A National Referral Service for Paediatric Brachytherapy: An Evolving Practice and Outcomes Over 13 Years.

AIMS: Most children requiring radiotherapy receive external beam treatment and few have tumours suitable for brachytherapy. No paediatric radiotherapy centre will treat enough patients from its own normal catchment population for expertise in brachytherapy to be developed and sustained. Following discussion and agreement in the national paediatric radiotherapy group, a service for paediatric brachytherapy in the UK has been developed. We report the process that has evolved over more than 10 years, with survival and functional outcome results. MATERIALS AND METHODS: Since 2009, potential patients have been referred to the central paediatric oncology multidisciplinary team meeting, where imaging, pathology and treatment options are discussed. Since 2013, the National Soft Tissue Sarcoma Advisory Panel has also reviewed most patients, with the principal aim of advising on the most suitable primary tumour management for complex patients. Clinical assessment and examination under anaesthetic with biopsies may be undertaken to confirm the appropriateness of brachytherapy, either alone or following conservative surgery. Fractionated high dose rate brachytherapy was delivered to a computed tomography planned volume after implantation of catheters under ultrasound imaging guidance. Since 2019, follow-up has been in a dedicated multidisciplinary clinic. RESULTS: From 2009 to 2021 inclusive, 35 patients (16 female, 19 male, aged 8 months to 17 years 6 months) have been treated. Histology was soft-tissue sarcoma in 33 patients and carcinoma in two. The treated site was pelvic in 31 patients and head and neck in four. With a median follow-up of 5 years, the local control and overall survival rates are 100%. Complications have been few, and functional outcome is good. CONCLUSION: Brachytherapy is effective for selected paediatric patients, resulting in excellent tumour control and good functional results. It is feasible to deliver paediatric brachytherapy at a single centre within a national referral service.

Caring for a patient with rabies: implications of the Milwaukee protocol for infection control and public health measures.

This article discusses the infection control and public health measures taken whilst managing a case of laboratory-confirmed rabies, and the challenges faced in implementing these measures. Case management requires intensive multi-disciplinary co-ordination. The Milwaukee protocol, which to date has five reported human rabies survivors associated with its use, has been suggested as a potential management pathway for human rabies. Consensus among hospital and public health clinicians would aid future deployment of this approach in selected cases.

Are changes in the evoked electromyogram during anaesthesia without neuromuscular blocking agents caused by failure of supramaximal nerve stimulation?

The evoked electromyogram often decreases during anaesthesia in the absence of neuromuscular block. We have measured the electromyogram of the first dorsal interosseous muscle evoked by train-of-four stimulation of the ulnar nerve in 63 patients undergoing anaesthesia for minor surgery. We used Medicotest P-00-S electrodes, a Datex Relaxograph and a current sink in the stimulating leads in parallel with the current path through the patient. The current sink was used to shunt some of the maximum available output current from the Relaxograph while maintaining the supramaximal stimulus current passing through the patient. After 30 min of anaesthesia, when the muscle response to train-of-four was stable, the ulnar nerve stimulus current was increased by reducing the proportion shunted through the current sink. The electromyographic response did not change during the study in 13 patients. In the remaining 50 patients, the response decreased to 78.4% (SD 27.1%, range 7.5-95.0%) of baseline values over the first 20 min of anaesthesia. In 22 of these patients, the electromyographic response increased from 71.4 (SD 22.6)% to 92.3 (9.5)% of baseline responses when the stimulus current was increased by 12.3 (2.4) mA, while in the remaining 28 patients the response decreased to 83.7 (10.6)% and did not increase with increasing stimulus current. These results suggest that loss of supramaximal stimulation is partly responsible for the observed changes in the evoked electromyogram during anaesthesia.