The UK Experience of a Treatment Strategy for Pediatric Metastatic Medulloblastoma Comprising Intensive Induction Chemotherapy, Hyperfractionated Accelerated Radiotherapy and Response Directed High Dose Myeloablative Chemotherapy or Maintenance Chemotherapy (Milan Strategy).

BACKGROUND: Historically, the 5-year overall survival (OS) for metastatic medulloblastoma (MMB) was less than 40%. The strategy of post-operative induction chemotherapy (IC) followed by hyperfractionated accelerated radiotherapy (HART) and response directed high dose chemotherapy (HDC) was reported in a single center study to improve 5-year OS to 73%. We report outcomes of this strategy in UK. METHODS: Questionnaires were sent to all 20 UK pediatric oncology primary treatment centers to collect retrospective data on delivered treatment, toxicity and survival with this strategy in children aged 3-19 years with MMB. RESULTS: Between February 2009 and October 2011, 34 patients fulfilled the entry criteria of the original study. The median age was 7 years (range 3-15). Median interval from surgery to HART was 109 versus 85 days in the original series. The incidence of grade 3 or 4 hematological toxicities with IC and HDC was 83-100%. All 16 patients who achieved complete response by the end of the regimen remain in remission but only three of 18 patients with lesser responses are still alive (P < 0.0001). With a median follow-up of 45 months for survivors, the estimated 3-year OS is 56% (95% CI 38, 71). This result is outside the 95% CI of the original study results and encompasses the historical survival result of 40%. CONCLUSION: Within the limits of statistical significance, we did not replicate the improved survival results reported in the original series. The reasons include differences in patient sub-groups and protocol administration. International randomized phase III studies are needed.

Non-irradiated female survivors of childhood acute lymphoblastic leukaemia are at risk of long-term increases in weight and body mass index.

We report long-term, including final height, auxological data from our retrospective study of non-irradiated survivors of childhood acute lymphoblastic leukaemia (ALL). Body mass index (BMI) standard deviation score (SDS) increases in females, due to increased weight-SDS, persisted to final height, with probable adverse long-term health outcomes. In contrast, males demonstrated increased BMI-SDS in follow-up, due to reduced height-SDS, not increased weight-SDS, but such changes had resolved by final height. Childhood ALL survivors, particularly females, are therefore at potential increased risk of developing the metabolic syndrome during follow-up. We recommend that strategies to minimize weight gain should be implemented during ALL treatment.

Paediatric short stay unit in a community hospital: effective, efficient and popular.

OBJECTIVES: Short stay medicine is a cost-effective and efficient way to manage patients with suitable conditions. Paediatric acute illness and injury are amenable to short stay medicine. Before January 2004, when Maroondah Hospital recommenced inpatient care for children, 700 children were transferred annually to other hospitals. We describe the implementation and performance of the first paediatric short stay unit (SSU) in Victoria, which was designed to remedy this situation. METHODS: Set in a 291-bed metropolitan hospital, we audited paediatric emergency attendances, admissions, transfers and discharges. We present quality and consumer satisfaction data. RESULTS: The environment was designed for the physical, developmental and social needs of children. We implemented education, a system of exclusion criteria and pathways to enhance safety. Over 12 months, of 9097 paediatric attendances, 1101 required inpatient care. Among them, 862 patients were admitted to the SSU and 239 were transferred. Accordingly, 78% of admitted patients were cared for in-house. Median length of stay was 20 h. Of the 708 reviewed cases, there were 19 (3%) unexpected transfers from the SSU, 59 (8%) long stays (>48 h) and no deaths. Via a telephone survey, there were 30/355 (8%) unplanned representations and satisfaction data were overwhelmingly positive. We suggest that this model is suitable for centres with limited paediatric cover. In-house senior emergency physician cover might be preferable to an after-hours junior staff-only model. CONCLUSION: A co-located paediatric SSU within an ED is an efficient, popular and viable alternative for paediatric services to be delivered in a suburban setting.