Con Debate Research Articles

Open vs Closed Intensive Care Unit: Pro–Con Debate

Open vs Closed Intensive Care Unit: Pro–Con Debate

ERS International Congress 2023: highlights from the Thoracic Surgery and Lung Transplantation Assembly.

Five sessions presented at the European Respiratory Society Congress 2023 were selected by Assembly 8, consisting of thoracic surgeons and lung transplant professionals. Highlights covering management of adult spontaneous pneumothorax, malignant pleural effusion, infectious and immune-mediated complications after lung transplantation, as well as the pro and con debate on age limit in lung transplantation and results of the ScanCLAD study were summarised by early career members, supervised by the assembly faculty.

Should opioids be used for breathlessness and in whom? A PRO and CON debate of the evidence.

Purpose of review The net clinical benefit of opioids for chronic breathlessness has been challenged by recent randomized clinical trials. The purpose was to review and weigh the evidence for and against opioid treatment for chronic breathlessness in people with serious disease. Recent findings Evidence to date on the efficacy and safety of opioids for chronic breathlessness was reviewed. Findings supporting a benefit from opioids in meta-analyses of earlier, mostly smaller trials were not confirmed by recent larger trials. Evidence pertains mostly to people with chronic obstructive pulmonary disease but also to people with pulmonary fibrosis, heart failure, and advanced cancer. Taken together, there is no consistent evidence to generally recommend opioids for severe breathlessness or to identify people who are more likely to benefit. Opioid treatment may be tested in patients with intractable breathlessness and limited other treatment options, such as in end-of-life care. Knowledge gaps were identified and recommendations were made for future research. Summary Opioids cannot be generally recommended for treating breathlessness based on insufficient evidence for net clinical benefit.

Oxygen Targets in Critical Illness: Commentary on the Pro–Con Debate

Oxygen Targets in Critical Illness: Commentary on the Pro–Con Debate

Allergy evaluation of messenger RNA vaccine reactions is crucial, with a specific role for polyethylene glycol testing

Allergy evaluation of messenger RNA vaccine reactions is crucial, with a specific role for polyethylene glycol testing

Global Surgery Pro–Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Global Surgery Pro–Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Con-debate: short circulatory arrest times in arch reconstructive surgery: is simple retrograde cerebral perfusion or hypothermic circulatory arrest as good or better than complex antegrade cerebral perfusion for open distal involvement or hemi-arch?

Con-debate: short circulatory arrest times in arch reconstructive surgery: is simple retrograde cerebral perfusion or hypothermic circulatory arrest as good or better than complex antegrade cerebral perfusion for open distal involvement or hemi-arch?

Mandatory Folic Acid Food Fortification to Prevent Neural Tube Defects: The Pro or Con Debate

Neural tube defects are the second most common congenital anomaly. Among the known risk factors, low levels of folic acid rank first as responsible for the majority of cases recorded worldwide. In 1986, the mandatory folic acid food fortification in the U.S.A. led to dramatic reduction of disease incidence, while for many people it was considered as one of the most successful interventions in the history of public health promotion. Despite the satisfactory results from all countries that adopted similar policies, a significant number of countries, including the EU, preferred alternative ways to address it, considering the very limited safety data for such an intervention. Today, after 20 years of mandatory fortification from a sufficiently representative sample (1/3 of the planet), the necessity to apply this at global level should probably be reviewed, since until now no correlation with unfavourable impacts has been demonstrated. Objective of the present review was to assess the necessity of mandatory folic acid food fortification in the context of congenital neural tube defects (NTDs) prevention. Material – Method : an extensive search in the electronic database PubMed was performed. Animal or in vivo studies and articles were excluded, due to the inability to draw conclusions that is frequently observed, as well as the strong suspicion of failure to respond to clinical data. Furthermore, part of the studies was derived from searches to the References of the articles of the aforementioned database. Conclusions : the decision of mandatory folic acid food fortification should be determined by specific factors as: disease prevalence, rates of planned pregnancies, efficiency of existing measures to decrease significantly the overall disease’s incidence and the folate level in the general population.

