Applying human factors to improve patient safety, morale and team working for oral pathology and medicine specialists.

BACKGROUND: Human error is inevitable, and therefore can be considered as a 'normal' part of everyday life. Unfortunately, error can never be eliminated completely. However, learning from our mistakes can help reduce problems in future. Fifty years ago, most clinicians paid little or no attention to the human factors (HF) that can affect individual and team performance. It has only been in the last 20-25 years that colleagues in healthcare have truly begun recognizing the importance of HF and non-technical skills in medicine and dentistry and how their application can significantly improve patient safety and aid better team working and staff morale in the clinical setting and laboratory. DISCUSSION: Personal factors such as stress, tiredness, hunger and dehydration all reduce human performance and can raise the risk of mistakes. In addition, how we work and interact with the wider team is important since many errors can occur because of ineffective communication, steep hierarchal (authority) gradients and loss of situational awareness.  This short HF overview in the 50th commemorative special of JOPM issue is timely. It provides a contemporary overview of human factors and performance that the authors consider important for oral medicine and pathology colleagues and which can affect individuals and teams This article also discuss ways to reduce the chances of medical and dental error and improve patient safety.

A commentary on a flawed public health investigation.

The possibility of hepatitis C being transmitted between dental patients was the genesis of an extensive and expensive look-back investigation conducted by an Ontario Public Health Unit. This investigation was performed with a minimal knowledge of nosocomial infections of dental origin, an enthusiastic reliance on untested checklist indicators and an absence of any of the criteria justifying such an investigation. As a consequence, the entire exercise was based on the false premise that an infection control lapse had occurred. This commentary will address these flaws, and other aspects of the Public Health Unit's response that detracted from its credibility. The provision of a realistic assessment of disease transmission in dentistry should result in Public Health Units conducting informed and mutually beneficial inspections of dental practices.

Estimating Survival in Patients With Lung Cancer and Brain Metastases: An Update of the Graded Prognostic Assessment for Lung Cancer Using Molecular Markers (Lung-molGPA).

IMPORTANCE: Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. As systemic therapies improve, patients with lung cancer live longer and thus are at increased risk for brain metastases. Understanding how prognosis varies across this heterogeneous patient population is essential to individualize care and design future clinical trials. OBJECTIVE: To update the current Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for patients with non-small-cell lung cancer (NSCLC) and brain metastases. The DS-GPA is based on data from patients diagnosed between 1985 and 2005, and we set out to update it by incorporating more recently reported gene and molecular alteration data for patients with NSCLC and brain metastases. This new index is called the Lung-molGPA. DESIGN, SETTING, AND PARTICIPANTS: This is a multi-institutional retrospective database analysis of 2186 patients diagnosed between 2006 and 2014 with NSCLC and newly diagnosed brain metastases. The multivariable analyses took place between December 2015 and May 2016, and all prognostic factors were weighted for significance by hazard ratios. Significant factors were included in the updated Lung-molGPA prognostic index. MAIN OUTCOMES AND MEASURES: The main outcome was survival. Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios. Log rank tests were used to compare adjacent classes and to compare overall survival for adenocarcinoma vs nonadenocarcinoma groups. RESULTS: The original DS-GPA was based on 4 factors found in 1833 patients with NSCLC and brain metastases diagnosed between 1985 and 2005: patient age, Karnofsky Performance Status, extracranial metastases, and number of brain metastases. The patients studied for the creation of the DS-GPA had a median survival of 7 months from the time of initial treatment of brain metastases. To design the updated Lung-molGPA, we analyzed data from 2186 patients from 2006 through 2014 with NSCLC and newly diagnosed brain metastases (1521 adenocarcinoma and 665 nonadenocarcinoma). Significant prognostic factors included the original 4 factors used in the DS-GPA index plus 2 new factors: EGFR and ALK alterations in patients with adenocarcinoma (mutation status was not routinely tested for nonadenocarcinoma). The overall median survival for the cohort in the present study was 12 months, and those with NSCLC-adenocarcinoma and Lung-molGPA scores of 3.5 to 4.0 had a median survival of nearly 4 years. CONCLUSIONS AND RELEVANCE: In recent years, patient survival and physicians' ability to predict survival in NSCLC with brain metastases has improved significantly. The updated Lung-molGPA incorporating gene alteration data into the DS-GPA is a user-friendly tool that may facilitate clinical decision making and appropriate stratification of future clinical trials.

The Effect of Gene Alterations and Tyrosine Kinase Inhibition on Survival and Cause of Death in Patients With Adenocarcinoma of the Lung and Brain Metastases.

