The development and implementation of a performance appraisal framework for radiation therapists in planning and simulation.

It is a challenge for radiation therapists (RTs) to keep pace with changing planning technology and techniques while maintaining appropriate skills levels. The ability of individual RTs to meet the demands of this constantly changing practice can only be assured through establishing clearly defined standards for practice and a systematic process for providing feedback on performance. Investigation into existing models for performance appraisal produced minimal results so a radiation therapy-specific framework was developed. The goal for this initiative was to establish a framework that would reflect the complexity of practice and provide a clear measure of performance against them. This paper outlines the implementation of this framework into practice and discusses some lessons learned in the process. The framework was developed and implemented in six stages: (1) project team, (2) scope, (3) dosimetry pilot, (4) staff consultation, (5) finalisation and implementation and (6) future development and evaluation. Both cultural and organisational obstacles needed to be addressed before this framework could be successfully introduced. Even though this slowed progress, addressing these obstacles during the development process was essential to the success of this framework. The incremental approach provided the opportunity for each aspect to be tested and the development of subsequent stages to be informed by lessons learned during the previous one. This approach may be beneficial when developing and implementing projects involving performance appraisal to promote consistency, fairness and quality.

Automated replication of cone beam CT-guided treatments in the Pinnacle(3) treatment planning system for adaptive radiotherapy.

INTRODUCTION: Time-consuming manual methods have been required to register cone-beam computed tomography (CBCT) images with plans in the Pinnacle(3) treatment planning system in order to replicate delivered treatments for adaptive radiotherapy. These methods rely on fiducial marker (FM) placement during CBCT acquisition or the image mid-point to localise the image isocentre. A quality assurance study was conducted to validate an automated CBCT-plan registration method utilising the Digital Imaging and Communications in Medicine (DICOM) Structure Set (RS) and Spatial Registration (RE) files created during online image-guided radiotherapy (IGRT). METHODS: CBCTs of a phantom were acquired with FMs and predetermined setup errors using various online IGRT workflows. The CBCTs, DICOM RS and RE files were imported into Pinnacle(3) plans of the phantom and the resulting automated CBCT-plan registrations were compared to existing manual methods. A clinical protocol for the automated method was subsequently developed and tested retrospectively using CBCTs and plans for six bladder patients. RESULTS: The automated CBCT-plan registration method was successfully applied to thirty-four phantom CBCT images acquired with an online 0 mm action level workflow. Ten CBCTs acquired with other IGRT workflows required manual workarounds. This was addressed during the development and testing of the clinical protocol using twenty-eight patient CBCTs. The automated CBCT-plan registrations were instantaneous, replicating delivered treatments in Pinnacle(3) with errors of ±0.5 mm. These errors were comparable to mid-point-dependant manual registrations but superior to FM-dependant manual registrations. CONCLUSION: The automated CBCT-plan registration method quickly and reliably replicates delivered treatments in Pinnacle(3) for adaptive radiotherapy.

Evaluation of a performance appraisal framework for radiation therapists in planning and simulation.

INTRODUCTION: Constantly evolving technology and techniques within radiation therapy require practitioners to maintain a continuous approach to professional development and training. Systems of performance appraisal and adoption of regular feedback mechanisms are vital to support this development yet frequently lack structure and rely on informal peer support. METHODS: A Radiation Therapy Performance Appraisal Framework (RT-PAF) for radiation therapists in planning and simulation was developed to define expectations of practice and promote a supportive and objective culture of performance and skills appraisal. Evaluation of the framework was conducted via an anonymous online survey tool. Nine peer reviewers and fourteen recipients provided feedback on its effectiveness and the challenges and limitations of the approach. RESULTS: Findings from the evaluation were positive and suggested that both groups gained benefit from and expressed a strong interest in embedding the approach more routinely. Respondents identified common challenges related to the limited ability to implement suggested development strategies; this was strongly associated with time and rostering issues. CONCLUSIONS: This framework successfully defined expectations for practice and provided a fair and objective feedback process that focussed on skills development. It empowered staff to maintain their skills and reach their professional potential. Management support, particularly in regard to provision of protected time was highlighted as critical to the framework's ongoing success. The demonstrated benefits arising in terms of staff satisfaction and development highlight the importance of this commitment to the modern radiation therapy workforce.

Pitch adaptation patterns in bimodal cochlear implant users: over time and after experience.

