Should Level I trauma centers be rated NC-17?

BACKGROUND: Previous studies have reached contradictory conclusions regarding where injured children are best treated. Our hypothesis was that no differences in survival outcome exist among trauma centers caring for pediatric patients. METHODS: For 16,108 injured children, we created a dependant variable, As-Ps (actual survival--predicted survival), which represents variation from TRISS-predicted outcome for each individual. We then used that variable to compare trauma centers' survival results overall and results for liver, spleen, and head injuries, statistically adjusting for age and injury severity. RESULTS: When adjusted for age and injury severity, centers with added qualifications in pediatrics and Level I centers had improved survival performance overall and in the subcategory of head injured children. No differences existed in other organ-specific injury categories. CONCLUSION: The improved unexpected outcome results at Level I centers and centers with Added Qualifications in Pediatrics suggest that a team of qualified professionals working in an institution willing to commit the required resources can sufficiently offer injured children the survival advantage expected of a trauma center.     

Should residents operate?

Surgical training requires that residents have the opportunity to operate. This tradition has now become complicated for teaching surgeons due to work surcharge, to the objective of reducing health costs, and to medical lawsuits. We support the necessity for residents to operate because academic hospitals have a moral and legal obligation to train future surgeons. This objective should be achieved without impairing the quality of care provided, and this must be explained to patients. More widely, the management of surgical training for residents should be rethought to maintain efficiency.     

Should airguns be banned?

In this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weapons of assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the head and neck, presenting to Alder Hey Children's Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patients who suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not in accordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurred through the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operative procedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients had penetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries with lodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arising from the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation has increased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is required to produce a reduction in the number of airgun-related injuries.     

Should there be an expanded role for kidney biopsy in the management of patients with type I diabetes?

Diabetic nephropathy is the single most important cause of end-stage renal disease (ESRD) in the United States. Further, the increased risk of mortality from type I diabetes is almost entirely confined to patients developing clinical diabetic nephropathy. Nonetheless, kidney biopsy has had little role in the clinical assessment of diabetic patients or in the design of clinical research in diabetic nephropathy. The development of dipstick-positive proteinuria in patients with type I diabetes of more than 10 years' duration is regularly associated with advanced structural changes of diabetic nephropathology; in these patients, clinical parameters, especially the rate of decline of glomerular filtration rate (GFR), are accurate monitors of disease progression. Microalbuminuria indicates a very high risk of overt proteinuria and thus ESRD. This increased risk is associated with levels of urinary albumin excretion (UAE; greater than 30 micrograms/min [45 mg/24 h]), which are frequently accompanied by hypertension and reduced or decreasing GFR. At this stage, lesions of diabetic nephropathy are usually already well established. Thus, microalbuminuria is more a marker of early nephropathy than a predictor of later renal injury. Before these clinical stages of nephropathy, there are no accurate predictors of renal risk. Renal biopsy may serve this role by indicating those patients who are developing significant lesions during the "silent" phase of the disease. In large measure, this value of the biopsy derives from evidence that the lesions tend to develop linearly over time and can be measured by techniques that are relatively easily established in standard surgical pathology environments. Renal biopsies can serve to assure the majority of diabetic patients that they are developing serious lesions slowly, if at all.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.