohorts. Wilcoxon rank-sum testing was performed to assess for differences in cohort patient characteristics. RESULTS Forty-four carriers of a pathogenic ATM variant, and 163 carriers of an ATM VUS, were identified. Fifteen pathogenic and 56 VUS patients, respectively, received RT at our institution and had available toxicity records. The cohorts did not statistically differ in race, medical comorbidities, clinical or pathologic T-stage, hormone receptor status, receipt of chemotherapy, fractionation schedule, or receipt of a boost. No patients had a known collagen vascular disease. 77% of patients (55/71) had breast conservation. 62% received whole breast RT, 7% received chest wall RT, 4.2% received partial breast RT, and 26.8% received whole breast or chest wall RT with regional nodal RT. 58% received conventionally-fractionated RT, and 38% received hypofractionated RT. Median toxicity follow up was 11.6 months. 29% (4/15) of pathogenic carriers and 26.4% (14/56) of VUS carriers developed moist desquamation (P = 0.7). The rates of grade 2+ acute dermatitis were 71% in pathogenic carriers and 57% in VUS carriers (P = 0.4). 100% of pathogenic carriers and 91% of VUS carriers had a good/excellent cosmetic outcome at first follow up (P > 0.9). No patients with a pathogenic variant had a fair or poor cosmetic outcome at last follow up. CONCLUSION RT is well tolerated in carriers of a pathogenic ATM variant, with rates of grade 2+ dermatitis and moist desquamation comparable to a matched VUS cohort. High rates of good or excellent cosmetic outcome were seen following treatment. Further analyses including an ATM wild type cohort and continued detailed toxicity documentation/analysis is on-going to elucidate longer term morbidity.

Outdoor photoautotrophic algal growth is limited by light attenuation and attendant respiratory CO2 losses during dark periods, limiting its productivity potential and carbon use efficiency. Developing a system that leverages mixotrophic growth (combining the benefits of both heterotrophic and photoautotrophic growth) has the potential to dramatically improve the total productivity and economics of the system. However, it is unknown if the productivity gains offset the added costs of outdoor mixotrophic cultivation using cellulosic hydrolysate as the feedstock. In this study, corn stover-derived cellulosic sugars were evaluated as the mixotrophic organic carbon source for the cultivation of Galdieria sulphuraria, which can metabolize both glucose and xylose from corn stover hydrolysate. A techno-economic analysis (TEA) and a life-cycle assessment (LCA) were conducted based on a detailed engineering process model for both glass helical photobioreactor and covered pond cultivation platforms, coupled with downstream conversion and upgrading to renewable diesel through hydrothermal liquefaction. Results show the minimum biomass selling price for cultivation in the photobioreactor design assuming a productivity of 1.575 kg m−3 day−1 and a substrate yield of 0.57 g g−1 is $2869 per dry metric ton. The costs are dramatically reduced in the covered pond design which assumes a productivity of 0.8 kg m−3 day−1 and a substrate yield of 0.7 g g−1, $921 per dry metric ton. Expanding the system boundary to include downstream processing results in a minimum fuel selling price of $8.24 and $3.32 dm3GE−1 for the photobioreactor and covered pond systems, respectively. Finally, life-cycle results demonstrate a global warming potential of 339 and 9.1 gCO2-eq. MJ−1 on a well-to-wheels basis and a net energy ratio of 2.21 and 0.25 MJ MJ−1 for the photobioreactor and covered pond systems, respectively. Discussion focuses on a required co-product selling price as a function of biomass diversion to meet economic parity with conventional fuels.

