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Because survival benefits of treatment with radiotherapy are questionable and such treatment can cause substantial damage to the brain over time, the optimum management strategy for low-grade gliomas remains controversial. We aimed to identify the specific effects of radiotherapy on objective and self-reported cognitive function, and on cognitive deterioration over time, in patients with low-grade gliomas treated with early radiotherapy. 195 patients with low-grade glioma (of whom 104 had received radiotherapy 1–22 years previously) were compared with 100 low-grade haematological patients and 195 healthy controls. Our analyses aimed to differentiate between the effects of the tumour (eg, disease duration, lateralisation) and treatment effects (neurosurgery, radiotherapy, antiepileptic drugs) on cognitive function and on relative risk of cognitive disability. Low-grade glioma patients had lower ability in all cognitive domains than did low-grade haematological patients, and did even less well by comparison with healthy controls. Use of radiotherapy was associated with poorer cognitive function; however, cognitive disability in the memory domain was found only in radiotherapy patients who received fraction doses exceeding 2 Gy. Antiepileptic drug use was strongly associated with disability in attentional and executive function. Our findings suggest that the tumour itself has the most deleterious effect on cognitive function and that radiotherapy mainly results in additional long-term cognitive disability when high fraction doses are used. Additionally, the effects of other medical factors, especially antiepileptic drug use, on cognitive function in glioma patients deserve attention.

Although rules support people while executing tasks, they are not the same as work-as-done. It can be impossible to follow the rules and finish the job at the same time. In this study, the objective is to better understand the stakes and interests that lie behind retaining gaps between work-as-prescribed and work-as-done, mapping the benefits and fears of noncompliance. The study was conducted along the vertical hierarchy of an operational flight squadron of the Royal Netherlands Air Force. We applied a qualitative survey research methodology using semi-structured interviews, complemented by an investigation of relevant documents. We found a public and political commitment to compliance made by the Dutch Department of Defence, which reinforces a cycle of issuing promises followed by pressure to keep the promise. This contradicts the found need for adaptation and freedom to use expertise. The official safety narrative seems to convey a hidden message—bad things happen to bad people, reminiscent of a bogeyman. One opportunity to resolve the situation is a doctrine change, changing prescriptive rules to guidelines.

Event-free survival (EFS) at 5 years in pediatric acute lymphoblastic leukemia (ALL) is >80%. Outcome in adult ALL is still unsatisfactory, which is due to less cumulative dosing of chemotherapy and less strict adherence to timing of successive cycles. In the present phase II trial, we evaluated a pediatric regimen in adult patients with ALL under the age of 40. Treatment was according to the pediatric FRALLE approach for high-risk ALL patients and characterized by increased dosages of asparaginase, steroids, methotrexate and vincristin. However, allogeneic stem cell transplantation was offered to standard risk patients with a sibling donor and to all high-risk patients in contrast to the pediatric protocol. Feasibility was defined by achieving complete remission (CR) and completion of treatment within a strict timeframe in at least 60% of patients. In all, 54 patients were included with a median age of 26. CR was achieved in 49 patients (91%), of whom 33 completed treatment as scheduled (61%). Side effects primarily consisted of infections and occurred in 40% of patients. With a median follow-up of 32 months, EFS estimated 66% at 24 months and overall survival 72%. These data show that a dose-intensive pediatric regimen is feasible in adult ALL patients up to the age of 40.

Deference to operational or engineering expertise is considered critical for maintaining safety in many industries. At the same time, legitimating specialized knowledge can help create “prima donnas,” expert operators who attain considerable organizational status and informal power. Safety can be used as a lever to gain industrial advantage or maintain inequitable perquisites. This paper first considers the common consensus about the need to defer to expertise in safety–critical organizations and industries and assesses available research on the relationship between deference to expertise and safety. Then, it reviews two psychological literatures that illuminate some of the cognitions, behaviors and organizational dynamics behind a prima donna syndrome: one on entitlement and another on organizational narcissism. Conclusions and recommendations center on how to defer to expertise (not necessarily experts) while dealing with “prima donnas.”

In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as new best practices. An explanation for this phenomenon was found in the fact that the military organisation was applying a top-down, classical, rational approach to rules. In contrast, the routines were generated by adopting a constructivist view of rules as dynamic, local, situated constructions with operators as experts. The results of this study suggest that organisations are more effective in solving goal conflicts and creating transparency on local ingenuity if they adopt a constructivist paradigm instead of, or together with, a classical paradigm.

Donor lymphocyte infusions (DLI) are used to treat relapsed haematological diseases after allogeneic stem cell transplantation (SCT). We treated seven patients with DLI for indolent non-Hodgkin's lymphoma relapsed after SCT. In available blood and bone marrow samples, lymphoma cells were analysed by real-time quantitative polymerase chain reaction of t(14;18)-positive cells in follicular lymphoma, and by immunophenotyping in small lymphocytic lymphoma. Before DLI, three patients were treated with chemo- and/or radiotherapy, and one with rituximab. Evaluable responses to pre-DLI therapy were stable disease in one and partial remission (PR) in two patients. Six patients responded to DLI (complete remission (CR) in four and PR in two). After DLI, acute graft-versus-host disease (GVHD) occurred in 3/6 patients, classified as grade 2, whereas only limited chronic GVHD was seen (n=5). The four continuous CR are lasting for median 65+ (43-89) months. In the remaining patient, not responding to DLI, progressive disease was seen later on; chemotherapy followed by another DLI resulted in CR. In three cases, clinical responses to DLI could be substantiated by molecular or immunophenotypic analysis of lymphoma cells. We conclude that DLI is effective for treatment of indolent lymphoma relapsing after SCT.

Saying that our constructs are more operational than representational is an ethical cop-out. Researchers and lay people alike use constructs such as complacency and situation awareness as reflective of an empirical reality. Instances of “loss of situation awareness” are counted by researchers and given causal status. Practitioners now get accused of “losing situation awareness” in investigations, court cases and inquests. As a human factors community, we cannot walk away from our responsibility for helping create that possibility.

A just culture is meant to balance learning from incidents with accountability for their consequences. All the current proposals for just cultures argue for a clear line between acceptable and unacceptable behavior. This alone, however, cannot promote just culture as it falsely assumes that culpability inheres in the act, bearing immutable features independent of context, language or interpretation. The critical question is not where to draw the line, but who gets to draw it. Culpability is socially constructed: the result of deploying one language to describe an incident, and of enacting particular post-conditions. Different accounts of the same incident are always possible (e.g. educational, organizational, political). They generate different repertoires of countermeasures and can be more constructive for safety. The issue is not to exonerate individual practitioners but rather what kind of accountability promotes justice and safety: backward-looking and retributive, or forward-looking and change-oriented.