Areas Of Controversy Research Articles

The oncologic benefits of lateral lymph node dissection after neoadjuvant therapy - local control or survival?

Lateral pelvic lymph node dissection (LPLND) for rectal adenocarcinoma is an established treatment modality for selected patients with abnormal lateral pelvic lymph nodes on magnetic resonance imaging (MRI) imaging. The goal of this treatment is to achieve a true R0 resection, including lymphadenectomy, with the aim of improving patient oncological outcome, potentially at the expense of surgical and functional complications. However, there remain several areas of controversy resulting from a distinct lack of clarity regarding effective patient selection, lymph node size criteria, the role and extent of routine neoadjuvant treatment versus surgery alone in selected cases, the impact on patient survival metrics and whether the existing data are even valid in the era of total neoadjuvant therapy (TNT). Furthermore, the lack of widely disseminated surgical standardisation and expertise in performing this procedure potentially contributes to the lack of utilisation in certain countries and regions. In this narrative review, we summarize the current state of the literature and attempt to answer the question of what oncological benefits there are, if any, from LPLND after neoadjuvant therapy in rectal cancer, and whether these justify the risks and potential need for inter-hospital transfer.

Acromioclavicular Joint Injuries: Multi-center Expert Consensus Study using the Delphi Method.

Acromioclavicular (AC) joint injuries pose significant challenges in clinical management, necessitating consensus guidelines for optimal treatment. There is a lack of consensus in several areas, including imaging protocols, surgical techniques, and rehabilitation timelines. This study aims to develop a consensus regarding the diagnosis, treatment, and rehabilitation of AC joint separations. Using the Delphi method to gather expert opinions, 18 fellowship trained surgeons from the American Shoulder and Elbow Surgeons (ASES) participated in three survey rounds, achieving a 100% response rate over each round. A total of 76 consensus statements were identified in six areas: history, physical examination, radiology, treatment, surgical technique, and rehabilitation. Consensus was reached on some of the fundamental principles of AC separation management, such as the importance of a comprehensive history and physical exam, multiple radiographic views of the joint, indications for surgery and the usefulness of allograft tendon augmentation for repair of the joint when surgery is indicated. The Delphi method proved effective in gathering diverse perspectives and quantifying consensus among experts, offering important insights into the management of AC joint injuries. Continued research efforts are warranted to address areas of controversy and establish improved guidelines for the diagnosis and treatment of these injuries.

The Society of Thoracic Surgeons (STS) Clinical Practice Guideline on Surgical Management of Oligometastatic Non-small Cell Lung Cancer.

The use of local consolidative therapy (LCT) in patients with oligometastatic non-small cell lung cancer (NSCLC) is rapidly evolving, with a preponderance of data supporting the benefits of such therapeutic approaches incorporating pulmonary resection for appropriately selected candidates. However, practices vary widely institutionally and regionally, and evidence-based guidelines are lacking. The Society of Thoracic Surgeons assembled a panel of thoracic surgical oncologists to evaluate and synthesize the available evidence regarding the role of pulmonary resection as LCT. Clinical and research questions of interest were identified, and a complete literature review was conducted. Best practice guidelines were developed accordingly. The panel identified 7 areas of controversy, and data were assimilated to support the best recommended practices related to these clinical issues. Ultimately, a number of issues in this realm were found to have a high level of evidence to support the role for surgical therapy in patients with stage IV lung cancer. However, the nuances of how these operations are conducted remain in equipoise, without ample evidence to support the extent of resection or nodal dissection. Clear data exist to support the use of surgical resection of the primary lung tumor as LCT in stage IV lung cancer. Evidence-based recommendations have been provided to guide multidisciplinary teams on the implementation of treatment plans as well as to guide researchers on areas of ongoing need for further investigation.

An international and multidisciplinary EORTC survey on resectability of stage III non-small cell lung cancer.

