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© Gallego Romero et al. Comparative genomics studies in primates are restricted due to our limited access to samples. In order to gain better insight into the genetic processes that underlie variation in complex phenotypes in primates, we must have access to faithful model systems for a wide range of cell types. To facilitate this, we generated a panel of 7 fully characterized chimpanzee induced pluripotent stem cell (iPSC) lines derived from healthy donors. To demonstrate the utility of comparative iPSC panels, we collected RNA-sequencing and DNA methylation data from the chimpanzee iPSCs and the corresponding fibroblast lines, as well as from 7 human iPSCs and their source lines, which encompass multiple populations and cell types. We observe much less withinspecies variation in iPSCs than in somatic cells, indicating the reprogramming process erases many inter-individual differences. The low within-species regulatory variation in iPSCs allowed us to identify many novel inter-species regulatory differences of small magnitude.

Importance: Nonrestorable teeth are recommended to be extracted prior to radiation therapy (RT). Occasionally, preradiation extractions introduce unacceptable delays in treatment initiation. Planned dental extractions immediately postradiation presents an alternative strategy, though outcomes are uncertain., Objective: To evaluate the feasibility and safety of dental extractions immediately postradiation., Design, Setting, and Participants: A prospective cohort study including patients planned for curative-intent RT but unable or unwilling to proceed with 1 or more extractions recommended pretreatment was carried out. From January 2020 to September 2022, 58 patients were screened and 50 enrolled. The dental care was performed at a single academic department and the cancer care at regional centers. Analysis took place between September 22, 2023, and June 10, 2024., Exposure: On completion of RT, patients were recommended to complete extractions as soon as feasible, and ideally within 4 months., Main Outcomes and Measures: The primary end point was the actuarial cumulative incidence of exposed alveolar bone noted by any practitioner at any time after extraction, calculated using Gray method with death as a competing risk. As a pilot study, no formal power calculation was performed; resources allowed for 50 evaluable patients., Results: Among the 50 participants enrolled, RT was nonoperative for 32 patients (64%) and postoperative for 18 patients (36%). Intensity-modulated RT (IMRT) was delivered in all patients. Of the 50 patients, 20 (40%) declined dental extractions immediately postradiation and the remaining 30 (60%) underwent a median (range) of 8.5 (1-28) extractions at a median (range) of 64.5 (13-152) days after RT. The median (IQR) follow-up for survivors without exposed bone was 26 (17-35) months from the end of RT. The 2-year cumulative incidence of any exposed bone was 27% (95% CI, 14%-40%). The 2-year incidence of exposed bone for those who underwent dental extractions immediately postradiation was 40% (95% CI, 22%-58%) and 7% (95% CI, 0%-22%) for those who did not. Of the 13 who developed exposed bone: 4 resolved, 1 was lost to follow-up, and 8 were confirmed as osteoradionecrosis., Conclusions and Relevance: This cohort study found that postradiation dental extractions incur considerable risk, even if performed within a 4-month window.

Cardiovascular disease (CVD) is associated with both genetic variants and environmental factors. One unifying consequence of the molecular risk factors in CVD is DNA damage, which must be repaired by DNA damage response proteins. However, the impact of DNA damage on global cardiomyocyte protein abundance, and its relationship to CVD risk remains unclear. We therefore treated induced pluripotent stem cell-derived cardiomyocytes with the DNA-damaging agent Doxorubicin (DOX) and a vehicle control, and identified 4,178 proteins that contribute to a network comprising 12 co-expressed modules and 403 hub proteins with high intramodular connectivity. Five modules correlate with DOX and represent distinct biological processes including RNA processing, chromatin regulation and metabolism. DOX-correlated hub proteins are depleted for proteins that vary in expression across individuals due to genetic variation but are enriched for proteins encoded by loss-of-function intolerant genes. While proteins associated with genetic risk for CVD, such as arrhythmia are enriched in specific DOX-correlated modules, DOX-correlated hub proteins are not enriched for known CVD risk proteins. Instead, they are enriched among proteins that physically interact with CVD risk proteins. Our data demonstrate that DNA damage in cardiomyocytes induces diverse effects on biological processes through protein co-expression modules that are relevant for CVD, and that the level of protein connectivity in DNA damage-associated modules influences the tolerance to genetic variation., Competing Interests: Declaration of interests The authors declare no competing interests.

Objective: The Commission on Cancer (CoC) recently introduced a quality metric to optimize time between major head and neck surgery and adjuvant treatment (TAT) ≤6 weeks, as TAT delay adversely impacts patient survival. This study evaluates whether enhanced recovery after surgery (ERAS) for this population reduces the rate of postoperative complications, length of stay (LOS), and TAT., Methods: Patients undergoing larynx or oral cavity resection with free flap reconstruction, ERAS, and adjuvant treatment after 2018 were compared to a historical pre-ERAS cohort. Patients underwent surgery at a single-institution tertiary referral center for complex head and neck oncology. Differences between groups were compared by chi-square, Fisher's exact, or Wilcoxon rank-sum test. TAT >6 weeks was evaluated with univariate and multivariable logistic regression., Results: Thirty-nine pre-ERAS patients were compared to 39 ERAS patients. No demographic differences existed between groups. LOS was improved with ERAS (p = 0.005). ERAS patients were discharged to home and returned to their activities of daily living (ADL) earlier (p = 0.004, 0.001). ADL recovery was associated with on-time TAT ≤42 days on univariate analysis (OR 1.36, 95% CI 1.13-1.63, p = 0.001). TAT delay was less frequent with ERAS (51.3% vs. 69.2%), but this was not significant after multivariable logistic regression (p = 0.11)., Conclusion: ERAS decreases LOS and returns advanced head and neck cancer patients to their ADL sooner. Postoperative ADL recovery independently predicts on-time adjuvant treatment. Still, compliance beyond 50% with the TAT ≤6 weeks CoC quality metric remains a major treatment barrier., (© 2024 Wiley Periodicals LLC.)

