Identifying radiation therapists' perceptions of potentially triggering aspects of care for survivors of sexual violence undergoing radiotherapy.

INTRODUCTION: Research shows that for survivors of sexual violence (SV), cancer procedures can be retraumatizing due to perceived similarities to the original SV. To date, there is no training program designed specifically for the radiation therapist (RTT) on how to deliver care sensitively to survivors of SV. A key component of sensitive practice is working with patients to identify and develop strategies to manage situations that could be triggering. The goal of this study was to understand the RTT recognition of potential sensory/environmental, relational, and mixed triggers in radiation oncology settings. METHODS: This quantitative research study conducted a secondary analysis on RTT responses to a learning activity from an online cancer education training program. The first section of the activity asked trainees to identify two potential triggers in a brachytherapy video, and the second portion of the activity asked trainees to describe two potential triggers in their own work. RESULTS: Descriptive statistics, χ2 tests, and t tests were used to analyze 50 RTT responses. RTTs tended to identify different types of triggers depending on the question (brachytherapy video vs. self-reflection). Data indicated that despite a lack of formal didactic training in trigger management, RTTs could identify triggers, and were most likely to recognize "mixed" type triggers. DISCUSSION: Triggers identified are consistent with past research on childhood sexual abuse survivors' healthcare retraumatization in obstetrics and gynecology, and cancer care. As in past research, invasive techniques, and situations where the patient was in a submissive position were identified as triggering aspects of care. It is interesting to note when reflecting on their own practice, the least identified triggers all fell under the environmental/sensory trigger category. RTTs may not fully appreciate a variety of potential triggers such as sounds of treatment or silence because they are outside of the room administering the beam when the machine is delivering treatment. Thus, they may not hear certain sounds or silence during their daily routine. CONCLUSIONS: Relatively few trainees identified sensory/ environmental triggers (e.g., restricted visibility and sounds of treatment, including silence) when reflecting on their own practice, which could potentially reduce their likelihood of helping patients minimize the impact of (or avoid) such triggers. Future research should identify a comprehensive list of triggers and then develop a training specific to the RTT focused on identifying environmental/sensory triggers from the perspective of the patient in the often unfamiliar and frightening radiotherapy suite.

Reconnecting the Hand and Arm to the Brain: Efficacy of Neural Interfaces for Sensorimotor Restoration after Tetraplegia.

Background: Paralysis after spinal cord injury involves damage to pathways that connect neurons in the brain to peripheral nerves in the limbs. Re-establishing this communication using neural interfaces has the potential to bridge the gap and restore upper extremity function to people with high tetraplegia. Objective: We report a novel approach for restoring upper extremity function using selective peripheral nerve stimulation controlled by intracortical microelectrode recordings from sensorimotor networks, along with restoration of tactile sensation of the hand using intracortical microstimulation. Methods: A right-handed man with motor-complete C3-C4 tetraplegia was enrolled into the clinical trial. Six 64-channel intracortical microelectrode arrays were implanted into left hemisphere regions involved in upper extremity function, including primary motor and sensory cortices, inferior frontal gyrus, and anterior intraparietal area. Nine 16-channel extraneural peripheral nerve electrodes were implanted to allow targeted stimulation of right median, ulnar (2), radial, axillary, musculocutaneous, suprascapular, lateral pectoral, and long thoracic nerves, to produce selective muscle contractions on demand. Proof-of-concept studies were performed to demonstrate feasibility of a bidirectional brain-machine interface to restore function of the participant's own arm and hand. Results: Multi-unit neural activity that correlated with intended motor action was successfully recorded from intracortical arrays. Microstimulation of electrodes in somatosensory cortex produced repeatable sensory percepts of individual fingers for restoration of touch sensation. Selective electrical activation of peripheral nerves produced antigravity muscle contractions. The system was well tolerated with no operative complications. Conclusion: The combination of implanted cortical electrodes and nerve cuff electrodes has the potential to allow restoration of motor and sensory functions of the arm and hand after neurological injury.

Promoting safety mindfulness: Recommendations for the design and use of simulation-based training in radiation therapy.