The EORTC-Lung Cancer Group initiated a Delphi consensus process to establish a consensual definition of resectable stage III non-small cell lung cancer (NSCLC) for the use in clinical trials, including a systematic review, survey, and review of clinical cases. Here, the survey results are presented, aimed to identify areas of controversy. A survey was distributed among the members of six international organizations related to lung cancer. Respondents were interrogated on the resectability (not limited to the technical resectability) of all stage III NSCLC TNM-subsets (8th edition). Additionally, four N2-subdivisions were used. The threshold for agreement was 75%. Answers with "yes" were considered upfront resectable. "Yes" and "maybe" were grouped together and considered potentially resectable. Answers with "no" were considered unresectable. 558 responses were collected from thoracic surgeons (38%), radiation oncologists (27%), medical oncologists (17%), pulmonologists (14%), and others (4%). Most worked in a specialized center (80%), had>5 years of experience (80%), were European (76%), male (73%), and treated>20 patients with stage III NSCLC annually (77%). Agreement was found in 26 (70%) out of 37 TNM-subsets: 9 (24%) were considered (potentially) resectable, and 17 (46%) unresectable. There was no agreement for 11 (30%) TNM-subsets: smaller tumors with N2-multistation, larger tumors with N2-single station, and invasive T4-tumors with maximum N2-single station involvement. This international and multidisciplinary survey showed agreement on the resectability for the majority of stage III NSCLC TNM-subsets, but also identified several TNM-subsets for which no agreement was found.

Ischemic Stroke Prevention in Patients Atrial Fibrillation and a Recent Ischemic Stroke, TIA, or Intracranial Hemorrhage; a World Stroke Organisation (WSO) Scientific Statement.

Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This Scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research. We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, whether the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g., observational vs. randomized controlled trial). Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data. Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

ChatGPT's Performance in Spinal Metastasis Cases-Can We Discuss Our Complex Cases with ChatGPT?

Background: The integration of artificial intelligence (AI), particularly large language models (LLMs) like ChatGPT-4, is transforming healthcare. ChatGPT's potential to assist in decision-making for complex cases, such as spinal metastasis treatment, is promising but widely untested. Especially in cancer patients who develop spinal metastases, precise and personalized treatment is essential. This study examines ChatGPT-4's performance in treatment planning for spinal metastasis cases compared to experienced spine surgeons. Materials and Methods: Five spine metastasis cases were randomly selected from recent literature. Consequently, five spine surgeons and ChatGPT-4 were tasked with providing treatment recommendations for each case in a standardized manner. Responses were analyzed for frequency distribution, agreement, and subjective rater opinions. Results: ChatGPT's treatment recommendations aligned with the majority of human raters in 73% of treatment choices, with moderate to substantial agreement on systemic therapy, pain management, and supportive care. However, ChatGPT's recommendations tended towards generalized statements, with raters noting its generalized answers. Agreement among raters improved in sensitivity analyses excluding ChatGPT, particularly for controversial areas like surgical intervention and palliative care. Conclusions: ChatGPT shows potential in aligning with experienced surgeons on certain treatment aspects of spinal metastasis. However, its generalized approach highlights limitations, suggesting that training with specific clinical guidelines could potentially enhance its utility in complex case management. Further studies are necessary to refine AI applications in personalized healthcare decision-making.

Use of blended feeds in children requiring tube feeding.

The use of blended tube feeding (BTF) in children is a controversial area with persistent concerns regarding the nutritional adequacy and risk of associated infections and equipment complications. Parents in Australia are electing to use BTF in their children despite local hospital guidelines, calling for further research to support its use. A retrospective case-series study was conducted at a tertiary paediatric hospital, to characterise the paediatric population electively using BTF and evaluate their clinical outcomes. Demographic, anthropometric and clinical data were collected from pre-existing medical records. Data from 178 clinical visits of 26 participants were included in analysis. The median age of participants was 4.1 years (range 7 months -14 years). BTF was most commonly used for symptom control (n = 8, 30.8%). The most common cause of clinical presentation during the use of BTF was respiratory conditions (number of presentations = 60, 47.2%). There was no reported increase in hospital presentations, gastrointestinal infections or equipment complications with the use of BTF. BTF did not promote weight gain in this population of children, particularly those who were already underweight. This case-series found the use of BTF in a paediatric population with underlying complex medical conditions requiring enteral nutrition was driven by parental preference and the goals of symptomatic control. BTF did not demonstrate benefits of weight gain, though it was not associated with an increase in complications and hospital admission.

