Safety culture and incident learning systems in radiation oncology: Staff perceptions across Australia and New Zealand.

INTRODUCTION: Radiation therapy has a highly complex pathway and uses detailed quality assurance protocols and incident learning systems (ILSs) to mitigate risk; however, errors can still occur. The safety culture (SC) in a department influences its commitment and effectiveness in maintaining patient safety. METHODS: Perceptions of SC and knowledge and understanding of ILSs and their use were evaluated for radiation oncology staff across Australia and New Zealand (ANZ). A validated healthcare survey tool (the Hospital Survey on Patient Safety Culture) was used, with additional specialty-focussed supporting questions. A total of 220 radiation oncologists, radiation therapists and radiation oncology medical physicists participated. RESULTS: An overall positive SC was indicated, with strength in teamwork (83.7%), supervisor/manager/leader support (83.3%) and reporting events (77.1%). The weakest areas related to communication about error (63.9%), hospital-level management support (60.5%) and handovers and information exchange (58.0%). Barriers to ILS use included 'it takes too long' and that many respondents must use multiple reporting systems, including mandatory hospital-level systems. These are generally not optimal for specific radiation oncology needs. Varied understanding was indicated of what and when to report. CONCLUSION: The findings report the ANZ perspective on ILS and SC, highlighting weaknesses, barriers and areas for further investigation. Differences observed in some areas suggest that a unified state, national or bi-national ILS specific to radiation oncology might eliminate multiple reporting systems and reduce reporting time. It could also provide more consistent and robust approaches to incident reporting, information sharing and analysis.

PCXMC cone beam computed tomography dosimetry investigations.

With cone beam computed tomography (CBCT) in image guided radiation therapy being amongst the most widely used imaging modalities, there has been an increasing interest in quantifying the concomitant dose and risk. Whilst there have been several studies on this topic, there remains a lack of standardisation and knowledge on dose variations and the impact of patient size. Recently, PCXMC (a Monte Carlo simulator) has been used to assess both the concomitant dose and dosimetric impact of patient size variations for CBCT. The scopes of these studies, however, have included only a limited range of imaging manufacturers, protocols, and patient sizes. An approach using PCXMC and MATLAB was developed to enable a generalised method for rapidly quantifying and formulating the concomitant dose as a function of patient size across numerous CBCT vendors and protocols. The method was investigated using the Varian on board imaging 1.6 default pelvis and pelvis spotlight protocols, for 94 adult and paediatric phantoms over 6 age groups with extensive height and mass variations. It was found that dose varies significantly with patient size, as much as doubling and halving the average for patients of lower and higher mass, respectively. These variations, however, can be formulated and accounted for using the method developed, across a wide range of patient sizes for all CBCT vendors and protocols. This will enable the development of a comprehensive catalogue to account for concomitant doses in almost any clinically relevant scenario.

Assessment of error in the MV radiation isocenter position calculated with the Elekta XVI software.

The assessment of the coincidence of imaging and radiation isocenters is an important task of regular quality assurance of medical linear accelerators (linacs) as recommended in national and international quality assurance guidelines. A previously reported investigation of the accuracy of the Elekta XVI software to localize the linac radiation isocenter, by comparing statistically with other independent software, has shown some discrepancies at the sub-mm level. A further investigation is carried out here using a set of reference images and mathematical operations to observe how the Elekta XVI software analyses them. Symmetric mathematical operations on reference images should result in symmetrical outcomes. Three different rotation functions are used in increasing degree of complexity to characterize the Elekta XVI software error in the linac radiation isocenter position. No independent algorithms or phantoms are used in this methodology. The magnitude and direction of the radiation isocenter localization error has been determined to be consistently 0.13 mm or 0.14 mm in the longitudinal direction towards the target depending on the case. The radiation isocenter localization error comprises two separated errors of the Ball Bearing Center by 0.13 mm and MV Field Center by either 0.00 mm or -0.01 mm in the longitudinal direction towards the target. The calculation of the MV Field Center is influenced by the polymethyl methacrylate rod supporting the ball-bearing. The precise value and the root cause of the error cannot be assessed due to the rounding effect of the results reported by the Elekta XVI software and lack of access to the source code.

Perceived Preparedness of Facial Plastic Surgery Fellows Over Time: A Survey of AAFPRS Fellowship Directors.

OBJECTIVE: Assess the effects of American Council for Graduate Medical Education (ACGME) resident work hour restrictions on the preparedness of incoming facial plastic surgery fellows as assessed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) fellowship directors. METHODS: Observational survey study evaluating the perception of ACGME resident duty hour change on resident surgical and clinical skills from fellowship directors of AAFPRS fellowship programs in the US. A cross-sectional survey was sent to 47 fellowship directors of AAFPRS fellowship programs. Perceived change in resident clinical and surgical skills were measured using a 5-point Likert scale (1 = significantly improved, 2 = improved, 3 = neither improved nor worsened, 4 = worsened, 5 = significantly worsened) to evaluate 15 benchmarks. RESULTS: Responses received from 36 fellowship directors. The results indicate no statistically significant perceived trend of ACGME duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, cohort analysis demonstrated that fellowship directors with more than 10 years of service perceived a more negative impact in 2 clinical benchmarks (assessment/planning and basic exposure) over time. CONCLUSIONS: The study results appear to show no significant perceived trend over time on the effect of duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, there are some apparent opinion differences between fellowship directors separated by years of service, with more negative perceptions noted in 2 clinical areas by those with more than 10 years of service. This study is in line with the more recent literature that suggests a trend toward a less negative perception of the duty hour change. This may suggest resident education is adapting to the ACGME duty hour regulations.