Peptide receptor radionuclide therapy (PRRT) is a rapidly developing treatment modality. These treatments are indicated for patients who are either heavily pretreated and/or may have neurohormonal active disease, increasing the risk of acute adverse effects and the need for unplanned acute care. The goals of this report were to characterize the frequency of unplanned acute care utilization after PRRT infusion and detail a comprehensive standard operating procedure (SOP) for radioprotection during unplanned post-PRRT acute care. The records of patients treated with PRRT were reviewed. The event of interest was emergency department (ED) utilization and/or inpatient admission within 7 days of PRRT infusion. A multidisciplinary group developed a radioprotection SOP for all phases of unplanned acute care including the clinical infusion space and emergency medical services transport to the ED, within the ED, and on the inpatient floor. A total of 232 patients received 814 infusions of PRRT, with 134 (58%) receiving Lutathera and 98 (42%) receiving Pluvicto. Nineteen patients received unplanned acute care at an ED within 7 days of PRRT infusion (8% of patients, 2% of infusions), of which 10 received Lutathera (8% of patients, 2% of infusions). Two patients (2% of patients, 0.5% of infusions) experienced carcinoid crises within 24 hours of Lutathera infusion. The median and average intervals between infusion and ED visit were 0.5 days and 1.3 days, respectively. Nine patients received Pluvicto (9% of patients, 3% of infusions). The median and average intervals between infusion and ED visit were 4 and 4.7 days, respectively. Emergency room utilization and/or inpatient admission after PRRT administration are relatively infrequent events, but not unexpected. Centers that administer PRRT should have a comprehensive SOP in place to effectively care for radioactive patient emergencies while maximizing medical staff protection., (Copyright © 2024 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Importance: Intensity-modulated radiation therapy (IMRT) reirradiation of nonmetastatic recurrent or second primary head and neck squamous cell carcinoma (HNSCC) results in poor progression-free survival (PFS) and overall survival (OS)., Objective: To investigate the tolerability, PFS, OS, and patient-reported outcomes with nivolumab (approved standard of care for patients with HNSCC) during and after IMRT reirradiation., Design, Setting, and Participants: In this multicenter nonrandomized phase 2 single-arm trial, the treatment outcomes of patients with recurrent or second primary HNSCC who satisfied recursive partitioning analysis class 1 and 2 definitions were evaluated. Between July 11, 2018, and August 12, 2021, 62 patients were consented and screened. Data were evaluated between June and December 2023., Intervention: Sixty- to 66-Gy IMRT in 30 to 33 daily fractions over 6 to 6.5 weeks with nivolumab, 240 mg, intravenously 2 weeks prior and every 2 weeks for 5 cycles during IMRT, then nivolumab, 480 mg, intravenously every 4 weeks for a total nivolumab duration of 52 weeks., Main Outcomes and Measures: The primary end point was PFS. Secondary end points included OS, incidence, and types of toxic effects, including long-term treatment-related toxic effects, patient-reported outcomes, and correlatives of tissue and blood biomarkers., Results: A total of 62 patients were screened, and 51 were evaluable (median [range] age was 62 [56-67] years; 42 [82%] were male; 6 [12%] had p16+ disease; 38 [75%] had salvage surgery; and 36 [71%.] had neck dissection). With a median follow-up of 24.5 months (95% CI, 19.0-25.0), the estimated 1-year PFS was 61.7% (95% CI, 49.2%-77.4%), rejecting the null hypothesis of 1-year PFS rate of less than 43.8% with 1-arm log-rank test P = .002 within a 1-year timeframe. The most common treatment-related grade 3 or higher adverse event (6 [12%]) was lymphopenia with 2 patients (4%) and 1 patient each (2%) exhibiting colitis, diarrhea, myositis, nausea, mucositis, and myasthenia gravis. Functional Assessment of Cancer Therapy-General and Functional Assessment of Cancer Therapy-Head and Neck Questionnaire quality of life scores remained stable and consistent across all time points. A hypothesis-generating trend favoring worsening PFS and OS in patients with an increase in blood PD1+, KI67+, and CD4+ T cells was observed., Conclusions and Relevance: This multicenter nonrandomized phase 2 trial of IMRT reirradiation therapy and nivolumab suggested a promising improvement in PFS over historical controls. The treatment was well tolerated and deserves further evaluation., Trial Registration: ClinicalTrials.gov Identifier: NCT03521570.

Surveillance for survivors of head and neck cancer (HNC) is focused on early detection of recurrent or second primary malignancies. After initial restaging confirms disease-free status, the use of surveillance imaging for asymptomatic patients with HNC is controversial. Our objective was to comprehensively review literature pertaining to imaging and biomarker surveillance of asymptomatic patients treated for head and neck squamous cell carcinoma and to convene a multidisciplinary expert panel to provide appropriate use criteria for surveillance in representative clinical scenarios. The evidence base for the appropriate use criteria was gathered through a librarian-mediated search of literature published from 1990 to 2022 focused on surveillance imaging and circulating tumor-specific DNA for nonmetastatic head and neck squamous cell carcinoma using MEDLINE (Ovid), Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. The systematic review was reported according to PRISMA guidelines. Using the modified Delphi process, the expert panel voted on appropriate use criteria, providing recommendations for appropriate use of surveillance imaging and human papillomavirus (HPV) circulating tumor DNA. Of 5178 studies identified, 80 met inclusion criteria (5 meta-analyses/systematic reviews, 1 randomized control trial, 1 post hoc analysis, 25 prospective, and 48 retrospective cohort studies [with ≥50 patients]), reporting on 27,525 patients. No large, randomized, prospective trials examined whether asymptomatic patients who receive surveillance imaging or HPV circulating tumor DNA monitoring benefit from earlier detection of recurrence or second primary tumors in terms of disease-specific or quality-of-life outcomes. In the absence of prospective data, surveillance imaging for HNC survivors should rely on individualized recurrence-risk assessment accounting for initial disease staging, HPV disease status, and tobacco use history. There is an emerging surveillance role for circulating tumor biomarkers., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Demand for trauma-focused therapy continues to increase, especially in community mental health care settings where group treatment models can be cost-effective and increase access to care. The Internal Family Systems (IFS) model for posttraumatic stress disorder (PTSD) may offer an effective therapeutic approach. The purpose of this proof-of-concept study was to evaluate the feasibility and acceptability of a novel, trauma-focused, group-based treatment approach and investigate potential mechanisms of action., Method: Study participants completed the Program for Alleviating and Resolving Trauma and Stress (PARTS), an online-delivered program including 16 weeks of 90-min IFS-based groups with eight 50-min individual IFS counseling sessions. Participants completed assessments including clinician-administered and self-report measures of PTSD, common comorbid conditions (e.g., complex PTSD [disturbances in self-organization], depression, anxiety, and suicidality), and potential mechanisms (e.g., decentering, self-compassion, and emotion regulation)., Results: Most participants ( n = 11/15; 73%) attended 12+ group sessions, with 92% (12/13 responders) reporting they would recommend PARTS to a friend. All respondents reported the program was helpful (13/13; 100%). PTSD symptom severity was reduced from baseline to Weeks 16 ( d = -0.7, p = .005) and 24 ( d = -0.9, p < .001). A clinically meaningful response (i.e., 10+ point reduction on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders [5th ed.]) was demonstrated in 53% of participants (8/15) by Week 24. Decentering, self-compassion, and emotion regulation all improved ( p < .05)., Conclusions: PARTS was feasible and acceptable as a group-based, online intervention in an urban, public community health care system. While PARTS showed promise in reducing overall PTSD symptom severity, well-controlled efficacy research is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Purpose: The schedule of cisplatin concurrent with definitive radiation for squamous carcinoma of the head and neck remains controversial. Most institutions deliver either a high-dose "bolus" schedule once every 3 weeks or a low-dose weekly schedule. We compared these 2 schedules via a simplified network meta-analysis with a common comparator., Methods and Materials: We performed a PRISMA-concordant systematic review to identify randomized controlled trials comparing cisplatin with cetuximab for nonmetastatic, locoregionally advanced squamous carcinoma of the head and neck treated with definitive radiation. Trials incorporating primary surgery or induction therapy were excluded. Patient survival times were extracted on a per-event basis from the published curves using a digitizer and validated against published point estimates and hazard ratios (HRs). Survival was compared using random effects Cox regression under a frequentist framework. Toxicity and secondary endpoints were analyzed qualitatively. The Cochrane method assessed the risk of bias. The analysis plan was preregistered with the Open Science Foundation., Results: Five randomized trials were identified, including 1678 patients. There was no statistical difference in overall survival between weekly and bolus regimens (HR, 0.90; 95% CI, 0.53-1.52, P = .345). This Cox model suggested that for the average patient in the cohort, the absolute difference in 5-year overall survival between weekly and bolus regimens was +1.2% (95% CI, -6.1%-+5.9%, P = .345). Secondary endpoints and toxicity were not obviously different by regimen, qualitatively., Conclusions: The cetuximab trials provide indirect data suggesting that the differences between cisplatin schedules are subtle., Competing Interests: Disclosures Matthew C. Ward reports receiving grant support from Varian Medical Systems, Naveris, Inc, consulting honoraria from Exact Sciences, and participating in an ad board for Bayer Pharmaceuticals with publishing royalties from Demos Medical Publishing. All was paid to his institution and none was related to the subject of this manuscript. The remaining authors declare no conflicts of interest., (Copyright © 2024 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients., Data Sources and Study Setting: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use., Study Design: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach-two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period)., Data Collection/extraction Methods: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209)., Principal Findings: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale., Conclusions: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere., (© 2024 Health Research and Educational Trust.)

