Standardization of post-operative antimicrobials reduced exposure while maintaining good outcomes in pediatric liver transplant recipients.

Infections following orthotopic liver transplant (OLT) result in significant morbidity and mortality, warranting careful consideration of risks associated with antibiotic overuse and benefits of infection prevention. In the absence of specific guidelines for antimicrobial prophylaxis in pediatric OLT, we developed a standardized approach to post-operative (post-op) antimicrobial therapy including 48 hours of antibiotics, no vancomycin for post-op fever within the first 48 hours, and caspofungin only for certain situations. The goal was to reduce antimicrobial utilization and adverse outcomes associated with longer duration of and broader treatment while maintaining good outcomes. The impact of this standardization on antimicrobial utilization and clinical outcomes at the largest pediatric liver transplant center in the United States is described. All individuals receiving an OLT from 1/1/17-9/30/17 (N = 38) and 3/14/18-12/13/18 (N = 27) were included in the pre-intervention (PreI) and post-intervention (PostI) groups, respectively. The intervention resulted in a significant reduction in individuals receiving post-op broad-spectrum gram-negative antibiotics for >48 hours (76% PreI vs 44% PostI OLT recipients, P = .01) and post-op vancomycin use (50% PreI, vs 7.4% PostI, P < .001). There were no statistically significant differences between groups for post-op fever, positive pre-/post-operative cultures, receipt of massive transfusion, or hospital length of stay. In conclusion, following the implementation of a standardized approach to post-op prophylaxis, antimicrobial exposure was significantly reduced without affecting OLT recipient outcomes.

Predictors of survival of advanced renal cell carcinoma: long-term results from Southwest Oncology Group Trial S8949.

PURPOSE: S8949 demonstrated improved overall survival for debulking nephrectomy in interferon treated patients with advanced renal cell carcinoma. We present an updated analysis of S8949, now with a median followup of 9 years. We explored clinical predictors of overall survival. MATERIALS AND METHODS: Univariate and multivariate Cox regression analysis was performed to evaluate the impact of clinical variables potentially influencing survival. RESULTS: Of 246 patients 241 were eligible and randomized to interferon with or without nephrectomy. Patients randomized to nephrectomy continued to have improved overall survival (HR 0.74, 95% CI 0.57-0.96, p = 0.022). Multivariate analysis showed that performance status 1 vs 0 (HR 1.95, p <0.0001), high alkaline phosphatase (HR 1.5, p = 0.002) and lung metastasis only (HR 0.73, p = 0.028) were overall survival predictors. There was no evidence of an interaction of performance status, measurable disease or lung metastases with nephrectomy (each p >0.30). In a patient subset that survived at least 90 days after randomization early progressive disease within 90 days was prognostic of overall survival in a multivariate model (HR 2.1, p <0.0001), as was performance status (HR 1.7, p = 0.0006). CONCLUSIONS: Nephrectomy prolonged long-term overall survival in this updated analysis, supporting its role as standard therapy in patients with advanced renal cell carcinoma. A nephrectomy benefit was seen across all prespecified patient subsets. Early progressive disease and performance status were strong predictors of overall survival. These results support efforts to identify biomarkers of renal cell carcinoma resistance to treatment and early progressive disease to facilitate rational patient selection for systemic therapy.

End-of-life planning with frail patients attending general practice: an exploratory prospective cross-sectional study.

BACKGROUND: End-of-life planning means decision making with patients, formulating and recording decisions regarding their end-of-life care. Although clearly linked with benefits including improved quality of life, reduced hospital admissions, and less aggressive medical care, it is still infrequently undertaken and is regarded as challenging by healthcare professionals. AIM: To ascertain the feasibility of improving the identification of patients at high risk of dying in general practice and the acceptability of providing patients identified with an end-of-life planning tool. DESIGN AND SETTING: Exploratory prospective cross-sectional study in four general practices. METHOD: Patients at high risk of dying were identified during routine consulting by their GP, using the Supportive and Palliative Care Indicators Tool (SPICT). Patients identified were invited to participate, and provided with Think Ahead - an end-of-life planning tool, which has been used previously in general practice. Participants completed telephone surveys, assessing their response to Think Ahead, and the acceptability of the GP raising end-of-life issues during routine consulting. RESULTS: Provision of Think Ahead to a purposive sample of preterminal patients identified by GPs was feasible, acceptable to most patients, and somewhat effective in increasing discussion among families and in practice on end-of-life planning. CONCLUSION: The SPICT and Think Ahead tools were mostly acceptable, effective, and enabling of discussions on end-of-life care in general practice.

Percutaneous central access in patients younger than 5 years: size does matter.

PURPOSE: The purpose of this study was to determine, in a pediatric population less than 5 years of age, which size catheter is ideal for central venous access via the subclavian and internal jugular vein based on the children's age, weight, and height. METHODS: This was a retrospective chart review of children less than 5 years of age at The Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, height, weight, primary disease, access site, type of central venous catheter, size of central venous catheter, and complications were recorded. Age, weight, and height were stratified and compared with catheter size to determine any correlation between age, weight, height, and complications. RESULTS: There were 430 central venous catheters placed via the subclavian or internal jugular vein in 331 patients less than 5 years old. One hundred ninety-five catheters (45.4%) were less than 6F in size, and 235 (54.6%) catheters were > or =6F in size. Children, who were between 0.5 and 0.99 years old, 5 to 7.49 kg in weight, 7.5 to 9.99 kg in weight, and 60 to 74.9 cm in height had higher complication rates (P <.05) when catheters > or =6F were inserted. Children who were greater than 1 year of age, greater than 10 kg in weight, and longer than 75 cm in height did not experience a significant difference (P >.05) in complications versus catheter size. CONCLUSIONS: The choice of central venous catheter size should be predicated, not only on the primary disease, but also on the child's age, weight, and height. Insertion of central venous catheters larger than 6F in children less than 1 year of age, less than 10 kg in weight, or less than 75 cm in height, was associated with higher complications compared with other settings.

Gastrostomy revision: incidence and indications.

BACKGROUND/PURPOSE: Although quite reliable, gastrostomy may require revision. However, there are no reports in the literature specifically delineating identifiable risk factors or circumstances that lead to gastrostomy revision in children with gastrostomy. The purpose of this report was to determine the rate of revision and correlate any factors that may lead to revision. METHODS: A retrospective chart review was performed on 1,042 children who underwent gastrostomy at The Children's Hospital, Denver, Colorado, between 1992 and 2002. Charts of children who underwent gastrostomy were reviewed for pertinent clinical factors and compared with those who required gastrostomy revision. RESULTS: Of the 1,042 children, who had gastrostomies, 67 revisions were required in 61 children (6%). Of the many possible factors that could have had an influence on the revision rate, only fundoplication, percutaneous endoscopic gastrostomy (PEG), migration of the gastrostomy site, and time correlated with the need for gastrostomy revision. CONCLUSIONS: Parents should be made aware that there is a 6% chance that their child's gastrostomy may need revision and that the need for revision may increase with PEG, initial construction before 18 months of age, and the advancing age of the gastrostomy. Surgeons should avoid placing the gastrostomy near the costal margin, making a large gastrostomy exit tract through the abdominal wall and inserting a gastrostomy into the nutritionally depleted pulmonary stressed neurologically challenged child without first attempting to improve the child's nutritional status.