Public perceptions of trustworthiness and authenticity towards scientists in controversial scientific fields

This study investigates public perceptions of trustworthiness and authenticity regarding scientists engaged in controversial and less controversial fields with a cross-sectional survey of a German sample (“N” = 1007). Results indicate that scientists in controversial fields like COVID-19 or climate change are perceived as less trustworthy and authentic compared to scientists in less controversial fields or scientists without specification of their field. Additionally, we found that science-related media consumption shaped people´s trustworthiness and authenticity perceptions towards scientists. Our analysis points out how public perceptions of scientists vary if these scientists research controversial areas, actively participating in public (and media) life.

Obesity: ethical issues.

This article reviews the ethical issues surrounding obesity in public health and clinical contexts. We examine how obesity intersects with medical and social norms that raise questions of liberty, fairness, safety, and effectiveness or consequences. PubMed, Cochrane Library, and Google Scholar. We identify three main areas of agreement that are pertinent to ethical analysis of obesity: stigma is considered harmful, there needs to be a more-than personal responsibility approach, and a general acceptance of a global rise in body weight. There are many areas of controversy, we limit our focus to four: conflicts of interest in the creation of guidelines and policies, mortality rates, whether weight is a meaningful proxy for health, and how to treat childhood obesity. Post-genomic explanations, such as exposure to endocrine disrupting toxins, and development of epigenomics and microbiomics in the form of personalized nutrition are two developing areas we identify.

Death of the paediatric manikin: a scoping review

IntroductionWhether the manikin should die in simulation training is a controversial area, with some educators stating that manikin death is essential in providing realistic training, while others state that the...

The 2024 updated WHO guidelines for the prevention and management of chronic hepatitis B: Main changes and potential implications for the next major liver society clinical practice guidelines.

Progress towards global elimination of hepatitis B virus (HBV) has been slow and most countries are far from reaching the elimination targets set out by the World Health Organization (WHO). The burden of chronic hepatitis B is mainly borne by resource-limited countries where only a minority of people living with HBV are diagnosed and treated and international guidelines are hardly applicable in real-life. In March 2024, the WHO released its revised guidelines for the prevention and management of chronic hepatitis B. Simplification of care and expansion of treatment criteria represent the core of this revision. Whether and how these updated WHO guidelines will influence the next hepatitis B recommendations from the international liver societies (EASL, AASLD and APASL) remain uncertain. Yet, the European, American and Asian regions encompass multiple low, middle and intermediate-income countries with high HBV endemicity and vulnerable populations that should benefit from simplified clinical algorithms. Here, from an analysis of the WHO guideline development process and its new recommendations, we aimed to identify the anticipated areas of agreement and controversies with the next liver society hepatitis B guidelines, which will have to balance clinical risks and benefits for patients.

How ethical is the use of financial incentives to promote medication adherence among patients with serious mental illness? - a scoping review of the literature

Poor adherence to medication treatment in those with serious mental illness is common. Typical solutions and consequences in Western, formal psychiatric care settings often involve coercive measures such as involuntary hospital admissions and treatment, and out-patient commitments, with serious infringements on civil liberty. We examine the relatively unfamiliar, controversial and under-explored area of using financial incentive (FI) to enhance medication adherence in this population through a comprehensive scoping literature review, focusing on the ethical aspects of this practice. From nineteen qualified papers, we identified seven key themes of ethical “concerns,” and opposing arguments on whether FI is: (1) itself a form of coercion affecting autonomy; (2) leading to erosion of a proper consent process; (3) causing indirect and unintended harm; (4) worsening multiple levels of stigma related to mental illness; (5) associated with loss of intrinsic motivation of treatment; (6) associated with misuse of the fund itself; and (7) potentially leading to negative impact on therapeutic relationships. The ethics review shows a moderate receptivity to the use of FI in some specific and individualized circumstances; exceptions for those with poor insight and lacking treatment capacity are particularly relevant in order to avoid other forms of coercion. Additional highlights of the review include the optimal amount, duration, scope, and target population of the FI, and need for rigorous attention to psychoeducation, process, therapeutic relationships, stigma, and not lose sight of ultimately aiming to improve on patients’ insight, autonomy, quality of life and intrinsic motivation in this controversial approach.