There is a need to better prepare radiation therapy (RT) providers to safely operate within the health information technology (IT) sociotechnical system. Simulation-based training has been preemptively used to yield meaningful improvements during providers' interactions with health IT, including RT settings. Therefore, on the basis of the available literature and our experience, we propose principles for the effective design and use of simulated scenarios and describe a conceptual framework for a debriefing approach to foster successful training that is focused on safety mindfulness during RT professionals' interactions with health IT.

Validation of electrical stimulation models: intracellular calcium measurement in three-dimensional scaffolds.

Peripheral nerve injury can be disabling. Regeneration is limited by the rate of axonal extension, and proximal injury to peripheral nerves can take over a year to reach target organs. Electrical stimulation (ES) has been shown to increase the rate of neurite growth, though the mechanism is not yet well understood. In our prior manuscript, we developed a computational model that demonstrates how ES can functionally elevate intracellular calcium concentration ([Ca2+]i) based on ES intensity and duration. In this article, we validate the computation model for the [Ca2+]i changes in neuron soma. Embryonic chicken dorsal root ganglion cells were suspended in 3-dimensional collagen scaffolds. Fura-2 was used to measure [Ca2+]i in response to biphasic ES pulses ranging from 70 to 60,000 V/m in intensity and from 10 µs to 100 ms in duration. The computational model most closely matched the experimental data of the neurons with the highest [Ca2+]i elevation for ES pulses 100 µs or greater in duration. Nickel (200 µM) and cadmium (200 µM) blocked 98-99% of the [Ca2+]i rise, indicating that the rise in [Ca2+]i in response to ES is via voltage-dependent calcium channels. The average [Ca2+]i rise in response to ES was about one-tenth of the peak rise. Therefore, the computational model is validated for elevating [Ca2+]i of neurons and can be used as a tool for designing efficacious ES protocols for improving neuronal regeneration.NEW & NOTEWORTHY Electrical stimulation is used to enhance neuron growth, and the role of neuronal intracellular calcium concentration ([Ca2+]i) is an area of research interest. Widely varying stimulation parameters in the literature make it difficult to compare stimulation protocols. The results in this manuscript are the first to show neuronal [Ca2+]i in response to a broad and defined range of electrical pulse durations and intensities. These results validate our previously published novel computational model of [Ca2+]i.

Improving radiation oncology providers' workload and performance: Can simulation-based training help?

PURPOSE: To help with ongoing safety challenges in radiation therapy (RT), the objective of this research was to develop and assess the impact of a simulation-based training intervention on radiation oncology providers' workload and performance during treatment planning and quality assurance (QA) tasks. METHODS AND MATERIALS: Eighteen radiation oncology professionals completed routine treatment planning and QA tasks on 2 clinical scenarios in a simulation laboratory as part of a prospective institutional review board-approved study. Workload was measured at the end of each assessment/scenario using the NASA Task-Load Index. Performance was quantified based on procedural compliance (adherence to preset/standard QA tasks), time-to-scenario completion, and clinically relevant performance. Participants were then randomized to receive (vs not receive) simulation-based training intervention (eg, standardized feedback on workload and performance) and underwent repeat measurements of workload and performance. Pre- and postintervention changes in workload and performance from participants who received (vs did not receive) were compared using 2-way analysis of variance. RESULTS: Simulation-based training was associated with significant improvements in procedural compliance (P = .01) and increases in time-to-scenario completion (P < .01) but had no significant impact on subjective workload or clinically relevant performance. CONCLUSION: Simulation-based training may be a tool to improve procedural compliance of RT professionals and to acquire new skills and knowledge to proactively maintain RT professionals' preoccupation with patient safety.

Occupational burnout among radiographers, sonographers and radiologists in Australia and New Zealand: Findings from a national survey.