PURPOSE/OBJECTIVE(S) Post-mastectomy radiotherapy (PMRT) improves survival in appropriately selected patients but is associated with a risk of unplanned surgery (US) and implant loss (IL) due to the impact of radiation on skin integrity, infection risk, contracture, and cosmetic outcome. If reliable dosimetric correlates for these outcomes can be found, optimization during radiation treatment planning may be useful to reduce their occurrence. We hypothesize that near-surface dosimetry predicts for increased US and IL risk. MATERIALS/METHODS Patients who received PMRT at a single institution from 2016-2019 were retrospectively analyzed. Demographic, clinical, and treatment parameters were reviewed. Three structures were retrospectively generated, encompassing the volumes bound by 0-3 mm (SR3), 0-5 mm (SR5), and 5-10 mm (SR10) from the skin surface. Dose volume histograms (DVHs) were exported for analysis. Univariate (UVA) and multivariate analyses (MVA) were used to identify predictors of US and IL among demographic and treatment variables. Dosimetric analysis was performed to determine candidate dose constraints for SR3, SR5, and SR10. Clinical variables included age, smoking history, hypertension, diabetes, body mass index (BMI), menopause status, TNM stages with total and positive lymph nodes as continuous variables, receptor status, margin status, type of lymph node surgery, reconstruction type, mastectomy type, and receipt of chemotherapy, trastuzumab, or hormone therapy. RESULTS Of 126 patients reviewed, 109 were analyzable. Median follow up was 2.3 years. Twenty-five patients (23%) underwent US, 10 (9.2%) of whom experienced IF. Among clinical variables, BMI significantly predicted for US on UVA and MVA. There were no significant predictors of IF per se. Dosimetric analysis in 2 Gy intervals identified V44 Gy < 81% to SR3 (AUC 0.711) or V44 Gy < 83% to SR5 (AUC 0.685) as potentially useful for predicting US. V44 Gy remained a significant predictor of US when included on MVA. There were no significant dosimetric parameters using SR10. CONCLUSION Near-surface dosimetry is useful to predict US following PMRT. V44 Gy < 81% to SR3 should be further explored as a constraint for treatment planning optimization. The absence of significant predictors for IF is likely due to a paucity of events in this cohort.

Purpose The purpose of this paper is to examine the moderating role of transformational leadership on the relationship between job characteristics of both leaders and followers and workplace bullying within the workgroup. The central hypotheses were that, in a process of resource erosion, leaders’ task demands would be positively associated with workplace bullying in the workgroup, but that transformational leadership would moderate this effect, and the effect of followers’ autonomy on bullying. Design/methodology/approach Anonymous surveys were completed by 540 volunteer fire-fighters’ from 68 fire brigades and, separately, by 68 brigade captains. Findings The multi-level analyses show that leaders’ task demands positively predicted both bullying outcomes, after controlling for followers’ emotional demands and autonomy. Of most interest, transformational leadership moderated the influence of leaders’ task demands and followers’ autonomy on workplace bullying assessed by two approaches: self-labeling and behavioral experience. Further, a significant three-way interaction demonstrated that transformational leadership is actually associated with higher bullying as followers’ emotional demands increase under conditions wherein followers’ autonomy is constrained, but not when followers’ autonomy is high. Practical implications This study offers important practical implications in terms of leadership development in bullying prevention and reduction. For transformational leadership to be effective in reducing bullying at work, the situation must be matched to support this leadership style, or bullying could actually increase. Originality/value The study contributes to the research on workplace bullying by advancing the understanding of organizational factors that can influence bullying at work. The study also provides the first quantitative evidence of a relationship between the demands faced by leaders and the bullying experienced by members of the workgroup.

Leader efficacy is a key outcome of leader development, but little is known about if and when developmental leader experiences, such as engaging in training, relate to gains in leader efficacy. We ...

