Kendra Harris

Tic Disorders: Neural Circuits, Neurochemistry, and Neuroimmunology

The neuroanatomy and neurochemistry underlying tic disorders are thought to involve corticostriatothalamocortical circuits and dysregulation of their component neurotransmitter systems. Tourette syndrome is a tic disorder that begins in childhood and follows a waxing and waning course of tic severity. Although it is generally believed to have a genetic component, its etiology has not been fully elucidated. The clinical entity pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) has led some to suggest that the pathophysiology of tics in some individuals might involve a postinfectious autoimmune component. We review the neural circuits and neurochemistry of Tourette syndrome and evaluate the evidence for and against a role for autoimmunity in the expression of tics. (J Child Neurol 2006;21:678—689; DOI 10.2310/7010.2006.00166).

Nonautistic Motor Stereotypies: Clinical Features and Longitudinal Follow-Up

To characterize further the clinical features and long-term outcomes among children with motor stereotypies who do not manifest mental retardation or pervasive developmental disorders, a review of clinical records and semistructured telephone interviews were undertaken. The identified clinical cohort consisted of 100 typically developing children with motor stereotypies. The mean length of follow-up was 6.8 +/- 4.6 years. At most recent follow-up, movements had continued in 94% of the sample (62% for >5 years). Only six children reported complete cessation of movements, with four (3 of 4 with head nodding) doing so >1 year after their initial diagnosis. Thus the course of motor stereotypies, especially in children with arm/hand movements, appears chronic. Nearly half the children in this cohort exhibit other comorbidities, including attention-deficit-hyperactivity disorder (30%), tics (18%), and obsessive-compulsive behaviors/obsessive-compulsive disorder (10%). Twenty-five percent of children with motor stereotypies reported positive family histories of motor stereotypies, suggesting an underlying genetic abnormality. Finally, evidence is emerging that the clinical course of children who exhibit head nodding may differ from those whose motor stereotypy predominantly involves the hands and arms.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

PURPOSE Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). METHODS AND MATERIALS All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. RESULTS Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. CONCLUSIONS A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.

Physician Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting

PURPOSE Incident learning systems are important tools to improve patient safety in radiation oncology, but physician participation in these systems is poor. To understand reporting practices and attitudes, a survey was sent to staff members of four large academic radiation oncology centers, all of which have in-house reporting systems. METHODS Institutional review board approval was obtained to send a survey to employees including physicians, dosimetrists, nurses, physicists, and radiation therapists. The survey evaluated barriers to reporting, perceptions of errors, and reporting practices. The responses of physicians were compared with those of other professional groups. RESULTS There were 274 respondents to the survey, with a response rate of 81.3%. Physicians and other staff agreed that errors and near-misses were happening in their clinics (93.8% v 88.7%, respectively) and that they have a responsibility to report (97% overall). Physicians were significantly less likely to report minor near-misses (P = .001) and minor errors (P = .024) than other groups. Physicians were significantly more concerned about getting colleagues in trouble (P = .015), liability (P = .009), effect on departmental reputation (P = .006), and embarrassment (P < .001) than their colleagues. Regression analysis identified embarrassment among physicians as a critical barrier. If not embarrassed, participants were 2.5 and 4.5 times more likely to report minor errors and major near-miss events, respectively. CONCLUSIONS All members of the radiation oncology team observe errors and near-misses. Physicians, however, are significantly less likely to report events than other colleagues. There are important, specific barriers to physician reporting that need to be addressed to encourage reporting and create a fair culture around reporting.

56 – Circuits to Synapses: The Pathophysiology of Tourette Syndrome

Tourette syndrome (TS) is a childhood-onset neuropsychiatrical disorder characterized by chronic motor and vocal tics that are frequently accompanied by coexisting problems such as obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). The precise underlying pathophysiological mechanism(s) for tics is unknown. This chapter provides an overview of clinical issues pertaining to tic disorders and discusses the pathobiology of TS. Neuroanatomical and neurophysiological studies suggest an abnormality involving cortico-striatal-thalamo-cortical (CSTC) circuits, but the site of primary dysfunction is controversial. A growing body of evidence indicates that an abnormality in CSTC circuits and their neurotransmitter systems are likely to be associated with tics and coexisting problems in TS. Neurochemically, evidence continues to support involvement of the dopaminergic system, but other neurotransmitters within CSTC circuits may also be involved. Although assigning a role to the immune system in the etiology of TS remains an intriguing hypothesis, convincing evidence supporting an immune-mediated process is not available.

WE‐C‐214‐05: A Quantification of the Effectiveness of Standard QA Measures at Preventing Errors in Radiation Therapy and the Promise of in Vivo EPID‐Based Portal Dosimetry

Purpose: We analyze the ability of standard quality assurance (QA) checks in radiation therapy to prevent errors commonly observed in the course of clinical operations. Methods and Materials: Near‐miss and error reports were collected over a 3‐year period by means of voluntary reporting systems at two academic medical centers. We analyzed 250 near‐misses, events that did not affect patients but which had the potential to do harm with at least “moderate side effects” (level 3 or greater on the French ASN scale) if they had not been detected prior to treatment. We determined which of these events could be detected by 13 commonly employed QA measures, including but not limited to physician plan review, physics chart check, port films, cone‐beam CT. We then determined which events could have been detected by in vivo portal dosimetry with an electronic portal imaging device(EPID). Results: QA checks vary greatly in their ability to detect reported errors. Port films, one of the most effective measures in place, had a 53% detection efficiency, while pre‐treatment IMRT QA had a detection efficiency close to 0%. EPID‐dosimetry had a detection rate of 83%. In some cases, EPID‐dosimetry would have detected errors which were introduced after the initial IMRT QA. Conclusions: No single QA check currently employed is 100% effective at detecting common errors. Most checks currently in use are less than 50% effective. By contrast, the data indicate that in vivo EPID‐dosimetry may be substantially more effective. Further work is needed to determine if these patterns hold across multiple institutions. Pilot research grant from Elekta Inc.