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An incident beam of x-rays or protons is moved around the patient in a precise manner so that the beam remains focused on the tumor minimizing the Today, radiation is used internally in the length of time the penetrating radiation beam doesn?t remain treatment of other cancers, and nearly half of on any of the healthy cells for very long. Internal radionuclide therapy can be administered by planting a small radiation source, usually a gamma or beta emitter in the target area(s). They are produced in wire form and are introduced through a catheter to the target area. Neutrons react with the boron to produce alpha particles that destroy the malignant cells in the immediate vicinity of the concentrated boron. Since alpha particles are stopped at a very short distance from their point of origin, intense radiation damage is localized. Boron neutron capture therapy can kill tumors without harming healthy neighboring tissue. The radiation from the radioactive source is delivered from many directions, with the beam continually focused on the target abnormality with only small amounts of radiation passing through healthy tissue. Brachytherapy is a form of internal radio therapy where a radiation source is placed inside or next to the area requiring treatment. These are enclosed in a protective capsule or wire that allows the ionizing radiation to escape. The radiation treats and kills surrounding tissue, but prevents the charge of radioisotopes from moving or dissolving in the body fuids. The capsule may be removed later, or with some isotopes, it may be allowed to remain in place for prolonged treatment. A key feature of brachytherapy is that the radiation affects a localized area around the radiation source. There is no doubt that medical research will fnd more ways to use radiation and radioisotopes to improve our lives. All Health Building Notes are supported by the overarching Health Building Note 00 in which the key the Health Building Note suite areas of design and building are dealt with. Healthcare delivery is constantly changing, and so too are the boundaries between primary, secondary and tertiary Example care. The supplement to Health Building Note 04-01 on isolation facilities is represented as follows: Health Building Note structure ?Health Building Note 04-01: Supplement 1 the Health Building Notes have been organised into a Isolation facilities for infectious patients in acute suite of 17 core subjects. Data is based on guidance given in the Health Building Notes, Health Technical Health Technical Memoranda give comprehensive advice Memoranda and Health Technical Memorandum and guidance on the design, installation and operation of Building Component series. Room data sheets provide an activity-based approach pipeline systems, and ventilation systems). Schedules of equipment/components are included for each room, which may be grouped into ergonomically All Health Building Notes should be read in conjunction arranged assemblies. Note the sequence of numbering within each subject area does not necessarily indicate the order in which the Health Building Notes were or will be published/printed. It covers specific planning and design considerations for 4 It also now includes an on-treatment review suite for chemotherapy and radiotherapy units. It describes spaces both chemotherapy and radiotherapy (two separate that are unique to those units. This provides clinicians with appropriate variations to common hospital spaces and clarifies facilities for reviewing patients at the same time as requirements for these spaces, where necessary. Units operating equipment at higher output levels than this are advised to seek specific advice on Key changes since Health Building Note radiation protection requirements. It has developed (January 2011), setting an aspirational challenge the Macmillan Quality Environment Mark for the National Cancer Programme. See year by 2015, in order to equal the European also: Macmillan Cancer Environments. However, earlier diagnosis is just the ?Functional design issues in Health Building Note beginning of the picture. Guidance applying to generic recurring treatment delivery and technology must also be accommodation such as in-patient accommodation capable of matching these aspirations. This is acceptable, as long as it is the Policy is continually reviewed and updated. Readers decision of the whole group and does not adversely are encouraged to ensure they are accessing the latest affect the care of others. Nor is it acceptable where the main justification is Quality of environment organisational convenience. Oncology out-patient facilities are Health Building Note 15, ?Facilities for pathology assumed to form part of the general out-patients services. These meetings can take place within generic seminar/ meeting rooms provided that there are suitable facilities for teleconferencing, accessing patient 2 3 Overview of treatment 3. The types include the prescribing of anti-emetic drugs, which of chemotherapy used will depend on a number of will require collection from a