OBJECTIVES: Pitch plasticity has been observed in Hybrid cochlear implant (CI) users. Does pitch plasticity also occur in bimodal CI users with traditional long-electrode CIs, and is pitch adaptation pattern associated with electrode discrimination or speech recognition performance? The goals of this study were to characterize pitch adaptation patterns in long-electrode CI users, to correlate these patterns with electrode discrimination and speech perception outcomes, and to analyze which subject factors are associated with the different patterns. DESIGN: Electric-to-acoustic pitch matches were obtained in 19 subjects over time from CI activation to at least 12 months after activation, and in a separate group of 18 subjects in a single visit after at least 24 months of CI experience. Audiometric thresholds, electrode discrimination performance, and speech perception scores were also measured. RESULTS: Subjects measured over time had pitch adaptation patterns that fit one of the following categories: (1) "Pitch-adapting," that is, the mismatch between perceived electrode pitch and the corresponding frequency-to-electrode allocations decreased; (2) "Pitch-dropping," that is, the pitches of multiple electrodes dropped and converged to a similar low-pitch; and (3) "Pitch-unchanging," that is, the electrode pitches did not change. Subjects measured after CI experience had a parallel set of adaptation patterns: (1) "Matched-pitch," that is, the electrode pitch was matched to the frequency allocation; (2) "Low-pitch," that is, the pitches of multiple electrodes were all around the lowest frequency allocation; and (3) "Nonmatched-pitch," that is, the pitch patterns were compressed relative to the frequency allocations and did not fit either the matched-pitch or low-pitch categories. Unlike Hybrid CI users which were mostly in the pitch-adapting or matched-pitch category, the majority of bimodal CI users were in the latter two categories, pitch-dropping/low-pitch or pitch-unchanging/nonmatched-pitch. Subjects with pitch-adapting or matched-pitch patterns tended to have better low-frequency thresholds than subjects in the latter categories. Changes in electrode discrimination over time were not associated with changes in pitch differences between electrodes. Reductions in speech perception scores over time showed a weak but nonsignificant association with dropping-pitch patterns. CONCLUSIONS: Bimodal CI users with more residual hearing may have somewhat greater similarity to Hybrid CI users and be more likely to adapt pitch perception to reduce mismatch with the frequencies allocated to the electrodes and the acoustic hearing. In contrast, bimodal CI users with less residual hearing exhibit either no adaptation, or surprisingly, a third pattern in which the pitches of the basal electrodes drop to match the frequency range allocated to the most apical electrode. The lack of association of electrode discrimination changes with pitch changes suggests that electrode discrimination does not depend on perceived pitch differences between electrodes, but rather on some other characteristics such as timbre. In contrast, speech perception may depend more on pitch perception and the ability to distinguish pitch between electrodes, especially since during multielectrode stimulation, cues such as timbre may be less useful for discrimination.

Use of touch imprint cytology as a simple method to enrich tumor cells for molecular analysis.

BACKGROUND: A relative excess of nonneoplastic cells in frozen carcinoma samples is often a cause of false-negative results in molecular assays. Given the greater cohesiveness of epithelial tumor cells compared with nonneoplastic epithelium and mesenchymal stroma, the authors hypothesized that tumor procurement by touch imprinting would provide a simple, cost-effective method of obtaining enriched neoplastic cells compared with frozen whole-tumor samples. METHODS: Eleven adenocarcinomas with known KRAS gene mutations were tested. Two sets of 8 touch imprint (TP) slides and 1 frozen whole-tumor sample (FS), both with a corresponding hematoxylin and eosin-stained slide, were obtained from each tumor. DNA from unstained TP and FS samples was tested for KRAS exon 2 mutations by Sanger sequencing. The percentage of carcinoma cells was determined by light microscopy of hematoxylin and eosin-stained slides. The fold increase in the mutant-enriched DNA in TP versus FS samples was determined by calculating the height ratio between the mutant and wild-type peaks on the sequencing electropherogram. RESULTS: Using light microscopy, TP demonstrated a 1.1-fold to 3.5-fold (mean, 1.8-fold) enrichment in neoplastic cells compared with the FS. The mutant-to-wild-type peak height ratio was 1.4-fold to 7.1-fold (mean, 3.1-fold) higher in TP compared with the corresponding FS samples. The average amount of extracted DNA ranged from 145 ng to 7.9 µg per TP slide. CONCLUSIONS: The procurement of carcinoma samples by TP is rapid, simple, and inexpensive; consistently provides a tumor-enriched sample; is an excellent source of high-quality tumor DNA; and could compensate for the relatively low sensitivity of direct sequencing. Cancer (Cancer Cytopathol) 2013;121:354-360. © 2013 American Cancer Society.