Role of surgery in clinical N2 non-small-cell lung cancer: a pro and con debate; the ‘con’ viewpoint

Abstract It has been proven that there is no survival advantage of surgery in clinical N2 non-small-cell lung cancer rather than chemoradiotherapy. Several decades ago, the results of thoracic radiotherapy for Clinical Stage III non-small-cell lung cancer were poor, and long-term survival rate was only 6%. Recent advances in combined therapy (radiotherapy and chemotherapy) have improved median survival to 15-20 months. In the Japanese registry of lung cancer surgery, the number of patients with Clinical Stage IIIA has decreased over the last decade because of the poor results of surgery alone for Clinical Stage III non-small-cell lung cancer. In contrast, survival of patients with Clinical Stage III non-small-cell lung cancer treated with surgery has improved gradually. This can be mainly attributed to the following: first, well-selected patients are treated with surgery; second, improved diagnostic imaging has produced a 'Will Rogers phenomenon'. Similarly, concurrent chemoradiotherapy has also further improved and in recent clinical trials, the median survival time was 28-40 months. Unfortunately, recent randomized trials comparing induction chemotherapy followed by surgery, or induction chemoradiotherapy followed by surgery with chemoradiotherapy showed no significant survival advantage of surgery. Until appropriate patient selection for surgery can be shown in randomized control trials, chemoradiotherapy is the mainstream treatment for clinical N2 non-small-cell lung cancer in clinical practice.

Role of surgery in clinical N2 non-small-cell lung cancer: a pro and con debate; the 'con' viewpoint.

It has been proven that there is no survival advantage of surgery in clinical N2 non-small-cell lung cancer rather than chemoradiotherapy. Several decades ago, the results of thoracic radiotherapy for Clinical Stage III non-small-cell lung cancer were poor, and long-term survival rate was only 6%. Recent advances in combined therapy (radiotherapy and chemotherapy) have improved median survival to 15-20 months. In the Japanese registry of lung cancer surgery, the number of patients with Clinical Stage IIIA has decreased over the last decade because of the poor results of surgery alone for Clinical Stage III non-small-cell lung cancer. In contrast, survival of patients with Clinical Stage III non-small-cell lung cancer treated with surgery has improved gradually. This can be mainly attributed to the following: first, well-selected patients are treated with surgery; second, improved diagnostic imaging has produced a 'Will Rogers phenomenon'. Similarly, concurrent chemoradiotherapy has also further improved and in recent clinical trials, the median survival time was 28-40 months. Unfortunately, recent randomized trials comparing induction chemotherapy followed by surgery, or induction chemoradiotherapy followed by surgery with chemoradiotherapy showed no significant survival advantage of surgery. Until appropriate patient selection for surgery can be shown in randomized control trials, chemoradiotherapy is the mainstream treatment for clinical N2 non-small-cell lung cancer in clinical practice.

Reply to

Editor, We thank Luedi et al.1 for their interest in the pro–con debate on etomidate.2–4 Over the past decade many studies and expert opinions have questioned the suitability of etomidate as an induction agent in critically ill patients and the time has probably come for editing official guidelines. As ‘con’ authors we fully agree with the opinion of the authors and their concerns on the use of etomidate in multiple trauma patients. We are pleased to read that the existing evidence presented in our article has been judged sufficiently valid to formulate a recommendation in the guidelines for multiple trauma patients in Germany (www.awmf.org: S3 Leitlinie Polytrauma/Schwerverletzten-Behandlungen 2011). The increased morbidity and prolonged length of hospital stay are good clinical reasons to avoid the use of etomidate in unstable trauma patients. We further emphasise that a very recent meta-analysis confirmed that etomidate is associated with mortality and adrenal insufficiency in the setting of sepsis.5 We therefore reiterate our statement, ‘its use in septic shock should be avoided considering the potential fatal consequences’.4 Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

Wither codeine?

Wither codeine?

The use of nitrous oxide as an adjuvant for inhalation inductions with sevoflurane: a pro–con debate

The use of nitrous oxide as an adjuvant for inhalation inductions with sevoflurane: a pro–con debate

DB01-01 - PRO and CON debate: polypharmacy is necessary in psychiatry (PRO)

It is not much more than a hundred years ago that psychiatry started to become a scientific discipline in the sense of a modern medical science. This statement is especially true if we focus on psychiatry as a discipline of neurobiology/neuroscience. The key inventions in psychopharmacology were reached not earlier than the 50ies of the last century. The detection of antipsychotic, antidepressive, tranquilising and mood stabilising medication at that time can be regarded as a therapeutic revolution in psychiatry, given the fact that from today's point of view no meaningful biologically oriented treatment procedures were available apart from ECT. In this pioneer time of psychopharmacology, psychopharmacological treatment became one of the main treatment approaches. This was in principal a success story, however also several limitations such as unsatisfying efficacy, tolerability problems etc. were to be observed in the following decades. In the last 20 to 30 years second generation of antipsychotics and antidepressants entered the market, developed to overcome some of these problems. There are still unmet needs in treating mental disorders with polypharmacy which can hopefully be reduced significantly in the near future. These unmet needs are related among others to delay of onset of therapeutic action, unsatisfying effect size, problems in treating medication refractory patients, side effect which are subjectively or objectively disturbing, some of them leading to problems e.g. in terms of metabolic issues. Although there has always been the theoretically based postulate that patients should be treated with monotherapy, clinicians tried to overcome at least some of these problems by switching strategies, comedication and augmentation strategies, believed to be meaningful due to clinical experience, although still lacking in evidence.