pharmacy facility factors including where the cancer started (primary) located close by. However, if the drugs have to patient basis) or as an infusion over hours (as a day be issued and there will be a short delay before case), but may be taken orally as a tablet or capsule. Health Service Circular 2008/001 ?Updated national guidance on the safe administration of 4. The process of in cancer treatment where it can be used on its prescribing is complicated and involves the own, with curative or palliative intent, or as part of definition of the target volume as well as a wider treatment of the cancer, which might also determining the radiation dose to be delivered. They are can lead to the cell being unable to reproduce, or to responsible for ensuring the proper commissioning cell death. Healthy cells are generally more able to and calibration of radiation-producing equipment repair this kind of damage than cancerous cells and, and the safe use of radiation, protecting the by splitting radiotherapy treatments into treatment patients, staff and members of the public in fractions, it is possible to take advantage of this compliance with the relevant legislation. They precise fractionation of the radiotherapy is therefore require good knowledge of human anatomy and a crucial part of the prescription. Dosimetrists also check enable the delivery of prescribed radiation doses to radiotherapy plans and help with the development the disease. They operate the receive low radiation doses to avoid long-term, therapy equipment to deliver the radiation dose undesirable side-effects. Radiotherapy treatments and have an important role in providing advice and are always, then, a careful balance of clinical risk counselling for the patient and their family. They are involved in diagnosing and determining the staging of the 5 Health Building Note 02-01 Cancer treatment facilities Teletherapy tumour has moved since the previous treatment, the patient can be repositioned so that the radiation 5. A radiation beam is generated by a machine source of radiation external to the patient 5. In the the patient on the treatment couch at treatment planning process, radiation beams/sources are delivery. A decision can then be made about simulated in order to calculate and assess the whether the patient position should be adjusted. Teletherapy is delivered by large Intensity-modulated radiotherapy is a way of machines (usually linear accelerators) situated improving these abilities by creating radiation fields within shielded facilities with very particular with varying intensities. Radiation beams are produced by accelerating electrons to very high energies and, 5. The linac measures the often required between the dose delivered to critical radiation output in order to deliver precisely organs and that delivered to the target volume. As the radiation beam is dose is more restricted to a short distance from the rotated around the patient, these shutters are used source and can reduce the irradiation of normal to shield parts of the patient, so creating dose tissue. Patients attend as day case patients or are distributions which can be designed to conform admitted as in-patients, depending on the type of tightly to the treatment regions. The doses used for gynaecological, prostate, breast and skin delivered per fraction are significantly larger than a cancers. As an example of a modern development conventional radiotherapy treatment, but the total in breast brachytherapy, a small balloon and biologically effective dose over the course of catheter can be inserted, intra-operatively, into the treatment is generally the same. Suitable tumour targets tend to be very small, and Temporary implants many beams are used to maximise the dose 5. While linacs can be used to perform applicators/catheters within the patient are radiosurgery, other pieces of equipment are connected to the after-loading machine via transfer increasingly being specifically designed for this tubes. Robotic radiosurgery can be performed radioactive source is then mechanically transferred with a linear accelerator attached to a robotic arm. At the the patient is positioned either sitting or lying end of the treatment, the applicators/catheters are down while the arm moves around, exposing the removed from the patient. It makes use of a number of imaging brachytherapy suite, provided that it is suitably techniques to locate the tumour throughout equipped for surgical procedures, including treatment, including respiratory and bone anatomy anaesthesia, and has suitable imaging facilities. It is then retracted and placed 7 Health Building Note 02-01 Cancer treatment facilities into the next applicator. The dose required is Unsealed radioactive sources delivered in a single treatment lasting typically 10 5. Some therapeutic the source is only a tenth of the activity of a high radiopharmaceuticals arrive from the manufacturer dose rate source, and instead of a single treatment ready to use, while others must be prepared in the lasting 10 to 20 minutes, several treatments are hospital radiopharmacy (due to limited stability