Development and Validation of a Photonumeric Scale for Assessment of Chin Retrusion.

BACKGROUND: A validated scale is needed for objective and reproducible comparisons of chin appearance before and after chin augmentation in practice and clinical studies. OBJECTIVE: To describe the development and validation of the 5-point photonumeric Allergan Chin Retrusion Scale. METHODS: The Allergan Chin Retrusion Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 298) completed during 2 sessions occurring 3 weeks apart. RESULTS: A difference of ≥1 point on the scale was shown to reflect a clinically meaningful difference (mean [95% confidence interval] absolute score difference, 1.07 [0.94-1.20] for clinically different image pairs and 0.51 [0.39-0.63] for not clinically different pairs). Intrarater agreement between the 2 live-subject validation sessions was substantial (mean weighted kappa = 0.79). Interrater agreement was substantial during the second rating session (0.68, primary end point). CONCLUSION: The Allergan Chin Retrusion Scale is a validated and reliable scale for physician rating of severity of chin retrusion.

Consensus panel's assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics.

In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.

Impact of the current economy on facial aesthetic surgery.

BACKGROUND: American Society for Aesthetic Plastic Surgery (ASAPS) survey data showed a 16.7% decrease in the total number of aesthetic surgical procedures from 2008 to 2009, whereas plastic surgeons have seen an increase of 0.6% in their nonsurgical cosmetic procedures. OBJECTIVE: The authors describe the results of two surveys-one administered to potential patients, one to physicians-assessing the impact of the economy on patient choices in aesthetic facial surgery. METHODS: Two surveys were conducted for this study-one from the American Academy of Facial Plastic and Reconstructive Surgeons (AAFPRS) and one from the Aesthetic Surgery Education and Research Foundation (ASERF). Both surveys utilized the unique maximum difference (MaxDiff) scaling format, which assesses respondent opinions through attribute/question grouping and multiple exposures to the same parameter, rather than traditional one-time questioning. In this way, MaxDiff analysis helped identify the varied drivers of patients' medical antiaging treatment (MAT) selection. The AAFPRS survey was conducted online through Synovate's Global Opinion Panel to identify an appropriate audience of potential patients. The ASERF survey contained both MaxDiff and traditional questions and was e-mailed to 2267 ASAPS members. RESULTS: Data from the AAFPRS patient survey showed that 53% of respondents had been affected by the economy in their decisions regarding MAT procedures, with many seeking out less-costly options such as microdermabrasion. An overwhelming majority (95%) also reported that they would prefer a longer-lasting treatment over an immediate effect with shorter duration; furthermore, 60% felt that duration of treatment was more important than cost in selecting a facial aesthetic procedure. In the ASERF surgeon-based portion of the study, 61% of plastic surgeons felt that patients preferred long-lasting results over immediate ones, but 63% also reported that cost was a more important factor for their patients than duration. CONCLUSIONS: Extrapolating from the patient-reported survey preferences, the authors conclude that nonsurgical facial aesthetic treatment plans should currently be focused more on longevity rather than on immediate impact. There is currently a disconnect between patient preferences and surgeon perception of those preferences, which may be remedied with increased education for both groups. It is worth noting that many patients would be willing to accept a higher cost if it was correlated with a longer-lasting result.

Assessment of bladder motion for clinical radiotherapy practice using cine-magnetic resonance imaging.

PURPOSE: Organ motion is recognized as the principal source of inaccuracy in bladder radiotherapy (RT), but there is currently little information on intrafraction bladder motion. METHODS AND MATERIALS: We used cine-magnetic resonance imaging (cine-MRI) to study bladder motion relevant to intrafraction RT delivery. On two occasions, a 28 minute cine-MRI sequence was acquired from 10 bladder cancer patients and 5 control participants immediately after bladder emptying, after abstinence from drinking for the preceding hour. From the resulting cine sequences, bladder motion was subjectively assessed. To quantify bladder motion, the bladder was contoured in imaging volume sets at 0, 14, and 28 min to measure changes to bladder volumes, wall displacements, and center of gravity (COG) over time. RESULTS: The dominant source of bladder motion during imaging was bladder filling (up to 101% volume increase); rectal and small bowel movements were transient, with minimal impact. Bladder volume changes were similar for all participants. However for bladder cancer patients, wall displacements were larger (up to 58 mm), less symmetrical, and more variable compared with nondiseased control bladders. CONCLUSIONS: Significant and individualized intrafraction bladder wall displacements may occur during bladder RT delivery. This important source of inaccuracy should be incorporated into treatment planning and verification.

Cleft lip-palate deformities in Western China: epidemiology, surgical reconstruction, and cost.

A series of 46 procedures (42 patients) was performed on youth with cleft lip-palate deformities in Lanzhou, China. Patients' ages ranged from 6 months to 18 years. There were no short-term complications in this series, which included many advanced cases. The estimated cost per patient was 1590 US dollars. Youth with unrepaired cleft lip-palate in western China can be treated in a cost-effective manner.