MGB-OAGB International Club-Results of a Modified Delphi Consensus on Controversies in OAGB.

One anastomosis gastric bypass (OAGB) presently constitutes 7.6% of all metabolic and bariatric surgery (MBS) procedures globally. Despite being approved by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) as a standalone MBS procedure and two consensus efforts in the past, multiple areas of controversies remain. This consensus builds upon previous consensus efforts to address unresolved controversies in the field. A modified Delphi consensus exercise was conducted over 4weeks under the aegis of the MGB-OAGB International Club. A panel of 86 bariatric experts from 25 countries participated in 3 rounds of voting on 29 questions on patient selection, technical standardization, revisional surgeries, and post-operative care. Consensus was defined as at least 70% agreement. Consensus was achieved on 22 out of 29 questions. Key areas of agreement included suitability of OAGB for adolescents above the age of 15years and patients with class 1 obesity with uncontrolled type 2 diabetes. Patients with severe esophagitis and Barrett's esophagus were not considered as good candidates for OAGB. Crural repair with OAGB was considered as an appropriate procedure in patients with large hiatus hernia. While a bilio-pancreatic limb (BPL) length of 150 - 200cm was deemed suitable, it was recommended to tailor the BPL length to prevent protein energy malnutrition. It was also agreed to routinely administer ursodeoxycholic acid and proton-pump inhibitors for 6months post-operatively. This modified Delphi consensus represents a critical step forward in addressing the controversies surrounding OAGB. It also emphasizes on the importance of individualized patient care and the need for ongoing research to refine surgical practices and improve outcomes.

Perioperative Acute Kidney Injury: Diagnosis, Prediction, Prevention, and Treatment.

In this review, the authors define acute kidney injury in the perioperative setting, describe the epidemiologic burden, discuss procedure-specific risk factors, detail principles of management, and highlight areas of ongoing controversy and research.

Challenges Of Obtaining Reliable Eyewitness Testimony from Children and Practical Implications

The reliability of eyewitness testimony provided by children has always been a controversial area in research. This paper addresses the challenges of obtaining reliable eyewitness testimony from children and explores its practical implications. The research background highlights the importance of understanding children's developmental stage, memory and language skills, and how these factors influence their ability to provide accurate testimony. The review explores the different aspects that influence the reliability of children's testimony, including verbal and non-verbal factors, cognitive instructions, and how to build trust. As children have high emotional needs, it is important to provide support while obtaining eyewitness testimony. The final section summarizes the main findings, highlighting the effectiveness of multiple interviews, flexible questioning strategies and the importance of parent and interviewer support. Disadvantages include differences in children's anxiety levels and the need to adapt interview techniques to children. Future research should focus on refining these techniques and studying the impact of different support systems on children from different backgrounds.

Annals of Surgical Oncology Practice Guidelines Series: Adjuvant and Neoadjuvant Therapy for Melanoma.

Surgery has always been the mainstay of melanoma treatment, but the risk of recurrence after curative-intent surgery remains high for some stages of the disease. In this Annals of Surgical Oncology Guidelines Review, we provide an overview of practice changing studies, review international guidelines, and highlight current recommendations and areas of controversy when treating melanoma patients in the adjuvant and neoadjuvant setting. Recent clinical trials have established important roles for adjuvant and neoadjuvant therapy in conjunction with surgery for selected patients with stage II, stage III, and even resectable stage IV melanoma. Patients with melanoma should be evaluated for multimodality therapy, including a combination of surgery, systemic therapy (i.e., BRAF-targeted therapy or checkpoint blockade immunotherapy), and at times radiotherapy. With the rapid pace of advances in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for adjuvant and neoadjuvant therapy and to continue to be leaders in this paradigm shift. Given the complex and evolving nature of treatment, this report reviews the latest practice guidelines in the context of modern multidisciplinary management of melanoma.