INTRODUCTION: Evidence demonstrates that health care professionals are more prone to burnout than other professionals due to the emotionally taxing interactions they have with their patients on a daily basis. The aims of this study were to measure occupational burnout levels among sonographers, radiographers and radiologists and to examine predictors of burnout according to demographic characteristics. METHODS: A cross-sectional online survey was administered in 2010 to radiographers, sonographers and radiologists who were members of the following professional bodies: Australian Institute of Radiography, Australian Sonographers Association and The Royal Australian and New Zealand College of Radiologists. The Maslach Burnout Inventory was used to measure burnout levels for each profession. Data were analysed using SPSS Ver 20 (IBM, Chicago, IL, USA) statistical software. RESULTS: A total of 613 radiographers, 121 sonographers and 35 radiologists participated in the survey. Radiographers, sonographers and radiologists had a high mean (±SD) burnout score for emotional exhaustion (39.9 ± 8.5, 42.2 ± 8.5 and 44.9 ± 7.1 respectively) and depersonalization (18.9 ± 5.5, 20.3 ± 5.8 and 20.6 ± 5.6) compared to MBI norms. Radiographers also had low personal achievement (30.8 ± 5.5) compared to MBI norms. Radiographers and sonographers who were male, worked >10 hours overtime and spent <10% of their time training students per week had significantly higher depersonalization scores (p < 0.05). CONCLUSION: Burnout levels among radiographers, sonographers and radiologists are high and likely to vary according to some demographic and work-related factors. Further research is needed to examine ways to alleviate burnout in these professions so that loss of experienced staff due to burnout can be minimized and quality of patient care can be maintained.

Computational modeling of neurons: intensity-duration relationship of extracellular electrical stimulation for changes in intracellular calcium.

In many instances of extensive nerve damage, the injured nerve never adequately heals, leaving lack of nerve function. Electrical stimulation (ES) has been shown to increase the rate and orient the direction of neurite growth, and is a promising therapy. However, the mechanism in which ES affects neuronal growth is not understood, making it difficult to compare existing ES protocols or to design and optimize new protocols. We hypothesize that ES acts by elevating intracellular calcium concentration ([Ca(2+)]i) via opening voltage-dependent Ca(2+) channels (VDCCs). In this work, we have created a computer model to estimate the ES Ca(2+) relationship. Using COMSOL Multiphysics, we modeled a small dorsal root ganglion (DRG) neuron that includes one Na(+) channel, two K(+) channels, and three VDCCs to estimate [Ca(2+)]i in the soma and growth cone. As expected, the results show that an ES that generates action potentials (APs) can efficiently raise the [Ca(2+)]i of neurons. More interestingly, our simulation results show that sub-AP ES can efficiently raise neuronal [Ca(2+)]i and that specific high-voltage ES can preferentially raise [Ca(2+)]i in the growth cone. The intensities and durations of ES on modeled growth cone calcium rise are consistent with directionality and orientation of growth cones experimentally shown by others. Finally, this model provides a basis to design experimental ES pulse parameters, including duration, intensity, pulse-train frequency, and pulse-train duration to efficiently raise [Ca(2+)]i in neuronal somas or growth cones.

Stimulation Frequency Alters the Dorsal Root Ganglion Neurite Growth and Directionality In Vitro.

OBJECTIVE: To improve peripheral nerve repair, new techniques to increase the speed of regeneration are required. Studies have shown that the electrical stimulation can enhance nerve regeneration; however, stimulation parameters that regulate the growth increases are unknown. The objective of this study was to examine dorsal root ganglion (DRG) neurite extension, directionality, and density after using methods to specifically control ac electrical field intensity and frequency exposure. METHODS: Chick DRG explants were exposed to 20-Hz, 200-Hz, 1-MHz, and 20-MHz sinusoidal electric field of 17.86 V/m, and tissue parameters were measured. RESULTS: Results show that neurite extension and directionality were influenced by frequency; however, the ratio of support cell emigration with respect to neurite extension from the DRG body was not. These results were further verified through finite-element modeling of intracellular calcium, which show that higher frequencies have minimal effect on intracellular calcium. CONCLUSION: In conclusion, these results demonstrate that 1) directional growth of neurites within EFs can be achieved, 2) high-frequency stimulation in megahertz does not enhance or impair the neurite growth, and 3) low-frequency stimulation affects the growth and directionality. SIGNIFICANCE: The significance of this study is the direct comparison of neurite extension after high stimulation frequencies (megahertz) with typical low-frequency fields (20 and 200 Hz), and modeling the results with finite-element modeling.