The authors report on their development of a National Advisory Board (NAB) to guide a funded project: Two in One: HIV + COVID-19 Screening and Testing Model. This project aimed to improve primary care practitioners' capacity to routinize HIV, PrEP/PEP, and COVID-19 vaccine screenings for all their patients while relying on culturally responsive communication with their minoritized patients. To approach their monumental research and education tasks, they created a NAB, drawing from the literature on advisory boards to (a) promote board member engagement and (b) progress successfully through the six stages suggested for successful advisory boards. A midpoint survey and final focus groups with NAB members indicated mixed levels of engagement, a sense of time and work being valued, and pride in the media and academic reach of the project. The authors offer considerations for others considering forming a NAB to guide primary care research and interventions.

Background and Objectives: Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events., Methods: In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity., Results: Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children., Conclusions: Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital., (Copyright © 2024 by the American Academy of Pediatrics.)

TOP2 inhibitors (TOP2i) are effective drugs for breast cancer treatment. However, they can cause cardiotoxicity in some women. The most widely used TOP2i include anthracyclines (AC) Doxorubicin (DOX), Daunorubicin (DNR), Epirubicin (EPI), and the anthraquinone Mitoxantrone (MTX). It is unclear whether women would experience the same adverse effects from all drugs in this class, or if specific drugs would be preferable for certain individuals based on their cardiotoxicity risk profile. To investigate this, we studied the effects of treatment of DOX, DNR, EPI, MTX, and an unrelated monoclonal antibody Trastuzumab (TRZ) on iPSC-derived cardiomyocytes (iPSC-CMs) from six healthy females. All TOP2i induce cell death at concentrations observed in cancer patient serum, while TRZ does not. A sub-lethal dose of all TOP2i induces limited cellular stress but affects calcium handling, a function critical for cardiomyocyte contraction. TOP2i induce thousands of gene expression changes over time, giving rise to four distinct gene expression response signatures, denoted as TOP2i early-acute, early-sustained, and late response genes, and non-response genes. There is no drug- or AC-specific signature. TOP2i early response genes are enriched in chromatin regulators, which mediate AC sensitivity across breast cancer patients. However, there is increased transcriptional variability between individuals following AC treatments. To investigate potential genetic effects on response variability, we first identified a reported set of expression quantitative trait loci (eQTLs) uncovered following DOX treatment in iPSC-CMs. Indeed, DOX response eQTLs are enriched in genes that respond to all TOP2i. Next, we identified 38 genes in loci associated with AC toxicity by GWAS or TWAS. Two thirds of the genes that respond to at least one TOP2i, respond to all ACs with the same direction of effect. Our data demonstrate that TOP2i induce thousands of shared gene expression changes in cardiomyocytes, including genes near SNPs associated with inter-individual variation in response to DOX treatment and AC-induced cardiotoxicity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Matthews et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Rates of the sexually transmitted infections (STIs) Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) have risen in women by 13% and 40%, respectively, since 2015. Women with Serious Mental Illness (SMI) are at disproportionate risk for STIs. A retrospective chart review was performed at a safety-net healthcare system in the Southeastern United States (US) from 2014 to 2017. CT/GC positivity rates did not differ between the general and SMI populations (6.6% vs. 6.5% for CT and 1.8% vs. 2.2% for GC, respectively). Emergency Medicine accounted for more positive STI test results in SMI patients than the general population (25.2% vs. 19.1% for CT, 47.8% vs. 35.5% for GC, respectively). SMI patients received large portions of STI care in emergency settings, where follow-up is poor. Point of Care (POC) testing could improve care in this setting, and mental healthcare providers must address sexual health with patients who otherwise may not receive this care., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Small carcinomas of the palatine tonsil are often diagnosed via simple tonsillectomy, a maneuver with non-therapeutic intent. Herein, practice patterns for this unique situation are evaluated., Patients and Methods: A retrospective review was performed across 10 facilities to identify patients with cT1-2 squamous carcinomas of the tonsil diagnosed by simple tonsillectomy between 2010 and 2018. Patients who received curative-intent intensity modulated radiotherapy (IMRT) without additional surgery were included. Target volumes were reviewed, and cumulative incidences of local failure and severe late dysphagia were calculated., Results: From 638 oropharyngeal patients, 91 were diagnosed via simple tonsillectomy. Definitive IMRT with no additional surgery to the primary site was utilized in 57, and three with gross residual disease were excluded, leaving 54 for analysis. Margins were negative in 13%, close (<5 mm) in 13%, microscopically positive in 61%, and not reported in 13%. Doses typically delivered to gross disease (68-70.2 Gy in 33-35 fx or 66 Gy/30 fx) were prescribed to the tonsil bed in 37 (69%). Sixteen patients (29%) received doses from 60 to 66 Gy (≤2 Gy/fx) and one received 50 Gy (2 Gy/fx). No local failures were observed. One late oropharyngeal soft tissue ulcer occurred, treated conservatively (grade 2). At five years, the cumulative incidence of severe late dysphagia was 17.4% (95% CI 6.1-28.8%)., Conclusion: Small tonsil carcinomas diagnosed by simple tonsillectomy represent a niche subset with favorable oncologic outcomes. Regardless, radiation oncologists tend to deliver full-dose to the tonsil bed. The necessity of this routine could be questioned in the modern era., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Racial, ethnic, sexual, and gender minoritized groups are considered historically excluded groups and have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. The influence of social determinants of health (SDOH), including access to screening and treatment, and other systemic and structural factors are largely responsible for these disparities. Primary care practitioner (PCP) competence in culturally responsive screening practices will be critical to reducing the impact of systemic and structural factors serving as barriers to screening and treatment. Correspondingly, improving the capacity of PCPs to communicate with patients in a culturally responsive manner may influence improved screening and treatment outcomes for minoritized groups related to COVID-19. This scoping literature review aims to determine the current breadth of literature on culturally responsive communication (CRC) in regard to COVID-19 vaccination screening for historically excluded, or minoritized groups. Results from this review will inform the development of a training series and social marketing campaign to improve PCPs capacity in CRC. This manuscript provides details on our study protocol., Objectives: This scoping literature review aims to analyze existing literature on culturally responsive COVID-19 vaccinations between PCPs and patients in the U.S., specifically for racial, ethnic, sexual, and gender minoritized groups. Results of this scoping review will inform the development of a training series and social marketing campaign to improve capacity of PCPs in this area. Additionally, the review will inform recommendations for future research., Materials and Methods: This scoping review will be performed following the framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Relevant studies between the years 2019-2022 were identified using a rigorous search strategy across four databases: MEDLINE (via PubMed), Scopus, Cochrane (CENTRAL; via Wiley), and CINAHL (via EBSCO), using Boolean and Medical Subject Headings (MeSH) search terms. Studies will be uploaded to the data extraction tool, Covidence, to remove duplicates and perform a title/abstract screening, followed by a full-text screening., Results: The data extraction and analysis phases of the scoping review are in progress. Data will be analyzed for themes related to culturally responsive COVID-19 screening practices in clinical encounters with the identified study populations. Results will be reported by theme and align to PRISMA-ScR guidelines., Discussion: To our knowledge, this is the first study to use scoping methods to investigate the barriers and facilitators to CRC of COVID-19 vaccine screening for historically excluded communities in the U.S. The work and results from this research will be directly utilized for the development of nationally-accessible, continuing medical education materials to teach PCPs about CRC, as well as other materials to influence relevant policy changes within the healthcare landscape., Competing Interests: This study is part of a grant (16610) from Gilead Sciences, Inc. (https://www.gilead.com/). There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Kalita et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A police encounter at a dental office reveals how racism can operate on many levels.

