Should keratoacanthoma be treated surgically?

Keratoacanthoma is a rapidly growing cutaneous neoplasia of adult persons that may regress spontaneously. It is believed to arise from the hair follicles. It is sometimes difficult to distinguish keratoacantoma from squamous cell carcinoma either clinically or histologically. During ten years period (1992-2001) we were treating 18 patients with keratoacanthoma of the skin. We discuss here our experience with this tumor, and we conclude that early, complete excision is the treatment of choice for it.     

Should Dialysate Calcium be Individualized?

The growing interest in a personalized choice of dialysate calcium concentration faces some important unsolved questions. First, the desired aims to be achieved should be clarified, as different d‐Ca concentrations might differentially impact dialysis calcium balance and serum calcium concentration. A second point to be addressed is how to achieve the desired goals; the kinetics of calcium during dialysis treatment are complex. This is not an easy task and probably only an automatic device able to read serum calcium concentration in real‐time and adjust d‐Ca to it might supply an effective method for individualizing d‐Ca. Finally, it is not even clear whether individualizing d‐Ca is worth doing; cost‐effectiveness studies might give some further insights into this intricate issue.     

Should aminoglycoside antibiotics be abandoned?

BACKGROUND: Aminoglycosides can cause nephrotoxicity and ototoxicity. Alternatives are available. METHODS: Surgical service antibiotic use, aminoglycoside toxicity, and perioperative culture/sensitivity results from July 1998 to June 1999 were reviewed. RESULTS: Of 289 positive cultures in 243 patients, 92 cultures (32%) grew 151 Gram-negative rods (GNRs). Aminoglycosides were used in 26 patients and 4 of 26 (15%) suffered nephrotoxicity. Of the 112 GNRs tested against ceftazidime, 111 (99%) were sensitive to it which was significantly better than amikacin (56 of 61, 92%, P = 0.038), gentamicin (116 of 134, 87%, P <0.001), and tobramycin (67 of 81, 83%, P <0.001). The proportion sensitive to cefuroxime (26 of 30, 87%) was equivalent to the proportions sensitive to gentamicin (87%, P = NS) and tobramycin (83%, P = NS). Of the 35 GNRs that were resistant to gentamicin and/or tobramycin, 15 (43%) were Pseudomonas aeruginosa. CONCLUSION: Aminoglycosides produce a significant rate of nephrotoxicity. There are antibiotics with equal or better sensitivity profiles than aminoglycosides against GNRs and Pseudomonas. Aminoglycoside use is rarely, if ever, indicated.     

Should all living donors be treated equally?

Recently, Matas et al. described a protocol to accept as potential donors altruistic strangers who offer to donate a kidney to any patient on the waiting list. The selection of donors would be the same as the process they use for living, emotionally related donors, except that the full work-up would have to be done at their institution and would include a detailed psychosocial evaluation. In this article, we present a case that raised the question of whether the medical standards for nonemotionally related donors should be the same as the standards for emotionally related donors. We argue that we must distinguish between the altruistic donation by a stranger and the voluntary donation by an emotionally related individual. We argue that voluntary donations have a degree of moral obligation based on intimacy and that intimacy allows, but does not require, that these donors take on slightly additional risk.     

Should patients undergoing a bronchoscopy be sedated?

BACKGROUND: The techniques, drugs and depth of sedation for flexible fiberoptic bronchoscopy is controversial, and several reports consider that the routine use of sedation is not a prerequisite. We evaluate whether the addition of sedation with propofol improves patient tolerance, compared to local anesthesic of the airway only. METHODS: Eighteen patients with pneumonia undergoing flexible fiberoptic bronchoscopy were included in a randomized, single blind, prospective controlled study. The non-sedation group received airway topical anesthesia, whereas the sedation group received topical anesthesia and intravenous sedation with propofol. The degree of pain, cough, sensation of asphyxiation, degree of amnesia, global tolerance and acceptance of another bronchoscopy in the future were noted. Changes in blood pressure, heart rate and saturation of oxygen by pulse oximetry were also evaluated. RESULTS: The patients in sedation group had less cough (P < 0.05), pain (P < 0.01) and sensation of asphyxiation (P < 0.001). Global tolerance to the procedure was significantly better in the group under sedation (P < 0.01). These patients had total amnesia to the procedure (P < 0.0001), thus is more probable that will accept another bronchoscopy in the future (P < 0.01). There was a significant rise in heart rate and blood pressure in the patients without sedation. There were no differences in oxygen saturation (P = 0.75). CONCLUSIONS: Our results show that if we administer propofol for sedation, in addition to local anesthesia of the airway, the tolerance to the procedure is much better. Also it appears that sedation with propofol is safe if we carefully select and monitor the patient.