Development of a postoperative care pathway for children with renal tumors

PURPOSE

To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery.

STUDY DESIGN

This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4).

RESULTS

A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0-7) and regular diet on a median postoperative day 3 (range 1-8). Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table).

DISCUSSION

Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy.

CONCLUSIONS

For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients.

Differences in vitamin D nutritional status between newly diagnosed cancer patients from rural or urban settings in Kentucky

Although poor nutritional status and weight loss in cancer patients is known to affect outcomes, little is known about malnutrition differences based on geographic location. We investigated nutritional and inflammatory status of 220 newly diagnosed adults with solid tumors at the University of Kentucky's Markey Cancer Center during December 2008 through October 2011. Chi-square tests were used to determine any associations between suboptimal nutritional levels and rural-urban areas of residence. Out of the 13 lab values collected, the only significant difference between rural and urban participants was found for vitamin D resulting in more rural subjects (67.4%) having a suboptimal vitamin D status as compared to those residing in urban areas (53.3%, P = 0.04). Controlling for baseline demographics including age, race, sex, body mass index, nutritional status, and type of cancer, logistic regression analyses concluded those in rural areas had nearly a twofold increase in the odds of having a suboptimal vitamin D level compared to those in urban areas (odd's ratio = 1.97; 95% confidence interval = 1.04, 3.74). Further investigation into the rural-urban differences in vitamin D needs to be investigated in order to improve outcomes during cancer treatment.

Effects of barotrauma and mitigation methods on released Australian bass Macquaria novemaculeata

The effects of barotrauma on the short-term mortality and physical condition of Australian bass Macquaria novemaculeata were investigated after being: (1) conventionally angled and released during two tournaments in deep impoundments and (2) released untreated or subjected to venting or recompression during a manipulative experiment. All fish were released into two 20 m deep bathy-cages and monitored for 3 days. Of 238 M. novemaculeata angled during the tournaments, 43 (18·1%) had clinical signs of barotrauma or were vented and five of these later died (11·6% mortality). Catch histories varied significantly between both barotrauma and non-barotrauma fish and tournaments, but only hook ingestion significantly influenced mortality (P < 0·05). During the manipulative experiment, venting significantly influenced mortality (13·3%) compared to no treatment or recompression (no deaths). Magnetic resonance images and dissections of barotrauma fish indicated large variation among clinical signs. On the basis of these results, wherever possible M. novemaculeata suffering barotrauma should be immediately released with no treatment. Fish that are unable to resubmerge should be recompressed, while those held in live wells and released in shallow water should be vented.

Spontaneous intraperitoneal rupture of a kidney in a patient with tuberous sclerosis

A case is reported of spontaneous intraperitoneal rupture of a kidney in a patient with tuberous sclerosis who presented with left renal colic and left lower quadrant abdominal pain.

Physical therapist assistant in a California home health agency

A perpetual shortage of physical therapists qualified to provide home health care exists in Southern California. This paper presents one solution to the problem: the employment of a physical therapist assistant. The preparation, implementation, and evaluation of a program for employing a physical therapist assistant in a home health agency is presented and discussed. The use of the assistant increased the availability of physical therapy, and quality was not adversely affected. The assistant was accepted by staff and derived job satisfaction. We concluded that this assistant was a valuable adjunct to the home health team. Subsequently, The Visiting Nurse Association of Los Angeles employed two additional assistants in 1980.