Study Objective: To determine the rate of hysterectomy over time after transcervical resection of the endometrium (TCRE) based on age., Design: Retrospective audit., Setting: A single gynecology clinic in regional Victoria, Australia., Patients: A total of 1078 patients who had undergone TCRE for abnormal uterine bleeding., Interventions: The likelihood of hysterectomy was compared across age groups using the chi-square test. Time to hysterectomy was summarized as a median with the 25th and 75th percentiles and compared across age groups using the Kaplan-Meier plot (log-rank test) and Cox proportional hazards regression., Measurements and Main Results: The overall rate of hysterectomy was 24.2% (261 of 1078, 95% confidence interval [CI] 21.7-26.9). When age was categorized into <40 years, 40 to 44 years, 45 to 49 years, and >50 years, the rate of hysterectomy after TCRE was 32.3% (70 of 217), 29.5% (93 of 315), 19.6% (73 of 372), and 14.4% (25 of 174), respectively (p <.001). The likelihood of hysterectomy at any time point after TCRE among those aged 45 to 49 years and older than 50 years was 43% and 59% lower, respectively, than patients under 40 years (hazard ratio, 0.57; 95% CI, 0.41-0.80, and hazard ratio, 0.41; 95% CI, 0.26-0.65, respectively). The median time to hysterectomy was 1.68 years (25th to 75th percentiles, 0.77-3.76)., Conclusion: This study demonstrated that patients who underwent a TCRE before the age of 45 years had a higher chance of having a hysterectomy than patients older than 45 years. This information will enable clinicians to inform patients of their chance of undergoing a hysterectomy at any time after TCRE., (Copyright © 2023 AAGL. Published by Elsevier Inc. All rights reserved.)

Issue : Historically excluded patient populations-particularly racial, ethnic, and sexually and gender minoritized people-experience gross inequities in health, worsened by the HIV and COVID-19 pandemics. Culturally responsive communication (CRC) is a vital tool health professionals can use to address these inequities. Yet, CRC can be challenging to teach , particularly during pandemics. The authors argue that pandemics magnify the powerful intersecting oppressions of heterosexism, racism, transphobia, nationalism, and sexism, essentially targeting Othered bodies for dying, a phenomenon known as necropolitics. Evidence : Five aspects of pandemics make teaching CRC more difficult and, because of the magnification of necropolitics, more critical. First, pandemics heighten teachers' and learners' personal frailties, engendering worries about their own and their families' health and increasing cognitive load. This can make it difficult for them to embrace the discomfort required of CRC, particularly when an increased patient load is squeezing instructional time. Second, guidelines for HIV and COVID-19 testing, prevention, and treatment are ever-changing, often faster than the pace of curriculum development and instructor professional development. Third, for instructors who may already be stretched thin, it is challenging to prepare learners for the variability in how their future practice contexts may address HIV and COVID-19 and, further, how to take a social justice approach to assess and resist the distinct equity issues of each of these contexts. Fourth, pandemics cause uncertain access to patient information about testing, disease status, and vaccination or pre-exposure prophylaxis. This worsens already disparate outcomes for minoritized patients and adds to the complexity of CRC curricula. Finally, virtual care is more prevalent in pandemics and teaching CRC in online contexts can be difficult. Implications : To address these challenges, we adopt the Dimensionality and R4P Health Equity Framework as a tool for evaluating academic programs for CRC so that it remains robust amidst pandemics. This tool addresses the varied social positions and identities (i.e., "dimensions") that present different opportunities for health. We offer specific evaluation questions programs can ask and approaches they can take to (a) redress past harms through removing existing racist, heteronormative and transphobic structures and repairing the damage they have done; (b) plan for a more equitable future by restructuring via policy and organizational change and providing programs that address intersectional disadvantage; and (c) critically evaluate the present by remediating current damage immediately until restructuring efforts are fully functional. As Martin Luther King, Jr. stated, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman because it often results in physical death." It is our imperative to teach CRC with intentionality; otherwise we will support necropolitics as we continue to condone disproportionate morbidity and mortality for racialized and queer bodies.

Purpose: The optimal management of early-stage, low-risk, hormone-positive breast cancer in older women remains controversial. Recent trials have shown that 5-fraction ultrahypofractionated whole-breast irradiation (U-WBI) has similar outcomes to longer courses, reducing the cost and inconvenience of treatment. We performed a cost-utility analysis to compare U-WBI to hormone therapy alone or their combination., Methods and Materials: We simulated 3 different treatment approaches for women age 65 years or older with pT1-2N0 ER-positive invasive ductal carcinoma treated with lumpectomy with negative margins using a Markov microsimulation model. The strategies were U-WBI performed with a 3-dimensional conformal technique over 5 fractions without a boost ("radiation therapy [RT] alone"), adjuvant hormone therapy (anastrozole for 5 years) without RT ("aromatase-inhibitor [AI] alone"), or the combination of the 2. The combination strategy was calibrated to match trial results, and the relative effectiveness of the RT alone and AI alone strategies were inferred from previous randomized trials. The primary endpoint was the cost-effectiveness of the 3 strategies over a lifetime horizon as measured by the incremental cost-effectiveness ratio (ICER), with a value of $100,000/quality-adjusted life-year deemed "cost-effective.", Results: The model results compared with the prespecified target outcomes. On average, RT alone was the least expensive strategy ($14,775), with AI alone slightly more ($14,998), and combination therapy the costliest ($19,802). RT alone dominated AI alone (the incremental cost-effectiveness ratio [ICER] -$5089). Combination therapy, compared with RT alone, was slightly more expensive than our definition of cost-effective (ICER $113,468) but was cost-effective compared with AI alone (ICER $54,451). Probabilistic sensitivity analysis demonstrated RT alone to be cost-effective in 50% of trials, with combination therapy in 36% and AI alone in 14%., Conclusions: U-WBI alone appears the more cost-effective de-escalation strategy for these low-risk patients, compared with AI alone. Combining U-WBI and AI appears more costly but may be preferred by some patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

As many residency programs expand teaching to address the knowledge, skills, and attitudes that residents need to dismantle structural racism and other systemic inequities, many faculty are not prepared to teach these topics. However, there is limited literature on which to base faculty development in this area. The aim of this article is to review how diversity, equity, inclusion, and justice education is integrated in pediatric faculty development efforts. This review will include published and gray literature on curricula and programs in medical education for faculty learners and will address common barriers and challenges faced by faculty members. [ Pediatr Ann . 2023;52(7):e266-e272.] .