The future of medical dosimetry.

The world of health care delivery is becoming increasingly complex. The purpose of this manuscript is to analyze current metrics and analytically predict future practices and principles of medical dosimetry. The results indicate five potential areas precipitating change factors: a) evolutionary and revolutionary thinking processes, b) social factors, c) economic factors, d) political factors, and e) technological factors. Outcomes indicate that significant changes will occur in the job structure and content of being a practicing medical dosimetrist. Discussion indicates potential variables that can occur within each process and change factor and how the predicted outcomes can deviate from normative values. Finally, based on predicted outcomes, future opportunities for medical dosimetrists are given.

PC12 cells that lack synaptotagmin I exhibit loss of a subpool of small dense core vesicles.

Neurons communicate by releasing neurotransmitters that are stored in intracellular vesicular compartments. PC12 cells are frequently used as a model secretory cell line that is described to have two subpools of vesicles: small clear vesicles and dense core vesicles. We measured transmitter molecules released from vesicles in NGF-differentiated PC12 cells using carbon-fiber amperometry, and relative diameters of individual vesicles using electron microscopy. Both amperometry and electron micrograph data were analyzed by statistical and machine learning methods for Gaussian mixture models. An electron microscopy size correction algorithm was used to predict and correct for observation bias of vesicle size due to tangential slices through some vesicles. Expectation maximization algorithms were used to perform maximum likelihood estimation for the Gaussian parameters of different populations of vesicles, and were shown to be better than histogram and cumulative distribution function methods for analyzing mixed populations. The Bayesian information criterion was used to determine the most likely number of vesicle subpools observed in the amperometric and electron microscopy data. From this analysis, we show that there are three major subpools, not two, of vesicles stored and released from PC12 cells. The three subpools of vesicles include small clear vesicles and two subpools of dense core vesicles, a small and a large dense core vesicle subpool. Using PC12 cells stably transfected with short-hairpin RNA targeted to synaptotagmin I, an exocytotic Ca(2+) sensor, we show that the presence and release of the small dense core vesicle subpool is dependent on synaptotagmin I. Furthermore, synaptotagmin I also plays a role in the formation and/or maintenance of the small dense core vesicle subpool in PC12 cells.

Electrical and neurotrophin enhancement of neurite outgrowth within a 3D collagen scaffold.

Electrical and chemical stimulation have been studied as potent mechanisms of enhancing nerve regeneration and wound healing. However, it remains unclear how electrical stimuli affect nerve growth, particularly in the presence of neurotrophic factors. The objective of this study was to explore (1) the effect of brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) supplementation to support neurite outgrowth in a 3D scaffold, and (2) the effect of brief, low voltage, electrical stimulation (ES) on neurite outgrowth prior to neurotrophin supplementation. Dissociated E11 chick dorsal root ganglia (DRG) were seeded within a 1.5 mg/mL type-I collagen scaffold. For neurotrophin treatments, scaffolds were incubated for 24 h in culture media containing NGF (10 ng/mL) or BDNF (200 ng/mL), or both. For ES groups, scaffolds containing neurons were stimulated for 10 min at 8-10 V/m DC, then incubated for 24 h with neurotrophin. Fixed and labeled neurons were imaged to measure neurite growth and directionality. BDNF supplementation was not as effective as NGF at supporting DRG neurite outgrowth. ES prior to NGF supplementation improved DRG neurite outgrowth compared to NGF alone. This combination of brief ES with NGF treatment was the most effective treatment compared to NGF or BDNF alone. Brief ES had no impact on neurite directionality in the 3D scaffolds. These results demonstrate that ES improves neurite outgrowth in the presence of neurotrophins, and could provide a potential therapeutic approach to improve nerve regeneration when coupled with neurotrophin treatment.