Pro con debate: the use of regional vs systemic analgesia for neonatal surgery

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro-con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.

Pro–con debate: intravenous vs inhalation induction of anesthesia in children

IntroductionInduction of anesthesia in a child can often be arelaxed event, but this is not always the case. Theselection of approach and technique has some basisin scientific evidence and published data, but in real-ity the procedure is more complex. Induction ofanesthesia is not simply a technical exercise. Itinvolves a variety of rapid individual evaluations andjudgements relating to both child and parent, the sit-uation and to some extent the experience and prefer-ences of the individual anesthetic team on aparticular day.It is clear from the outset that one mode of induc-tion may be indicated over the other in particular clini-cal situations, but that in more general terms, it is nota case of one or the other. Most pediatric anesthetistsuse both induction methods at different times but usu-ally have a preference. The articles below thereforereflect the personal opinions of two experienced pediat-ric anesthetists who have kindly agreed to put a casefor each method. They have addressed the sciencewhere possible but also have given personalizedaccounts which will stimulate individual reflection onpractice and rationale.In support of intravenous induction of anesthesiaDr Marzena ZielinskaFor many children, the induction of anesthesia can behighly stressful and current estimations, indicate thatmore than 60% of children suffer anxiety in the pre-operative period (1). The reasons of this are complex:first, children are afraid of being separated from theirparents and home environment and this is com-pounded by unfamiliar routines, new strange people,frightening equipment such as anesthetic machine andsurgical instruments which all contribute to the processof building high levels of anxiety.Not surprisingly then, the method of induction canplay a crucial role in generation of perioperative anxi-ety. Pediatric anesthesiologists make a choice betweentwo recommended methods: inhalational or intra-venous. Traditionally, the inhalational method ofinduction of anesthesia is thought to be less harmfulfor children (2–4). In many textbooks of pediatricanesthesia, the potential fear of a needle among pediat-ric patients is stressed. But it is clear to experiencedanesthesiologists working with children that childrenare not only afraid of a needle but also a mask. Usu-ally, children struggle to accept the presence of anyforeign body on their face and they start to expresstheir dissatisfaction immediately after placing the maskclose to their face. This then becomes even less accept-able if the mask is then kept against their face despitetheir protests. Volatile agents have an unfamiliar andoften pungent smell causing even the most well-pre-pared child to lose composure when the concentrationof anesthetic gas is increased.

Pro–Con Debate: Pro–con debate: cohort studies vs the randomized clinical trial methodology in pediatric anesthesia

<i>Pro–Con Debate</i>: Pro–con debate: cohort studies vs the randomized clinical trial methodology in pediatric anesthesia

Pro–con debate: is codeine a drug that still has a useful role in pediatric practice?

Pro–con debate: is codeine a drug that still has a useful role in pediatric practice?

Presumed Consent for Organ Donation: Is Romania Prepared for It?

Introduction In November 2007, a legislative initiative regarding the presumed consent for organ donation was proposed for parliamentary debate in Romania and was followed by public debate. The study aimed to asses public opinions expressed in the Romanian media. Materials and Methods An Internet search was made. The pro and con reasons, the affiliation of parts involved in the debate and suggested future direction of action were identified. Results The Internet search had 8572 results. The parts involved in the pro and con debate consisted of governmental structures, physicians, ethicists, politicians, media, religious authorities, nongovernmental associations, and lay persons. The main pros were the low rate of organ donation and the long waiting lists, enhancement of organ procurement, avoidance of wasting valuable organs, avoiding responsibility, and the stress imposed to the family in giving the donation consent, humanitarian purposes (saving lives), going along with the scientific progress, and less bureaucracy. The main cons were an unethical issue, violation of human rights, denial of brain death, unethical advantage of public ignorance, unethical use of underprivileged people, little results in terms of organ procurement, but huge negative effects on public opinion, public mistrust in transplant programs and impossibility of refusal identification due to particularities of the Romanian medical system. Conclusion The con opinions prevailed. For the moment, Romania seems to be unprepared to accept presumed consent. A future change in public perception regarding organ transplantation may modify the terms of a public debate.

Minimally invasive surgery and cancer: controversies part 1.

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro–con debate format.