delivered, each lasting about 10 minutes and after preparation). The prepared on-site, they should be delivered on a patient remains within the brachytherapy suite, shielded trolley. Surgical oncology is undertaken in standard operating theatres, which will usually form part of the main operating theatre suite. Guidance on the design of surgical facilities for in-patients is provided in Health Building Note 26 Volume 1 ?Facilities for surgical procedures. Where this facility is not available, patients will be seen in the main Accident and Emergency department. If a patient becomes unwell on the oncology unit itself, clinical spaces within the on-treatment suites in the 10 8 In-patient care 8. Depending on the scale of the facilities, Critical care facilities designated oncology beds may be provided within 8. This guidance assumes the former, and facilities, the patient pathways should be kept therefore the schedule of accommodation does not separate as far as possible and, depending on local provide an allowance for these facilities. Drugs storage and disposal facilities (Paediatric patients should be treated in age 9. It is not Clinical trials appropriate to deliver cytotoxic drugs by pneumatic tube owing to the risks involved. If the out-patients department is not close by, these services should be delivered from generic rooms in this suite. The design of treatment areas should facilitate easy cleaning and decontamination. The design considerations and space information for a design should also allow for neutron protection to main radiotherapy unit that includes the following be added, if and when required. The schedule of accommodation includes an example Use of radiation for a satellite unit (two bunkers). This requires the consulted and records examined to determine the construction of storage facilities known as ?decay nature of the radioactive materials present. Where the half-life or into the air may also occur routinely in the use is long or such delay cannot be accommodated, of radioactive materials or as a result of accidents. This may result in should only be used where there is no viable radioactive gases being released into the immediate alternative. However, where their use cannot be environment increasing the hazard to workers. Accordingly, for the discharge can be rapidly diluted by enabling a majority of such installations, there are no special drain to join with others of larger flow and decommissioning criteria, and no special capacity, this will minimise radioactive precautions need be taken in respect of concentrations and the associated hazards. This should take place in a play should be consulted as to whether or not special therapy room, close to the treatment area. However, the issue of disposing of large amounts of shielding does have a potential impact. The use of adult using heavy vehicles and disposed of by landfill or facilities is feasible but difficult in both nursing recycling, which involves crushing the material. The giving of such treatments on Some shielding materials, for example Ledite, can the open ward is unlikely to be lawful under the be re-used by simply dismantling and returning to Ionising Radiations Regulations 1999. Early children treated under general anaesthetic or consultation with the project team will be essential sedation. Bespoke engineering devices may be required (for example plastic immobilising shells and supporting 10. However, good access is also required to the general medical physics/clinical engineering 10. The entrance to the room should be wide Reception/waiting area enough to allow access for linear accelerators, large heavy components and subsequent replacement 10. Corner/wall protection against damage patients arriving for treatment on beds and in by equipment, wheelchairs, stretchers, beds etc wheelchairs with or without drip stands/oxygen should be provided, as should crash rails. Radiotherapy treatment suite the effectiveness of shielding in the maze is often 10. These should overlap delivered by large machines (usually linear to stop the direct path of radiation, but should be accelerators) situated within shielded facilities, the offset from each other and positioned in such a requirements for which are described in this way as to allow services to weave through them. It may be possible to establish, through consultation with Radiotherapy treatment rooms (linear accelerators) manufacturers, the extent and critical dimensions 10. This information should be designed treatment rooms (known as bunkers) available to the design team at an early stage in the with very heavy protective radiation shielding built design process to allow the features to be into the construction. The design must also allow full clinical use and setup of all machines, 20 10 Radiotherapy unit 10.