Fostering a culture of interprofessional education for radiation therapy and medical dosimetry students.

A less-studied aspect of radiation therapy and medical dosimetry education is experiential learning through attendance at interprofessional conferences. University of North Carolina radiation therapy and medical dosimetry students regularly attended morning conferences and daily pretreatment peer review, including approximately 145 hours of direct interaction with medical attending physicians and residents, medical physicists, and other faculty. We herein assessed the effect of their participation in these interprofessional conferences on knowledge and communication. The students who graduated from our radiation therapy and medical dosimetry programs who were exposed to the interprofessional education initiative were compared with those who graduated in the previous years. The groups were compared with regard to their knowledge (as assessed by grades on end-of-training examinations) and team communication (assessed via survey). The results for the 2 groups were compared via exact tests. There was a trend for the examination scores for the 2012 cohort to be higher than for the 2007 to 2011 groups. Survey results suggested that students who attended the interprofessional education sessions were more comfortable speaking with attending physicians, residents, physicists, and faculty compared with earlier students who did not attend these educational sessions. Interprofessional education, particularly vertical integration, appears to provide an enhanced educational experience both in regard to knowledge (per the examination scores) and in building a sense of communication (via the survey results). Integration of interprofessional education into radiation therapy and medical dosimetry educational programs may represent an opportunity to enrich the learning experience in multiple ways and merits further study.

Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: Executive summary.

This report is part of a series of white papers commissioned for the American Society for Radiation Oncology (ASTRO) Board of Directors as part of ASTRO's Target Safely Campaign, focusing on the role of peer review as an important component of a broad safety/quality assurance (QA) program. Peer review is one of the most effective means for assuring the quality of qualitative, and potentially controversial, patient-specific decisions in radiation oncology. This report summarizes many of the areas throughout radiation therapy that may benefit from the application of peer review. Each radiation oncology facility should evaluate the issues raised and develop improved ways to apply the concept of peer review to its individual process and workflow. This might consist of a daily multidisciplinary (eg, physicians, dosimetrists, physicists, therapists) meeting to review patients being considered for, or undergoing planning for, radiation therapy (eg, intention to treat and target delineation), as well as meetings to review patients already under treatment (eg, adequacy of image guidance). This report is intended to clarify and broaden the understanding of radiation oncology professionals regarding the meaning, roles, benefits, and targets for peer review as a routine quality assurance tool. It is hoped that this work will be a catalyst for further investigation, development, and study of the efficacy of peer review techniques and how these efforts can help improve the safety and quality of our treatments.

National study to determine the comfort levels of radiation therapists and medical dosimetrists to report errors.

PURPOSE: Better understanding of the error reporting culture in radiation oncology treatment facilities, and obstacles to reporting, can provide insight into potential areas for improvement. We conducted a survey of radiation therapists and dosimetrists to examine the error reporting cultures in radiation oncology facilities across the United States and staff comfort in reporting errors. METHODS AND MATERIALS: In 2011, a national sample of 1500 radiation therapists and 528 dosimetrists was mailed a 27-item survey assessing perceptions regarding communication among staff, comfort in error reporting, and associated obstacles. Survey results were summarized using descriptive statistics, and factors associated with discomfort with error reporting analyzed using multivariate logistic regression. RESULTS: A total of 356 radiation therapists from 47 states (24% response rate) and 190 dosimetrists from 35 states (36% response rate) responded to the survey. Almost all (87% of therapists and 88% of dosimetrists) reported that there is an error reporting system in their treatment facility. Most feel that communication between them and physicians and dosimetrists or physicists (81% and 88% of therapists, and 89% and 88% of dosimetrists, respectively) is good, but only 65% of therapists and 66% of dosimetrists agree that communication with administrators is good. Obstacles to reporting errors included hierarchy within the treatment facility, poor communication, and fear of reprimand. On multivariate analysis, previous personal reprimand for reporting errors (odds ratio, 4.13, P = .001) and reprimand of other therapists and dosimetrists (odds ratio, 2.55, P = .03) were significantly associated with discomfort in error reporting. CONCLUSIONS: The majority of therapists and dosimetrists feel communication in their treatment facilities is good and that there are systems in place to report errors. A sizable minority reported experience with reprimand for error reporting that significantly reduced their comfort level with reporting errors. Obstacles identified in this study represent opportunities for future research and potential ways for improvement in radiation oncology treatment facilities.