Introduction: While mainstream messaging about human immunodeficiency virus (HIV) disparities continues to highlight individual risk-taking behavior among historically marginalized groups, including racial, ethnic, sexual, and gender minoritized patients, the effect of structural factors and social determinants of health (SDOH) on morbidity and mortality remain underestimated. Systemic barriers, including a failure of adequate and acceptable screening, play a significant role in the disparate rates of disease. Primary care practitioner (PCP) competency in culturally responsive screening practices is key to reducing the impact of structural factors on HIV rates and outcomes. To address this issue, a scoping review will be performed to inform the development of a training series and social marketing campaign to improve the competency of PCPs in this area., Objectives: This scoping review aims to analyze what recent literature identify as facilitators and barriers of culturally responsive HIV and pre-exposure prophylaxis (PrEP) screening practices for historically marginalized populations, specifically racial, ethnic, sexual, and gender minoritized groups. A secondary aim is to identify themes and gaps in the literature to help guide future opportunities for research., Methods: This scoping review will be performed following the framework set forth by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Relevant studies between the years 2019-2022 will be identified using a rigorous search strategy across four databases: MEDLINE (via PubMed), Scopus, Cochrane (CENTRAL; via Wiley), and CINAHL (via EBSCO), using Boolean and Medical Subject Headings (MeSH) search terms. Studies will be uploaded to the data extraction tool Covidence to remove duplicates and perform a title/abstract screening, followed by a full-text screening and data extraction., Results: Data will be extracted and analyzed for themes related to culturally responsive HIV and PrEP screening practices in clinical encounters with the identified target populations. Results will be reported according to PRISMA-ScR guidelines., Discussion: To our knowledge, this is the first study to use scoping methods to investigate barriers and facilitators to culturally responsive HIV and PrEP screening practices for racial, ethnic, sexual, and gender minoritized populations. The limitations of this study include the analysis restrictions of a scoping review and the timeframe of this review. We anticipate that this study's findings will interest PCPs, public health professionals, community activists, patient populations, and researchers interested in culturally responsive care. The results of this scoping review will inform a practitioner-level intervention that will support culturally sensitive quality improvement of HIV-related prevention and care for patients from minoritized groups. Additionally, the themes and gaps found during analysis will guide future avenues of research related to this topic., Competing Interests: This study is part of a grant from Gilead Sciences, Inc. (https://www.gilead.com/). This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare., (Copyright: © 2023 Xavier et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To estimate the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide-related events among a cohort of Veterans., Data Sources: Data were obtained from the VHA Corporate Data Warehouse, the Department of Defense and Veterans Administration Infrastructure for Clinical Intelligence, the VHA survey of enrollees, and customized VHA databases tracking suicide-related events. Geographic variables were obtained from the Area Health Resources Files and the Centers for Medicare and Medicaid Services., Study Design: We used an instrumental variables (IV) design with a Heckman correction for non-random partial observability of the use of mental health services. The principal predictor was a measure of provider staffing per 10,000 enrollees. The outcome was the probability of a suicide-related event., Data Collection/extraction Methods: Data were obtained for a cohort of Veterans who recently separated from active service., Principal Findings: From 2014 to 2018, the per-pay period probability of a suicide-related event among our cohort was 0.05%. We found that a 1% increase in mental health staffing led to a 1.6 percentage point reduction in suicide-related events. This was driven by the first tertile of staffing, suggesting diminishing returns to scale for mental health staffing., Conclusions: VHA facilities appear to be staffing-constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality., (© 2022 Health Research and Educational Trust.)

Introduction: Faculty are increasingly expected to teach about the impact of racism on health and to model the principles of health equity. However, they often feel ill-equipped to do so, and there is limited literature on faculty development on these topics. We developed a curriculum for faculty education on racism and actions to advance racial health equity., Methods: The curriculum design was based on a literature review and needs assessments. Implementation consisted of four live virtual 1-hour sessions incorporating interactive didactics, cases, reflection, goal setting, and discussion offered to a multidisciplinary group of pediatric faculty at a children's hospital. Topics included the history of racism, racism in health care, interacting with trainees and colleagues, and racial equity in policy. Evaluation consisted of pre- and postsurveys at the beginning and end of the curriculum and a survey after each session., Results: A mean of 78 faculty members attended each session (range: 66-94). Participants reported high satisfaction and increased knowledge at the end of each session. Qualitative themes included self-reflection on personal biases, application of health equity frameworks and tools, becoming disruptors of racism, and the importance of systemic change and policy., Discussion: This curriculum is an effective method for increasing faculty knowledge and comfort. The materials can be adapted for various audiences., (© 2023 Falusi et al.)