Better data for budgetary surveillance: EU law on statistics as key to unlocking the potential of public sector accounting

The quality of the data available for monitoring budgetary discipline of the Member States has been a hot topic within the European Union (EU) institutions and in the literature ever since the beginning of the economic crisis in 2008. The COVID-19 pandemic has shown the inadequacy, not only of the data, but also of the policy instruments available for coordinating efforts and decision-making. In this paper, we attempt to unlock the potential of public sector accounting (PSA) for contributing to the improvement of EU surveillance mechanisms. We look beyond the idea of standardised accounting rules for the entire EU public sector (European Public Sector Accounting Standards) into a less controversial area of EU competence, and we explore the conditions for introducing reporting obligations based on PSA data as part of EU law on statistics. Points for practitioners The current succession of crises might create momentum for a change in EU fiscal policy-making. New instruments for the monitoring of the budgetary situation in the Member States could become necessary. The EU institutions cannot impose the European Public Sector Accounting Standards. However, a new standardised reporting instrument could become binding EU law if it would come in the shape of a statistical methodology. Basic principles of EU law guarantee that any new statistical reporting obligations are limited to what is necessary, proportionate and cost-effective.

The Role of Confirmatory Testing in Carpal Tunnel Syndrome: Electrodiagnostic Study, Ultrasound and CTS-6.

Carpal tunnel syndrome (CTS) is the most common upper extremity compressive neuropathy. The reference standard for the diagnosis of CTS remains an area of controversy. The diagnosis can be established clinically, but options for confirmatory testing include electrodiagnostic studies, ultrasound and diagnostic aids such as the CTS-6 score. This review article summarises the current evidence for each confirmatory testing modality, contrasts their advantages and disadvantages and discusses future directions for investigation. Level of Evidence: Level V (Diagnostic).

Controversies in the Management of Acute Pulmonary Embolism in the Emergency Department

Backgroundacute pulmonary embolism is frequently diagnosed in the Emergency Department, and the management approach can be nuanced. Objective: in this narrative review, we synthesize the literature in selected areas of ongoing controversy regarding the diagnostic and management approaches for acute pulmonary embolism (PE) in the Emergency Department, and provide evidence-based recommendations to empower emergency physicians to provide optimal care in these situations. DiscussionD-dimer is used to clinically exclude the diagnosis of PE patients who are stratified as low risk. However by utilizing likelihood ratio and with certain scoring tools, patient historically considered moderate or high risk for PE may safely be able to have the diagnosis excluded with a negative D-dimer. Traditional risk stratification and management strategies can be cautiously applied to patients with concomitant Coronavirus-19 infection while awaiting more definitive studies. There is an increasing trend in the diagnosis of isolated subsegmental PE, and many patients receiving this diagnosis may be treated without anticoagulation provided that they have no evidence of associated DVT and can be closely followed as an outpatient. There is a persistent hesitancy to discharge patients with newly-diagnosed acute PE, and existing well-supported risk stratification tools and clinical decision frameworks can support the emergency physician's decision to safely discharge low-risk patients. Conclusion: this review of the literature empowers emergency clinicians to manage challenging PE cases in the ED.

Hyaluronan‐protein interactions: Lilliput revisited

AbstractHyaluronan (HA) is a huge linear polysaccharide composed entirely of a simple repeating disaccharide that has been preserved unchanged since the evolution of vertebrates ~520 million years ago. It is present in all mammalian tissues, being synthesised within the cell membrane and extruded into the extracellular space where it dictates tissue elasticity, hydration and permeability. HA also directs cell behaviour via engagement with cell surface receptors. These properties allow it to mediate diverse functions in a wide range of physiological and pathological processes, including development, mammalian reproduction and inflammation. There is growing evidence that the way in which the HA biopolymer is differentially organised, through its interaction with a repertoire of HA‐binding proteins (HABPs), is key to the diversity of its biological functions. This review summarises current knowledge of HA‐protein interactions and how their diversity may lead to the formation of HA/protein complexes with distinct molecular architectures that in turn underpin different physical properties and receptor‐mediated effects. Potentially controversial areas such the pro‐inflammatory effects of low molecular weight HA fragments and how short HA‐binding peptides modulate HA function are considered from a molecular perspective.