Purpose Prostate-specific antigen (PSA) bounce is a temporary elevation of the PSA level above a prior nadir. The purpose of this study was to determine whether the frequency of a PSA bounce following high-dose-rate (HDR) interstitial brachytherapy for the treatment of prostate cancer is associated with individual treatment fraction size. Methods and Materials Between 1999 and 2014, 554 patients underwent treatment of low- or intermediate-risk prostate cancer with definitive HDR brachytherapy as monotherapy and had ≥3 subsequent PSA measurements. Four different fraction sizes were used: 950 cGy × 4 fractions, 1200 cGy × 2 fractions, 1350 cGy × 2 fractions, 1900 cGy × 1 fraction. Four definitions of PSA bounce were applied: ≥0.2, ≥0.5, ≥1.0, and ≥2.0 ng/mL above the prior nadir with a subsequent return to the nadir. Results The median follow-up period was 3.7 years. The actuarial 3-year rate of PSA bounce for the entire cohort was 41.3%, 28.4%, 17.4%, and 6.8% for nadir +0.2, +0.5, +1.0, and +2.0 ng/mL, respectively. The 3-year rate of PSA bounce >0.2 ng/mL was 42.2%, 32.1%, 41.0%, and 59.1% for the 950-, 1200-, 1350-, and 1900-cGy/fraction levels, respectively ( P =.002). The hazard ratio for bounce >0.2 ng/mL for patients receiving a single fraction of 1900 cGy compared with those receiving treatment in multiple fractions was 1.786 ( P =.024). For patients treated with a single 1900-cGy fraction, the 1-, 2-, and 3-year rates of PSA bounce exceeding the Phoenix biochemical failure definition (nadir +2 ng/mL) were 4.5%, 18.7%, and 18.7%, respectively, higher than the rates for all other administered dose levels ( P =.025). Conclusions The incidence of PSA bounce increases with single-fraction HDR treatment. Knowledge of posttreatment PSA kinetics may aid in decision making regarding management of potential biochemical failures.

Objective Needlestick and sharp injuries (NSIs) experienced by physicians have been identified as a major occupational hazard. Blood-borne pathogens resulting from the NSIs experienced by physicians pose severe physical and psychological threats to them, as well as people who are around them. However, there is little research focusing on physicians’ behaviours to prevent NSIs. In the present study, we investigated the roles of safety climate, job demands experienced by physicians, and physicians’ self-efficacy in affecting physicians’ behaviours to prevent NSIs. Methods 401 physicians from four teaching hospitals in Northern Taiwan were recruited to participate in an anonymous survey. Among them, 189 physicians returned the completed survey with a response rate of 47.1%. Results Overall, respondents reported frequently engaging in NSI prevention behaviours. As expected, safety climate in hospitals and physicians’ self-efficacy to prevent NSIs were significantly related to their behaviours to prevent NSIs (r = 0.22 and r = 0.33, respectively). The moderating analysis also revealed that physicians with high self-efficacy tended to engage in NSI prevention behaviours regardless of levels of job demand they experienced. In contrast to our expectation, however, physicians with low self-efficacy engaged in more NSI prevention behaviours when job demands were high than when the demands were low. Conclusions Our findings show the important roles safety climate, job demands and self-efficacy play in shaping physicians’ NSI prevention behaviours. Hospitals may consider improving safety climate via strengthening management commitments to NSIs prevention, reducing job demands by training physicians to proactively redesign their own jobs, and increasing physicians’ self-efficacy via well-designed skill-based training.

BACKGROUND Using a prospectively collected institutional database, we compared rectal toxicity following high dose rate (HDR) brachytherapy as monotherapy relative to dose-escalated external beam radiotherapy (EBRT) for patients with localized prostate cancer. METHODS 2683 patients treated with HDR or EBRT between 1994 and 2017 were included. HDR fractionation was 38 Gy/4 fractions (n = 321), 24 Gy/2 (n = 96), or 27 Gy/2 (n = 128). EBRT patients received a median dose of 75.6 Gy in 1.8 Gy fractions [range 70.2-82.8 Gy], using either 3D conformal or intensity modulated radiotherapy (IMRT). EBRT patients underwent 3D image guidance via an off-line adaptive process. RESULTS Median follow-up was 7.5 years (7.4 years for EBRT and 7.9 years for HDR). 545 patients (20.3%) received HDR brachytherapy and 2138 (79.7%) EBRT. 69.1% of EBRT patients received IMRT. Compared to EBRT, HDR was associated with decreased rates of acute grade ≥2 diarrhea (0.7% vs. 4.5%, p