Purpose: TARGIT-A was a pragmatic randomized noninferiority trial including women with early-stage breast cancer treated postlumpectomy with either external beam radiation therapy (EBRT) or 50 kV x-rays delivered intraoperatively with or without EBRT, as indicated. The long-term update of the pre-pathology cohort did not include a 10-year estimate of the primary endpoint of local failure (although tabular 5-year data was provided). Here, we used the data from the pre-pathology manuscript to estimate the cumulative incidence of local failure., Methods and Materials: Using digitizer software and the published survival curves, we extracted the Kaplan-Meier rate of local recurrence-free survival and overall survival. The extracted data were calibrated to the published point-estimates to within ±0.5%. The data were then fit to parametric survival models, and overall survival and local recurrence-free survival curves were subtracted to give the estimate of local failure in the presence of the competing risk of death. Bootstrap resampling was used to assess for parameter uncertainty in the modeling process., Results: Our analysis estimated that the risk of local failure at 10 years in the TARGIT-A pre-pathology cohort is approximately 1.7% with EBRT (95% confidence interval [CI], 0%-4.3%) and 5.5% in the pragmatic risk-adapted TARGIT strategy (95% CI, 2.9%-8.0%). A weighted average estimate suggests that the risk of local failure in low-risk women treated with TARGIT alone is approximately 6.6% at 10 years (95% CI, 3.3%-10.0%), with an estimated difference of 4.9% (95% CI, 0.6%-9.2%) compared with EBRT., Conclusions: These data allow for contextualization and informed decisions when considering megavoltage EBRT, kilovoltage intraoperatively, or omission of radiation therapy entirely., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: The impact of a coronavirus disease (COVID-19)-specific professional development programme on the well-being of obstetrics and gynaecology (O&G) doctors in training (DiT) working during the pandemic., Design: A mixed-method evaluation of a single group pre-post test design study., Setting: Melbourne, Australia between September 2020 and April 2021., Participants: 55 O&G DiT working across four healthcare sites of a major tertiary hospital in Victoria, Australia, were included in the programme., Interventions: The delivery of a codesigned peer-to-peer programme, which identified and addressed the well-being goals of O&G DiT. Seven interactive workshops were run alongside the implementation of a number of participant-led wellness initiatives., Main Outcome Measures: Repeated-measures analysis of WHO Well-being Index (WHO-5) and Copenhagen Burnout Innovatory (CBI) scores across three time points during the programme. Multilevel generalised linear mixed-effects models with random intercept were fit to the data, both in the entire population (intention-to-treat) and restricted to those who attended the workshop ('per-protocol' analysis). Participatory experiences and programme learning were captured using the Most Significant Change (MSC) technique, which included inductive thematic analysis., Results: We demonstrated an overall 31.9% improvement in well-being scores (p=0.006). The MSC evaluation captured a shift in workplace culture as a result of the programme, with improvement across the domains of connection, caring, communication, confidence and cooperation., Conclusions: We have successfully used a mixed-method approach to contextualise a productive programme to improve the well-being of COVID-19 front-line healthcare workers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: United States oncology trends consistently demonstrate that nearly half of T4a larynx carcinoma patients are treated with larynx preservation, despite national guidelines favoring laryngectomy. This study identifies clinical decision-making drivers and defines patient subsets that should become targets for care improvement., Methods: Retrospective analysis of patients with cT4 squamous cell carcinoma of the larynx from US National Cancer Database 2005-2016. Demographic data and survival rates between clinical pathways were compared. Survival was estimated by Kaplan-Meier method with statistical comparisons assessed by log-rank test., Results: Of 11,556 patients with cT4 disease, laryngectomy (TL) was the initial treatment for 4627 (40%) patients. Larynx preservation via chemoradiation (CRT) occurred for 4307 patients. TL and CRT patients had similar Charlson-Deyo comorbidity indices and insurance status. TL patients had higher total tumor size, lower N3 rates and were more often seen at academic institutions ( p  < .0001). N0 surgery patients with adjuvant treatment demonstrated superior median survival (MS) compared to CRT (surgery + radiation MS: 69 months, surgery + chemoradiation MS: 66, CRT MS: 37.7), p  < .0001. MS for N1/N2 disease patients was 56.5 months for surgery + radiation and 35.5 months for surgery + CRT, superior to CRT, MS 30.8 months, p  < .0001. Tri-modality N3 patients with up front surgery had similar MS compared to CRT (surgery + chemoradiation 21.3 months vs. CRT 16.1), p  = .95., Conclusion: National quality improvement initiatives are needed to promote guideline adherence and improve survival in advanced larynx cancer. Targets for such initiatives should be patients with limited or no nodal disease burden, that meet clear T4a imaging criteria., Level of Evidence: Level IV, non-randomized controlled cohort., Competing Interests: The authors have no relevant conflicts of interest to disclose., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC. on behalf of The Triological Society.)

Achieving population behavioral health is urgently needed. The mental health system struggles with enormous challenges of providing access to mental health services, improving quality and equitability of care, and ensuring good health outcomes across subpopulations. Little data exists about increasing access within highly constrained resources, staging/sequencing treatment along care pathways, or personalizing treatments. The conceptual model of the learning healthcare system offers a potential paradigm shift for addressing these challenges. In this article we present an overview of how the three constructs of population health, learning health systems, and measurement-based care are inter-related, and we provide an example of how one academic, community-based, safety net health system is approaching integrating these paradigms into its service delivery system. Implementation outcomes will be described in a subsequent publication. We close by discussing how ultimately, to meaningfully improve population behavioral health, a learning healthcare system could expand into a learning health community in order to target critical points of prevention and intervention., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

There are few things that I don't know, feel, do, want or get to do as a Black woman public health professional. First, unlike the public health datasets that separate race from gender, I don't know life in any other way than as a Black woman. Second, when other educators and public health professionals get to decide when to think about race and racism in their classrooms or research, I don't know life without being reminded of my Blackness. I am treated accordingly and explains why I grew up believing that I needed to hide and shrink myself to get dubbed as professional. Third, anti-Black calls to codeswitch have had me feeling some kind of way about my hoops, braids, and nail art in predominately white spaces. I have since decided to carve out spaces for youth to show up unapologetically themselves and take up space. These experiences allow me to design youth programs and contribute to the literature in ways that affirm their identities and amplify their voice. And, despite being exhausted by the ongoing expectations to teach everyone about racism while being targeted by racism, there is one thing I do get to do . . . love being a Black woman in public health. To view the original version of this poem, see the supplemental material section of this article online.

Background/aim: Survivorship care programs (SCPs) educate patients on post-treatment side-effects, which may lead to earlier identification and mitigation of their impact. This study assessed the impact of SCP on identification and management of post-treatment hypothyroidism in a head and neck cancer population and evaluated socio-demographic factors in the effectiveness of SCPs., Patients and Methods: A retrospective analysis was performed of sociodemographic and clinical characteristics of patients with head and neck cancer treated with radiation therapy between January 2011 and January 2019 at a large community cancer institution. Development of hypothyroidism was defined as elevated thyroid-stimulating hormone (TSH) or initiation of supplementation post-treatment. Cumulative incidence of hypothyroidism was analyzed with Gray's method., Results: Of 608 patients, 483 (79%) had post-treatment TSH surveillance. A total of 203 (42%) of those patients developed hypothyroidism; 53 (11%) patients completed SCPs. The median follow-up was 1.4 (interquartile range=0.7-2.6) years with a median time until diagnosis of hypothyroidism of 1.2 (interquartile range=0.7-2.1) years. The median time to diagnosis was 12.0 months with SCP versus 14.2 months without. Race and insurance status were not associated with differences in thyroid surveillance. Patients with laryngeal cancer were at greatest risk of developing hypothyroidism (hazard ratio=1.92, confidence interval=1.44-2.56; p<0.077). Cumulative incidence of post-treatment hypothyroidism was higher in patients managed with SCP, 65.4% at 4 years, compared to those without (49.0%). Receipt of SCP was independently associated with an increased incidence of hypothyroidism detection (hazard ratio=1.51, confidence interval=1.04-2.20; p=0.030)., Conclusion: In our experience, SCP utilization was independently associated with a diagnosis of hypothyroidism. This study supports implementation of a survivorship program for identification and management of post-treatment sequelae., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background and Objectives: Compared with population-based rates, at-risk rates (ARRs) account for underlying variations of asthma prevalence. When applied with geospatial analysis, ARRs may facilitate more accurate evaluations of the contribution of place-based social determinants of health (SDOH) to pediatric asthma morbidity. Our objectives were to calculate ARRs for pediatric asthma-related emergency department (ED) encounters and hospitalizations by census-tract in Washington, the District of Columbia (DC) and evaluate their associations with SDOH., Methods: This population-based, cross-sectional study identified children with asthma, 2 to 17 years old, living in DC, and included in the DC Pediatric Asthma Registry from January 2018 to December 2019. ED encounter and hospitalization ARRs (outcomes) were calculated for each DC census-tract. Five census-tract variables (exposures) were selected by using the Healthy People 2030 SDOH framework: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty., Results: During the study period, 4321 children had 7515 ED encounters; 1182 children had 1588 hospitalizations. ARRs varied 10-fold across census-tracts for both ED encounters (64-728 per 1000 children with asthma) and hospitalizations (20-240 per 1000 children with asthma). In adjusted analyses, decreased educational attainment was significantly associated with ARRs for ED encounters (estimate 12.1, 95% confidence interval [CI] 8.4 to 15.8, P <.001) and hospitalizations (estimate 1.2, 95% CI 0.2 to 2.2, P = .016). Violent crime was significantly associated with ARRs for ED encounters (estimate 35.3, 95% CI 10.2 to 60.4, P = .006)., Conclusion: Place-based interventions addressing SDOH may be an opportunity to reduce asthma morbidity among children with asthma., (Copyright © 2022 by the American Academy of Pediatrics.)

