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 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 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 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.     

Immunosuppression minimization protocols: how should they be monitored?

This Practice Point commentary discusses the experience of Shapiro et al. with renal allograft recipients at a single center who underwent significant minimization of immunosuppressive treatment with alemtuzumab induction and tacrolimus monotherapy (weaned to three times weekly by 1 year after transplantation). Donor-specific antibodies (DSAs) against human leukocyte antigen were monitored after transplantation in some patients. Although 44% of patients did not develop acute rejection or DSAs and had excellent 2-year graft survival (96%), spaced weaning was not attempted in 20% of patients, generally those with early rejection and poor allograft function. During tapering, 20% of patients developed acute rejection and 15% developed DSAs. Two-year graft survival was 63% in patients for whom weaning was not attempted and 78% in patients who experienced acute rejection. Alemtuzumab preconditioning with tacrolimus monotherapy and spaced weaning increased the risk of acute rejection and development of DSAs. Patients should be carefully selected for this protocol and monitored closely for DSAs. Results of a long-term controlled trial that includes protocol biopsies are required to reach more-definitive conclusions.