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The tentorium is cut under the microscope behind the trochlear nerve and in front of the vein of Labbe 168 Presigmoid approach | 5 169 5 | Sitting position Supracerebellar infratentorial approach 5 gastritis diet èãðàòü buy rabeprazole 10 mg on-line. Patients with septal defects of the heart gastritis for 6 months cheap rabeprazole 20 mg on line, pracerebellar infratentorial approach; and (b) such as patent foramen ovale chronic gastritis flatulence buy 20mg rabeprazole free shipping, and blood? The advantages of the sitting position tion to avoid spinal cord compression injury gastritis symptoms nhs direct cheap rabeprazole 20 mg. The disadvantages on the During sitting position gastritis diet and yogurt cheap 20mg rabeprazole amex, an even closer co other hand include risks of air embolism gastritis diet ïåðåêëàäà÷ generic rabeprazole 10mg on line, mye operation between the neurosurgeon and the lopathy of the cervical spine, and hypotension. Especially older patients with heart inform the neurosurgeon, who reacts without A 170 Sitting position Supracerebellar infratentorial approach | 5 5. Indications any delay and takes appropriate counteraction the supracerebellar infratentorial approach is measures (Table 5-1). In many institutions the used to reach lesions located at the pineal re sitting position was earlier used regularly but gion and the tectum of the midbrain. We use gradually went out of fashion due to the fear the supracerebellar infratentorial approach of complications. All we can say is that in Hel most often for pineal region lesions, since this sinki the sitting position is being used regularly, approach evades most of the large draining safely and e?ectively in all those cases where veins of the pineal region located superior to we see a true bene? We position, the gravity pulls on the cerebellum, take only simple practical precautions and min which falls down and exposes this region. Utmost vigilance is required when operating on such a pathology near the trans verse sinus and con? Positioning the supracerebellar infratentorial approach Placing the patient in a sitting position is a can be carried out either as a direct midline demanding task and requires an experienced approach or a paramedian approach. There are several key factors that need used the midline approach quite frequently, but always to be remembered (Table 5-1). The ac nowadays we have switched almost exclusively tual practical tricks may vary from department to the paramedian approach. Here we describe in detail how median approach there are several advantages the sitting position is executed in Helsinki. The compared to the classical midline supracere sitting position requires special equipment and bellar approach. In position or forward somersault position, with addition, there is no need to extend the crani the upper torso and the head bent forward and otomy over the sinus con? During surgery, the approach, which decreases the risk of possible operating table is often tilted even further for venous damage and air embolism. The great ward to gain optimal view into the posterior est disadvantage of the paramedian approach fossa along the tentorium. If not, as is usually the case with chil it rises steeply upwards especially close to the dren, then one or several extra cushions need midline. Without this free shoulder zontal providing good viewing angle even to margin, the optimal approach angle from cau the most cranial portions of the posterior fossa. This is less tiring for the neurosurgeon than if the pushes the upper body and shoulders forward. The whole upper body and pelvis to keep the ankles in neutral position and to rests on a large suction mattress. The sitting position is the only shell protecting the whole upper body and pre position where we routinely prefer to use May venting any undesired slipping or sliding. The neurosurgeon the head position varies slightly depending on then holds the head until the position is? The head is rotated One burr hole is placed about 3 cm lateral from 5?10 to the side of the planned approach, the midline over the occipital lobe superior without any lateral tilt. In older patients with tightly attached dura a second With the patient in the proper position, a pre burr hole can be placed inferior to the trans cordial Doppler device is attached over the right verse sinus. The dura is carefully detached with atrium and all the joints of the clamping sys a curved dissector especially along the trans tem are checked once more to make sure that verse sinus. Both cuts start from the burr is paid to peroneal nerve at the lateral aspect hole, they curve sideways and join caudally of the knee which can easily get compressed exposing about 2 cm of the dura below the if the knees fall outward. Skin incision and craniotomy prepared for the use of tack-up sutures at the end of the procedure. A straight skin incision is planned 2?3 cm lat eral from the midline (Figure 5-7b). The incision When detaching the dura and performing the starts about an inch cranial from the external craniotomy, the most critical area is the site of occipital protuberance (the inion) and extends the sinus con? For a right-handed neurosurgeon to preserve it as well as both transverse sinus a right-sided approach is more convenient if es. The medial border of the craniotomy should the target is located in the