Nephron-Sparing Approach For Familial Bilateral Synchronous Wilms Tumors.

Wilms tumors are the most common renal malignancy of childhood, often presenting as asymptomatic abdominal masses. These tumors can occur either in a unilateral or bilateral fashion, with bilateral tumors more commonly associated with various genetic syndromes and familial inheritance with some known loci. Bilateral tumors present challenges with regards to balancing oncologic control with renal function. Here, we present an unusual case of a young female patient diagnosed with bilateral Wilms tumors on the background of a strong family history and unknown genetic loci.

Cost effectiveness of the quality assurance and performance improvement project for suspected appendicitis study.

INTRODUCTION: Appendicitis is the most common pediatric emergent surgical condition, with 77,000 American pediatric admissions costing $680 million US annually. Diagnosing appendicitis can be challenging. The prospective Quality Assurance and performance improvement project for suspected aPPEndicitis (QAPPE) study implemented a standardized appendicitis assessment pathway. This current study aims to assess the cost-effectiveness of the QAPPE pathway. METHODS: QAPPE data (February 2018-January 2019) were compared to retrospective data from the year prior (January-December 2017). Patients aged <18, presenting with suspicion of appendicitis were identified using the emergency department patient database. Patients were excluded if they were transferred from an outside center or if appendicitis was not suspected. Study arms were compared using Student's t-test and assessed with standard costing techniques. The Incremental Cost-Effectiveness Ratio (ICER) was determined. Deterministic and probabilistic sensitivity analyses of the model were performed. Effectiveness was assessed by percent of negative appendectomies where alternate diagnosis was made intraoperatively or histologically. Significance was set at p < 0.05. RESULTS: QAPPE (n = 247) and traditional care (n = 234) patients were compared. Traditional care had higher admission frequency and lower pediatric appendicitis score. Demographics between all included patients and those admitted were similar overall. Patient costs were $3656.32 (95% CI $2407-$5250) Canadian (CAD) for QAPPE and $3823.56 (95% CI $2604-$5451) CAD for traditional care. QAPPE was the dominant strategy in the base model and probabilistic simulation found it favored in 64.7% of model iterations with a willingness to pay of $70,000 CAD. CONCLUSION: Using the QAPPE pathway to assess patients with suspected appendicitis reduced costs and improved effectiveness of patient care. LEVEL OF EVIDENCE: 2.

Evidence-based thermal care of low birthweight neonates. Part one.

Neonates are at a high risk of temperature loss. Those born at less than 30 weeks' gestation should be placed in a plastic bag or wrapped immediately at birth, drying the head and putting on a hat, while maintaining routine precautions, such as warming the delivery room, pre-warming surfaces and eliminating draughts. Environmental humidity greater than 50 per cent is required, with up to 85 per cent for extreme prematurity, subject to individual assessment. Using regular or, ideally, continuous monitoring, the child's central (core) body temperature should be maintained at 36.7-37.3 degrees C with a core-peripheral difference, if measured, of 0.5-1 degrees C. Stabilised newborns can be transferred from an incubator into an unheated bassinet or open cot at an optimum weight of > 1.6kg, however individual assessment of each neonate is essential before transferring out of the incubator. In the absence of sufficient research, fully evidence-based recommendations cannot be made and individual unit protocols should be followed with careful clinical judgement. In resource-limited settings--in developing countries around the globe, for example--staff should be trained in simple resuscitation techniques, with keeping newborns warm as a key objective.

Evidence-based thermal care of low birthweight neonates. Part two: family-centred care principles.

Parents should be involved in the care of, and decision making for, their newborn, and separations should be minimised. Their needs should be anticipated, respected and catered for in the neonatal unit. Open, clear, consistent information and communication should be maintained. Recommended facilities include accommodation and equipment for expressing breast milk, 24-hour visiting, psychological support services and maximised opportunities for parents to provide positive, gentle touch and skin-to-skin contact with their child during the admission.