PURPOSE: Lung cancer remains the most common cause of both cancer mortality and brain metastases (BM). The purpose of this study was to assess the effect of gene alterations and tyrosine kinase inhibition (TKI) on median survival (MS) and cause of death (CoD) in patients with BM from lung adenocarcinoma (L-adeno). METHODS: A multi-institutional retrospective database of patients with L-adeno and newly diagnosed BM between 2006 and 2014 was created. Demographics, gene alterations, treatment, MS, and CoD were analyzed. The treatment patterns and outcomes were compared with those in prior trials. RESULTS: Of 1521 L-adeno patients, 816 (54%) had known alteration status. The gene alteration rates were 29%, 10%, and 26% for EGFR, ALK, and KRAS, respectively. The time from primary diagnosis to BM for EGFR-/+ was 10/15 months (P=.02) and for ALK-/+ was 10/20 months (P<.01), respectively. The MS for the group overall (n=1521) was 15 months. The MS from first treatment for BM for EGFR and ALK-, EGFR+, ALK+ were 14, 23 (P<.01), and 45 (P<.0001) months, respectively. The MS after BM for EGFR+ patients who did/did not receive TKI before BM was 17/30 months (P<.01), respectively, but the risk of death was not statistically different between TKI-naïve patients who did/did not receive TKI after the diagnosis of BM (EGFR/ALK hazard ratios: 1.06 [P=.84]/1.60 [P=.45], respectively). The CoD was nonneurologic in 82% of patients with known CoD. CONCLUSION: EGFR and ALK gene alterations are associated with delayed onset of BM and longer MS relative to patients without these alterations. The CoD was overwhelmingly nonneurologic in patients with known CoD.

Evaluation of RANO response criteria compared to clinician evaluation in WHO grade III anaplastic astrocytoma: implications for clinical trial reporting and patterns of failure.

The utility of current response criteria has not been established in anaplastic astrocytoma (AA). We retrospectively reviewed MR images for 20 patients with AA and compared RANO-based approaches to clinician impression described as follow: (1) standard RANO-based criteria met by growth of or development of new enhancing lesion (RANO-C), (2) RANO criteria for progression based on significant FLAIR increase (RANO-F) and (3) clinical progression usually resulting in change of treatment (Clinical). Patterns of failure (POF) were analyzed utilizing all proposed progression MRIs fused with the patients' radiotherapy treatment plan. With an overall median survival of 24.3 months, development of new enhancing lesion was the most common determinant of progression (70 % of patients). Median time to RANO-C, RANO-F and Clinical progression was 9.2, 9.2 and 11.76 months respectively. RANO-C and RANO-F preceded Clinical in 70 and 55 % of patients, respectively. In six patients (30 %) Clinical was concurrent with RANO-F; four of six also met RANO-C. POF for FLAIR component differed based on time point used to determine progression. FLAIR POF was more often marginal or distant when progression was defined clinically compared to either RANO-C or RANO-F criteria. Central POF based on FLAIR at Clinical determination of progression was associated with significantly poorer OS (9.8 vs. 34.4 months). Clinical progression occurs later than progression determined by RANO-based criteria. Evaluation of POF based on FLAIR signal abnormality at the time of clinical progression suggests central recurrences are associated with worse survival.

The impact of concurrent temozolomide with adjuvant radiation and IDH mutation status among patients with anaplastic astrocytoma.

This study assesses the controversial role of temozolomide (TMZ) concurrent with adjuvant radiation (RT) in patients with anaplastic astrocytoma (AA). The impact of isocitrate dehydrogenase (IDH) status on therapy and outcomes is also examined. All adult patients diagnosed with AA from 2001 to 2011 and treated with standard doses of adjuvant RT were identified retrospectively for clinical data extraction. IDH status was determined by IDH1-R132H immunostain and sequencing for other mutations in IDH1/IDH2. Cumulative survival probabilities were estimated using the Kaplan-Meier method. Cox proportional hazards regression models were fit for univariable/multivariable analyses. 136 patients had received concurrent TMZ while 29 had not. Of these, IDH status was determined on 114 and 27 patients, respectively. On univariable analysis, improved five-year survival was independently associated with concurrent TMZ (46.2 vs. 29.3%, p = 0.02) and IDH mutation (78.9 vs. 22.0%, p < 0.001). IDH mutation was additionally associated with a greater likelihood of extensive resection possibly secondary to a more favorable tumor location. Gross total/subtotal resections also led to improved survival when compared to biopsy alone on univariable analysis. On multivariable analysis, the association with five-year survival persisted for both concurrent TMZ and IDH mutation, but not with extent of surgery. Both IDH mutation and concurrent TMZ are associated with improved five-year survival in patients with AA who are receiving adjuvant RT. Secondarily, the association between five-year survival and extent of resection is lost on multivariable analysis. This suggests a possible association between IDH mutation, tumor location and consequent resectability.

Evidenced-based hypnotherapy for the management of sleep disorders.

There is a plethora of research suggesting that combining cognitive-behavioral therapy with hypnosis is effective for a variety of psychological, behavioral, and medical disorders. Yet, very little empirical research exists pertaining to the use of hypnotherapy as either a single or multitreatment modality for the management of sleep disorders. The existing literature is limited to a small subset of nonbiologic sleep disorders. The objectives of this paper are: to provide a review of the most common sleep disorders, with emphasis on insomnia disorders; discuss the cognitive-behavioral approaches to insomnia; and review the existing empirical literature on applications of hypnotherapy in the treatment of sleep disturbance. The overreaching goal is to educate clinicians on how to incorporate sleep therapy with hypnotherapy. There is an immediate need for research evaluating the efficacy of hypnotherapy in the management of sleep disturbance.