midline or lateral be left about 10 mm lateral from the midline. The muscles are split in a ver There are usually several venous canals running tical fashion all the way down to the occipital inside the bone close to the sinus con? A curved retractor is used By keeping the craniotomy lateral to this region, to spread the wound from the cranial direc there is much less risk of opening the venous tion. Even with diathermia and the occipital bone is exposed these preventive measures, a sudden decrease (Figure 5-7d). A second curved precordial Doppler device is indicative of an air retractor can be used to get a better exposure embolism. Compression of the jugular veins only about 3?4 cm of bone below the level of by the anesthesiologist is extremely helpful in the transverse sinus, so that the exposure does localizing the bleeding site. While sealing one not have to extend anywhere near the foramen possible bleeding site, the rest of the wound magnum. Me ticulous waxing of the craniotomy edges closes the venous channels inside the bone, which 177 5 | Sitting position Supracerebellar infratentorial approach Figure 5-7 (f). In general, the re or several sutures as sutures do not acciden action to possible air embolism needs always tally slide o like. In midline, there are usually no major bridging our series, we have had no major complications veins obstructing the view. With the situation under bellar vein and draining veins coming from the control, we proceed with the surgery, we do not surface of the cerebellum are typically close to abandon the procedure. In case there is a vein obstructing the approach the dura is usually opened under the microscope towards the pineal region it may be necessary to avoid accidental injuries of the sinuses. The to coagulate and cut it, preferably closer to dura is opened in a V-shaped fashion with the the cerebellum than to the tentorium. Also the remaining dural edges more di?cult to treat if severed accidentally are lifted with sutures placed over the crani later during some of the critical steps of the otomy dressings to prevent both oozing from dissection. It is better to save as many of the the epidural space as well as compression of draining veins as possible to prevent venous in the cortical cerebellar veins (Figure 5-7g). If this sinus is acci bridging veins between the cerebellum and the dentally opened, it does not bleed profusely in tentorium have been coagulated and cut, the the sitting position unlike in the prone position. Exposure of the precentral more carefully than in other positions cerebellar vein, and coagulation and cutting. Utmost care is needed close to venous of this vein if needed, clears the view so that sinuses due to high risk of air embolism the vein of Galen and the anatomy beneath it. Bridging veins should be left intact as part of the operation, and sometimes the thick much as possible adhesions associated with chronic irritation of. Close to pineal region the dissection the arachnoid caused by the tumor makes this should start laterally dissection step very tedious. Perfect hemostasis throughout the of the posterior choroidal artery and the pre procedure, no oozing is allowed central cerebellar vein the orientation towards other anatomic structures becomes easier. Spe cial care is needed not to damage the posterior choroidal arteries during further dissection. All the same rules for direction, and the possibility of adjusting the sitting position and risks apply as for the su view by rotating the table forward even further. The anesthesiologic principles of the prone position requires placing the head well sitting position were reviewed in section 3. Positioning tends more caudally; (d) the transverse sinuses are not exposed, the craniotomy is placed be the positioning is almost identical to that of low their level; and (e) the craniotomy extends the supracerebellar infratentorial approach to both sides of the midline. As with the supracerebellar infratentorial approach, our sitting position is more like a forward somer 5. The only di?erence for the low midline ap this approach provides excellent visualization of proach is that the head is not rotated. With this approach it is ing are carried out in the same way as already possible to enter into the fourth ventricle from described above (see section 5. We usually use the skin incision is placed exactly on the mid this low posterior fossa midline approach to line (Figure 5-8b). It starts just below the level access midline tumors of the fourth ventricle, of the external occipital protuberance and ex vermis and the cisterna magna region, such tends caudally all the way down to the C1?C2 as medulloblastomas, pilocytic astrocytomas, level. It is For lateral lesions in the posterior fossa we pre important to remember that the posterior fossa fer the lateral park bench position. The advan drops steeply towards the foramen magnum, 183 5 | Sitting position Approach to the fourth ventricle and foramen magnum region Figure 5-8 (b). The bone is thicker split with diathermia all the way to the occipi around the foramen magnum and it might be