Retreatment of recurrent or second primary head and neck cancers occurring in a previously irradiated field is complex. Few guidelines exist to support practice. We performed an updated literature search of peer-reviewed journals in a systematic fashion. Search terms, key questions, and associated clinical case variants were formed by panel consensus. The literature search informed the committee during a blinded vote on the appropriateness of treatment options via the modified Delphi method. The final number of citations retained for review was 274. These informed 5 key questions, which focused on patient selection, adjuvant reirradiation, definitive reirradiation, stereotactic body radiation, and reirradiation to treat nonsquamous cancer. Results of the consensus voting are presented along with discussion of the most current evidence. This provides updated evidence-based recommendations and guidelines for the retreatment of recurrent or second primary cancer of the head and neck., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: COVID-19 self-testing (ST) is an innovative strategy with the potential to increase the access and uptake of testing and ultimately to limit the spread of the virus. To maximize the uptake and reach of this promising strategy and inform intervention development and scale up, research is needed to understand the acceptability of and willingness to use this tool. This is vital to ensure that Black/African Americans are reached by the Biden-Harris Administration's free national COVID-19 ST program. This study aimed to explore the acceptability and recommendations to promote and scale-up the uptake of COVID-19 ST among Black/African Americans., Methods: We conducted a cross-sectional qualitative study using a semi-structured questionnaire to assess barriers and facilitators to the uptake of COVID-19 ST among a convenience sample of 28 self-identified Black/African Americans from schools, community centers, and faith-based institutions in Ohio and Maryland. Inductive content analysis was conducted to identify categories and subcategories related to acceptability and recommendations for implementing and scaling up COVID-19 ST in communities., Results: Participants perceived COVID-19 self-testing as an acceptable tool that is beneficial to prevent transmission and address some of the barriers associated with health facility testing, such as transportation cost and human contact at the health facility. However, concerns were raised regarding the accurate use of the kits and costs. Recommendations for implementing and scaling up COVID-19 ST included engagement of community stakeholders to disseminate information about COVID-19 self-testing and creating culturally appropriate education tools to promote knowledge of and clear instructions about how to properly use COVID-19 ST kits. Based on these recommendations, the COVID-19 STEP (Self-Testing Education and Promotion) Project is being developed and will involve engaging community partners such as barbers, church leaders, and other community-based organizations to increase the uptake and use of free COVID-19 ST kits among Black/African Americans., Conclusion: Findings showed that most participants considered COVID-19 ST valuable for encouraging COVID-19 testing. However, cost and accuracy concerns may pose barriers. Future work should consider implementing interventions that leverage the benefits of COVID-19 ST and further assess the extent to which these identified facilitators and barriers may influence COVID-19 ST uptake., (© 2022. The Author(s).)

Purpose: Following treatment of HPV-driven oropharynx cancer, surveillance nasopharyngoscopy and imaging are often performed but are expensive and frequently ineffective. A novel plasma circulating tumor-tissue modified viral HPV DNA (TTMV-HPV-DNA) assay accurately detects recurrences. We modeled the cost of the new assay., Methods: We designed and validated a partitioned survival model which replicated the results of the RTOG 1016 study and calculated cumulative surveillance costs from the payer's perspective. Two strategies were considered: a standard of routine endoscopy with imaging as needed and an alternative strategy which omitted scopes and imaging but obtained serial TTMV-HPV-DNA samples. No difference in effectiveness (QALY or LY) was assumed in the base case. A 5-year horizon was used, costs were reported in 2020 U.S. dollars discounted by 3%. Seven scenarios tested model assumptions and practice variation. Deterministic and probabilistic sensitivity analyses assessed parameter uncertainty., Results: In the base case, at the list TTMV-HPV-DNA price, the cumulative cost of surveillance was $11,674 for the standard strategy and $20,756 for the TTMV-HPV-DNA strategy (+$9082 over 5 years). Probabilistic sensitivity analysis demonstrated the cost difference ranged from $4917-$12,047. The TTMV-HPV-DNA strategy was most likely to be either cost saving or cost-effective if future data demonstrate small improvements in quality or quantity of life (approximately 33 quality-adjusted life-days), if the assay reduces utilization of imaging, and if the periodicity of TTMV-HPV-DNA draws could be reduced from that on clinical trials., Conclusions: This data informs providers seeking to design more accurate, accessible, and economical post-treatment surveillance strategies., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Volumetric modulated arc therapy (VMAT) craniospinal irradiation (CSI) has been shown to have significant dosimetric advantages compared to 3-dimensional conformal therapy but is a technically complex process. We sought to develop a guide for all aspects of the VMAT CSI process and report patient dosimetry results., Methods and Materials: We initiated VMAT CSI in 2017 and have regularly revised our standard operating procedure for this process since then. Herein, we report a detailed template for the entire VMAT CSI process from initial patient setup and immobilization at time of computed tomography (CT) simulation to contouring and treatment planning, quality assurance, and therapy delivery. The records of 12 patients who were treated with VMAT CSI were also retrospectively reviewed., Results: Patient age ranged from 2 to 59 years with 5 pediatric patients (age <18 years), 5 young adults (age 18-35 years), and 2 older adults (age >35 years). The majority of patients (67%) had medulloblastoma. CSI dose ranged from 21.6 to 36 Gy, with a median of 36 Gy. The median CSI planning target volume was 2383 cc with a median V 95% of 99.8% and median 0.03 cc hotspot of 112.5%. The average V 107% was 7.4% and the average conformality index was 1.01., Conclusions: VMAT CSI has potentially significant dosimetric and acute toxicity advantages compared to 3-dimensional conformal. However, proper procedures need to be in place throughout the process in order to be able to realize these potential advantages. We herein describe our detailed standard operating procedure for VMAT CSI. Recognizing the scarcity of proton beam centers in many areas, VMAT CSI represents a feasible treatment with more widespread availability., (Copyright © 2021 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Purpose: Patients with head and neck cancer are at risk of long-term dental complications. Proper dental assessment pre- and post-treatment can improve outcomes but is logistically challenging. We surveyed oncologists to better understand their perspectives surrounding dental care in this unique population., Methods: We surveyed oncologists at institutions associated with an ongoing national study of oral health after treatment of head and neck cancer. Seventeen questions were used to assess provider characteristics, patterns of practice, patterns of referral, barriers to referral, and willingness to apply fluoride varnish in the oncology clinic., Results: Ninety-seven oncologists were invited from six institutions, of whom 40 (41%) responded. Surgeons represented 45% of the sample, followed by radiation oncologists (40%) and medical oncologists (15%). Both generalists and subspecialists were included. All practiced in a metropolitan area with an academic dental practice, and many felt that this improved access to care. Despite this, most oncologists thought that financial factors were a significant barrier to obtaining timely dental care. Most oncologists performed a dental assessment during visits. Oncologists felt qualified to identify the most significant complications of treatment, such as exposed bone, but felt underqualified to identify early changes in need of intervention. When asked if the oncology clinic could apply fluoride varnish during follow-ups, most stated that this seemed feasible but would require education and financial support., Conclusion: Oncologists often perform limited dental evaluations during their routine visits. Given the challenges associated with access to proper dental care for this population, these oncology visits may provide a window for preventative intervention., Competing Interests: Matthew C. WardConsulting or Advisory Role: AstraZenecaResearch Funding: Varian Medical Systems, Naveris Daniel CarrizosaConsulting or Advisory Role: Curio Science, Cardinal HealthSpeakers' Bureau: Research to PracticeResearch Funding: Merck, Celgene, Loxo, Aeglea Biotherapeutics, GlaxoSmithKline, Coordination Pharmaceuticals, Takeda, PfizerOpen Payments Link: https://openpaymentsdata.cms.gov/physician/446184/summary Benjamin J. MoellerEmployment: Southeast Radiation Oncology GroupStock and Other Ownership Interests: Moderna Therapeutics Rajesh V. LallaStock and Other Ownership Interests: Logic Biosciences IncConsulting or Advisory Role: Ingalfarma, Monopar Therapeutics, Colgate Palmolive, Alira Health, Enlivity, Cellix Biosciences, Meiji Seika KaishaResearch Funding: Galera Therapeutics, Vigilant Biosciences, OragenicsPatents, Royalties, Other Intellectual Property: Patent pending, applied by University of Connecticut, on which I am a named inventor Michael T. BrennanConsulting or Advisory Role: MedImmune, DermtreatResearch Funding: Dermtreat, ActoGeniX, Meira TxNo other potential conflicts of interest were reported.