Quantitative assessment of workload and stressors in clinical radiation oncology.

PURPOSE: Workload level and sources of stressors have been implicated as sources of error in multiple settings. We assessed workload levels and sources of stressors among radiation oncology professionals. Furthermore, we explored the potential association between workload and the frequency of reported radiotherapy incidents by the World Health Organization (WHO). METHODS AND MATERIALS: Data collection was aimed at various tasks performed by 21 study participants from different radiation oncology professional subgroups (simulation therapists, radiation therapists, physicists, dosimetrists, and physicians). Workload was assessed using National Aeronautics and Space Administration Task-Load Index (NASA TLX). Sources of stressors were quantified using observational methods and segregated using a standard taxonomy. Comparisons between professional subgroups and tasks were made using analysis of variance ANOVA, multivariate ANOVA, and Duncan test. An association between workload levels (NASA TLX) and the frequency of radiotherapy incidents (WHO incidents) was explored (Pearson correlation test). RESULTS: A total of 173 workload assessments were obtained. Overall, simulation therapists had relatively low workloads (NASA TLX range, 30-36), and physicists had relatively high workloads (NASA TLX range, 51-63). NASA TLX scores for physicians, radiation therapists, and dosimetrists ranged from 40-52. There was marked intertask/professional subgroup variation (P<.0001). Mental demand (P<.001), physical demand (P=.001), and effort (P=.006) significantly differed among professional subgroups. Typically, there were 3-5 stressors per cycle of analyzed tasks with the following distribution: interruptions (41.4%), time factors (17%), technical factors (13.6%), teamwork issues (11.6%), patient factors (9.0%), and environmental factors (7.4%). A positive association between workload and frequency of reported radiotherapy incidents by the WHO was found (r = 0.87, P value=.045). CONCLUSIONS: Workload level and sources of stressors vary among professional subgroups. Understanding the factors that influence these findings can guide adjustments to the workflow procedures, physical layout, and/or communication protocols to enhance safety. Additional evaluations are needed in order to better understand if these findings are systemic.

The challenge of maximizing safety in radiation oncology.

There is a growing interest in the evolving nature of safety challenges in radiation oncology. Understandably, there has been a great deal of focus on the mechanical and computer aspects of new high-technology treatments (eg, intensity-modulated radiation therapy). However, safety concerns are not limited to dose calculations and data transfer associated with advanced technologies. They also stem from fundamental changes in our workflow (eg, multiple hand-offs), the relative loss of some traditional "end of the line" quality assurance tools (port films and light fields), condensed fractionation schedules, and an under-appreciation for the physical limitations of new techniques. Furthermore, changes in our workspace and tools (eg, electronic records, planning systems), and workloads (eg, billing, insurance, regulations) may have unforeseen effects on safety. Safety initiatives need to acknowledge the multiple factors affecting risk. Our current challenges will not be adequately addressed simply by defining new policies and procedures. Rather, we need to understand the frequency and causes of errors better, particularly those that are most likely to cause harm. Then we can incorporate principles into our workspace that minimize these risks (eg, automation, standardization, checklists, redundancy, and consideration of "human factors" in the design of products and workspaces). Opportunities to enhance safety involve providing support through diligent examinations of staffing, schedules, communications, teamwork, and work environments. We need to develop a culture of safety in which all team members are alerted to the possibility of harm, and they all work together to maximize safety. The goal is not to eliminate every error. Rather, we should focus our attention on conditions (eg, rushing) that can cause real patient harm, and/or those conditions that reflect systemic problems that might lead to errors more likely to cause harm. Ongoing changes in clinical practice mandate continued vigilance to minimize the risks of error, combined with new, nontraditional approaches to create a safer patient environment.