tal bone (Figure 5-8c). One large curved retrac necessary to thin it further down along the tor is placed from cranial and the other from craniotome cut before the bone? Finger pal tachments to the atlanto-occipital ligament, pation is used to identify the level of the fo which often need to be cut with scissors. Dam ramen magnum as well as the spinous process age to the epidural venous plexus is most likely of the C1, which is partially exposed with blunt to happen during this step, so extra caution is dissection using cottonoid balls. With the bone removed we should be ing the muscles and exposing the bone close able to distinguish medial aspects of both cere to the foramen magnum, care is needed not to bellar tonsils as well as the medulla oblongata, accidentally cut into the vertebral artery. The other problem may be the large venous epidural si A high-speed diamond drill or a small rongeur nuses at the foramen magnum. If the posterior is used if needed to remove bone in the lat atlanto-occipital ligament is cut accidentally, eral direction on both sides to expose the fo these veins may start to bleed heavily. Few drill holes are prepared to be used with tack-up sutures At this point the occipital bone should be ex during closure. We do not routinely remove the posed all the way down to the foramen mag spinous process or the lamina of C1 vertebra. One burr hole is placed about 1 cm par In our experience, the total removal of C1 arch amedian to the midline, well below the level does not provide any additional bene? In older ing the exposure of the lower posterior fossa, patients with densely attached dura another but carries signi? It is performed burr hole can be placed on the opposite side only when truly necessary in lesions that ex of the midline. The the dura is opened under the operating micro dura should be released all the way towards scope in X-like fashion. A critical region to re shaped dural leaf is cut from the midline below lease the dura from is next to the burr hole the occipital sinus, everted caudally and at towards and over the midline overlying the oc tached tightly to the muscles with a suture to cipital sinus and the falx cerebelli. All the dural over the midline to the opposite side and then leafs are lifted up with sutures placed over the curves laterally and caudally to the foramen craniotomy dressings. Arachnoid mem cranial edge with a large rongeur, is everted brane of the cisterna magna is often still intact 185 5 | Sitting position Approach to the fourth ventricle and foramen magnum region Figure 5-8 (c). By tilting the table forward, good visualization of the upper parts of the fourth ventricle and even the aqueduct can be obtained. We cases the neuronavigator may be helpful in will not go through indications for surgical planning the approach trajectory. Even if one could reach erate more than 300 patients with intracranial the actual aneurysm with the subtemporal ap aneurysms, more than half of them with rup proach, especially after cutting the tentorium, tured ones. Over the last 20 years the catch the true problem in basilar bifurcation aneu ment area of our department has remained rysms is proximal control. During control one often needs to make much more this time the number of ruptured aneurysms extra work, but it is generally time well spent. The basilar trunk and the vertebrobasi of incidentally found aneurysms, and also the lar junction aneurysms at the middle third of policy for preventive treatment of these lesions the clivus, are the most di?cult to approach. The presigmoid approach is often the only op tion and the clipping of the aneurysms is fur ther hampered by the perforators arising from 6. Those through a paramedian interhemispheric ap closer to the foramen magnum require the lat 195 6 | Aneurysms eral approach with more bone removal. In the majority of cases we midline approach depending on the exact loca can follow a relatively standardized strategy. The selection of microsurgical approach is based on the aneurysm location as described 6. The basic steps in an matous brain and the constant fear of aneu eurysm surgery for unruptured aneurysms are rysm re-rupture. One is not a problem and even the aneurysm can needs to open several cisterns to remove suf be approached more freely. Smaller opening established as soon as possible, and the actual of the arachnoid is often su?cient and less of aneurysm is better left alone before the proxi the surrounding structures need to be exposed. The blood in the Intraoperative rupture can happen even in un subarachnoid space obstructs vision, makes ruptured aneurysms, but this is often caused identi? We prefer to use near the aneurysm dome should be performed temporary clips even in unruptured aneurysms only after proper proximal control has been es as they soften the aneurysm dome and facili tablished. It is often wiser to leave some blood tate safer dissection and clipping of the neck. When operating on a ruptured aneurysm in a patient with multiple aneurysms, we do not perform multiple craniotomies.

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