Municipal wastewater (MWW) effluent discharges can introduce contaminants to receiving waters which may have adverse impacts on local ecosystems and human health. Conservative chemical constituents specific to the MWW effluent stream can be used to quantify and trace wastewater effluent-sourced contaminant inputs. Gadolinium (Gd), a rare earth element used as a contrasting agent in medical magnetic resonance imaging, can be found in urban MWW streams. Dissolved anthropogenic Gd has been shown to be an indicator and potential conservative tracer for MWW effluent in receiving waters. Like other known MWW tracers, it can be difficult and expensive to measure. Dissolved rubidium (Rb) to strontium (Sr) ratio enrichment in biological materials such as blood and urine can lead to enriched Rb/Sr values in MWW effluent relative to natural waters. This ratio is relatively easy and inexpensive to measure and represents a promising additional indicator for MWW effluent in receiving waters in urbanized freshwater systems. In July 2015 and 2016 surface water samples were collected from sites in the tidal-fresh Potomac River in the vicinity of the Blue Plains Advanced Wastewater Treatment Plant (BPAWWTP) outfall near Washington, DC USA along with treated MWW effluent samples from the BPAWWTP. Dissolved Rb/Sr ratios were measured in these waters and compared to dissolved Gd concentrations in order to demonstrate the potential of the dissolved Rb/Sr ratio as a conservative indicator for MWW effluent. Results suggest the dissolved Rb/Sr ratio represents a simple and cost-effective indicator and conservative tracer for MWW effluent. It can be used with, or in place of, other proven tracers to investigate wastewater impacts in highly-urbanized, anthropogenically-impacted freshwater systems like the tidal fresh Potomac River and perhaps in a wider range of geologic settings than previously thought. A case study is presented as an example to demonstrate the potential of using dissolved Rb/Sr ratios to trace MWW-sourced nutrient inputs from a major WWTP like BPAWWTP to the receiving waters of tidal-fresh Potomac River., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The drive towards living well with dementia has resulted in a growing recognition of the value of community-based participatory arts activities. This review aimed to explore their overall impact and holistic benefits for people with early to moderate stages of dementia., Methods: Using a scoping review methodology and thematic analysis, this review explored relevant literature published between 2008 and 2019., Results: 26 published papers were identified, comprising visual arts, literary arts, comedy, music and dance. The key themes included person-centred, in-the-moment approaches; participation and communication; attention and cognition; social cohesion and relationships; and the role of space, place and objects., Conclusions: There is strong evidence in support of using participatory arts for dementia, regardless of art form. In-the-moment and person-centred approaches were deemed impactful. Further research is needed to explore the importance of setting, material culture and the methodological or theoretical perspectives in participatory arts and dementia research.

Introduction: It has been suggested that post-transoral robotic surgery (post-TORS) radiotherapy (RT) might reduce the dose to organs at risk (OARs) adjacent to the primary tumor bed; however, the evidence supporting this has yet to be sufficient. This study examined the radiation dose reduction to OARs by omitting the primary tumor bed through the use of an Auto-Planning (AP)-based workflow., Methods:  Twelve patients were identified who underwent post-TORS RT to the primary tumor bed and the unilateral/bilateral neck lymph nodes. In each patient, two treatment plans were designed: a Comprehensive (Comp)-plan treating the original planning target volume (PTV) including both the primary tumor bed and the lymph nodes, and a Neck-plan treating only the lymph nodes and omitting the primary tumor bed. Both plans were optimized using AP to ensure plan quality consistency. We compared the doses received by 95% of the primary tumor beds and lymph nodes (D95%) and our institutional dose constraints for the OARs between the Comp- and Neck-plans. Statistical analysis was performed using R Statistical Software (R Foundation for Statistical Computing, Vienna, Austria) with a two-tailed paired Wilcoxon signed-rank test., Results:  All plans met target dose coverage requirements with at least 95% of the PTVs covered with the corresponding prescription doses. The primary tumor bed in the Neck-plans was spared with a significantly lower mean D95% (25.9 Gy vs. 60.0 Gy; p < 0.01; Wilcoxon test). The mean dose to the oral cavity (20.9 Gy vs. 28.1 Gy; p < 0.01) and the supraglottis (36.9 Gy vs. 28.2 Gy; p < 0.01) was significantly lower in the Neck-plans., Conclusion:  This study suggests that sparing the primary tumor bed during post-TORS RT offers dosimetric benefits to nearby OARs with significant dose reductions to the oral cavity and supraglottis. Further study of the clinical risks and benefits afforded by this strategy is needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Cui et al.)