Purpose We examined the distribution of pretreatment nodal metastases to the level I axilla (Ax-L1) to assess the appropriateness of current breast atlases and provide guidelines in relationship to easily identifiable anatomic landmarks for accurate delineation of this lymph node (LN) basin. Methods and Materials Patients with newly diagnosed breast cancer and biopsy-proven metastatic Ax-L1 LNs were identified. We related the location of each LN to its most adjacent rib and its distance from the bottom of the humeral head, axillary vessels, and a line connecting the anterior aspects of the pectoralis and latissimus dorsi muscles (P-L line). LNs were mapped onto a representative planning computed tomography scan, and their distribution was used to validate the current Radiation Therapy Oncology Group, European Society for Radiotherapy and Oncology, and Radiotherapy Comparative Effectiveness breast atlases. Furthermore, we examined metastases to a subregion encompassing the superolateral Ax-L1, irradiation of which correlates highly with lymphedema. Results We identified 106 eligible patients with 107 biopsied LNs. All LNs fell between the second and fifth ribs (mean, 3.8 ± 0.56). Mean distance from the inferior aspect of the humeral head was 4.3 ± 1.6 cm (range, 0.3-8.4). Mean distance from the inferior aspect of the axillary vessels was 2.9 ± 1.5 cm (range, –0.6 to 5.4). Mean distance from the P-L line was 0.01 ± 1.9 cm (range, –2.2 to 2.4); negative and positive values denote medial or lateral to the P-L line. A Radiation Therapy Oncology Group–compliant Ax-L1 consensus contour, created from contours by 4 attending breast radiation oncologists, partially or fully missed 45% of mapped LNs. European Society for Radiotherapy and Oncology– and Radiotherapy Comparative Effectiveness–compliant Ax-L1 similarly missed 46% and 34% of mapped LNs, respectively. LNs were most frequently missed in the lateral direction. The superolateral Ax-L1 encompassed 9.3% of the mapped LNs. Conclusions A significant percentage of at-risk Ax-L1 tissue falls outside current contouring atlases. We propose expansion of the recommended Ax-L1 borders, most notably in the lateral direction.

Nurses experience psychosocial work stress that may negatively affect physical and mental health over time. In this cross-sectional study we investigated prevalence of job stress and oxidative stress in nurses, and determined if significant relationships exist between higher job stress scores and demographic factors and working conditions. Emergency department nurses (n = 42) were recruited from a University Hospital following Institutional Review Board approval. Job stress indicators, effort&ndash, reward ratio and overcommitment were evaluated from survey questionnaires using the effort&ndash, reward imbalance model, and associations with age, sex, body mass index, and working conditions were measured by logistic regression analysis. Oxidative stress biomarkers, 8-isoprostane, malondialdehyde, and antioxidant levels were measured from urine specimens. Job stress was prevalent with effort&ndash, reward ratio &gt, 1 in 93% and overcommitment &gt, 50 in 83% of the study participants. Age, body mass index, years of experience, weekend work, work hours per week, and shift work showed strong associations with effort&ndash, reward ratio and overcommitment scores. Malondialdehyde was higher in participants with high overcommitment. We report that psychosocial job stress is prevalent among nurses, as revealed by the high effort&ndash, reward and overcommitment scores. Job stress may be reduced through implementation of appropriate stress reduction interventions.

BACKGROUND Atypical teratoid/rhabdoid tumors (AT/RTs) are rare aggressive central nervous system tumors. The use of radiation therapy (RT) remains controversial, especially for patients younger than three years of age. The purpose of the current investigation is to robustly analyze the impact of RT among pediatric AT/RT patients using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS SEER 18 Custom Data registries were queried for AT/RT (ICD-0-3 9508/3). A total of 190 pediatric AT/RT patients were identified, of whom 102 underwent surgery + chemotherapy and 88 underwent trimodality therapy. Univariate and multivariable analyses using Kaplan-Meier and Cox proportional hazards regression modeling were performed. Propensity-score matched analysis with inverse probability of treatment weighting was performed to account for indication bias. The landmark method was used to account for immortal time bias. RESULTS The majority of patients were

To explore the relationship between baseline information, personal factors, working characteristics and job performance among nurses in emergency department in northern Taiwan. Two-hundred twenty-two nursing staff were interviewed repeated with structured questionnaires for data collection in 3 time points (From August to September, 2008, from February to March, 2009, and from November to December, 2009). The generalized estimating equation (GEE) is used to test the relationship between the domains of independent variables (baseline information, personal factors, working characteristics) and dependent variables (task performance, contextual performance). The mean age of participants is 30.1 ± 5.1 years. 50.0% are junior college or bachelor degrees. From the GEE model, biological protection (β = 0.17, P value = .002) and safety climate (β = 0.24, P value