Computer-Based Patient Bias and Misconduct Training Impact on Reports to Incident Learning System.

OBJECTIVE: To assess the effect of computer-based training (CBT) and leadership communication on incident learning system reports pertaining to institutional policy that targets biased, prejudiced, and racist behaviors of patients and visitors toward health care employees. PATIENTS AND METHODS: Mayo Clinic developed a CBT module and comprehensive communication strategy to educate staff on the Patient and Visitor Conduct Policy. Additional goals were to demonstrate leadership endorsement and support of the policy, teach how to report an incident, and facilitate how policy enforcement might occur. Using descriptive statistics, we compared the reporting data before and after the intervention. RESULTS: Participants were 13,980 employees in 68 clinics and 18 hospitals in the US Midwest. Bias and misconduct incidents entered in the incident reporting system increased 312% (n=140 incidents; preintervention, n=34) in the quarter (ie, 3 months) immediately after intervention. The number of incidents in the next quarter stayed increased (234%; n=114) compared with the preintervention number. Secondary debriefing with employees showed the value of the education and the importance of leadership support at the highest level to facilitate comfort in policy enforcement. CONCLUSION: Institutional policy that targets biased, prejudiced, and racist behaviors of patients toward employees in a health care setting can be augmented with employee education and leadership support to facilitate change. The CBT, paired with a robust communication plan and active leadership endorsement and engagement, resulted in increased reporting of biased, prejudiced, and racist behaviors of patients.

Results of a questionnaire regarding practice patterns for the diagnosis and treatment of intracranial radiation necrosis after SRS.

Although stereotactic radiosurgery (SRS) is an effective treatment option for patients with brain tumors, its increased use has raised concern for increased incidence of radiation necrosis (RN). No established standard or guidelines exists regarding non-invasive techniques to diagnose or treat RN. This study was conducted to assess current patterns of evaluation and treatment of RN among physicians who treat intracranial malignancies. A questionnaire consisting of 20 questions was sent to 3,041 members of the American Society for Radiation Oncology (ASTRO) and the Society for Neurologic Oncology (SNO). Questions addressed demographics, utilization of SRS, perceptions regarding RN diagnosis treatment, approach to steroid-refractory RN, and management of two clinical scenarios using Kwiksurvey© software. The survey response rate was 8.74 % (266/3,041). Most respondents practice in an academic and/or university setting (62 %) at a facility that performs SRS (94 %) with a variety of systems. The number of annual cases performed at the participant's institution varied from <50 to >400, with a wide degree of variability. Most respondents practice at an institution that performs 50-100 cases/year (28 %). The most common range of symptomatic RN seen in clinical practice was 1-5 % (61 %). Most respondents reported that asymptomatic RN occurs in 6-10 % (33 %). Favored non-invasive diagnostic mechanisms were clinical evaluation (37 %) and MRI (19 %). In response to a clinical scenario depicting an asymptomatic patient post-SRS for brain metastasis with an enlarging lesion and edema at the treatment site, most respondents felt the image represented RN or a combination of RN and tumor progression. Most (58 %) favored short-term follow-up with repeat MRI. Ninety-three percent of the respondents initiated steroids as a first-line approach if patient was to develop symptoms. Steroids were the preferred first therapy in symptomatic patients on initial follow-up (81 %). In steroid-refractory patients, most recommend surgical intervention (63 %). Most physicians who responded to this questionnaire believe that post-SRS RN is uncommon (≤10 % of cases). The approach to establish the diagnosis of RN is variable. Steroids are the most commonly utilized first-line treatment for suspected RN. Considerable variation exists in the management of steroid-refractory RN. Additional studies are required to establish guidelines for evaluation and treatment of RN.

Challenges with the diagnosis and treatment of cerebral radiation necrosis.

The incidence of radiation necrosis has increased secondary to greater use of combined modality therapy for brain tumors and stereotactic radiosurgery. Given that its characteristics on standard imaging are no different that tumor recurrence, it is difficult to diagnose without use of more sophisticated imaging and nuclear medicine scans, although the accuracy of such scans is controversial. Historically, treatment had been limited to steroids, hyperbaric oxygen, anticoagulants, and surgical resection. A recent prospective randomized study has confirmed the efficacy of bevacizumab in treating radiation necrosis. Novel therapies include using focused interstitial laser thermal therapy. This article will review the diagnosis and treatment of radiation necrosis.

Conventional MRI does not reliably distinguish radiation necrosis from tumor recurrence after stereotactic radiosurgery.

Distinguishing radiation necrosis (RN) from tumor recurrence after stereotactic radiosurgery (SRS) for brain metastases is challenging. This study assesses the sensitivity (SN) and specificity (SP) of an MRI-based parameter, the "lesion quotient" (LQ), in characterizing tumor progression from RN. Records of patients treated with SRS for brain metastases between 01/01/1999 and 12/31/2009 and with histopathologic analysis of a subsequent contrast enhancing enlarging lesion at the treated site at a single institution were examined. The LQ, the ratio of maximal nodular cross sectional area on T2-weighted imaging to the corresponding maximal cross sectional area of T1-contrast enhancement, was calculated by a neuroradiologist blinded to the histopathological outcome. Cutoffs of <0.3, 0.3-0.6, and >0.6 have been previously suggested to have correlated with RN, mixed findings and tumor recurrence, respectively. These cutoff values were evaluated for SN, SP, positive predictive value (PPV) and negative predictive value (NPV). Logistic regression analysis evaluated for associated clinical factors. For the 51 patients evaluated, the SN, SP, PPV and NPV for identifying RN (LQ < 0.3) were 8, 91, 25 and 73 %, respectively. For the combination of recurrent tumor and RN (LQ 0.3-0.6) the SN, SP, PPV and NPV were 0, 64, 0 and 83 %. The SN, SP, PPV and NPV of the LQ for recurrent tumor (LQ > 0.6) were 59, 41, 62 and 39 %, respectively. Standard MRI techniques do not reliably discriminate between tumor progression and RN after treatment with SRS for brain metastases. Additional imaging modalities are warranted to aid in distinguishing between these diagnoses.

Management of recurrent brain metastasis after radiosurgery.

Stereotactic radiosurgery (SRS) has become a first-line treatment option for brain metastases, both as a boost following whole-brain radiation therapy (WBRT), and as stand-alone treatment. When SRS is used as a single modality treatment, the local and distant brain recurrence rates range from 73 to 76.4%. When used in combination with WBRT, recurrence rates range from 27 to 46.8%. As systemic therapies improve, the number of patients who develop new or recurrent brain metastases after SRS is likely to increase. The evidence regarding the safety and efficacy of salvage therapies is very limited, making options for treatment unclear and controversial. In this report, we review current diagnostic challenges regarding local recurrence after SRS and the development of new brain metastases after SRS. Potential therapeutic strategies and the patients for who each is recommended are discussed, including repeat SRS, surgical resection, WBRT, fractionated stereotactic radiosurgery, chemotherapy, and supportive care.