Pro-con Debate Research Articles

Pro-Con Debate: Nitrous Oxide for Labor Analgesia.

This Pro-Con debate will provide the practitioner with an evidence-based knowledge approach to assist the clinician in determining whether to employ (Pro) or not to employ (Con) this technique in the obstetrical suite for labor analgesia. Nitrous oxide has been used safely in dentistry and medicine for many centuries. However, accumulating preclinical and clinical evidence increasingly suggests previously unrecognized adverse maternal and fetal effects of nitrous oxide, which warrants reconsideration of its use in pregnant women and a more detailed informed consent. Nitrous oxide is associated with metabolic, oxidative, genotoxic, and transgenerational epigenetic effects in animals and humans that may warrant limiting its usefulness in labor. This debate will discuss and review the clinical uses, advantages, and disadvantages of nitrous oxide on occupational effects of nitrous oxide exposure, neuroapoptosis, FDA warning on inhalational anesthetics and the developing brain, research limitations, occupational exposure safety limits, effects on global warming, and potential for diversion.

Pro: “Debate: does every ascending aorta repair require at least an open distal anastomosis at the innominate, Or not?”

Youmust have already read my opponent’s opinion regarding this controversial topicto which he concluded, and I quote: “ open distal anastomosis is not alwaysrequired for every ascending aortic repair except cases of acute aorticdissection ”. The truth to the matter is far than this Pro-Con Debate andits more intrinsic to the nature of the operation performed, skills anddiscretion of the surgeon, patient selection and associated morbidities, andunderstanding of the value of avoiding the patient “a second look”!

A pro-con debate: current controversies in PAH pathogenesis at the American Thoracic Society International Conference in 2017.

The following review summarizes the pro-con debate about current controversies regarding the pathogenesis of pulmonary arterial hypertension (PAH) that took place at the American Thoracic Society Conference in May 2017. Leaders in the field of PAH research discussed the importance of the immune system, the role of hemodynamic stress and endothelial apoptosis, as well as bone morphogenetic protein receptor-2 signaling in PAH pathogenesis. Whereas this summary does not intend to resolve obvious conflicts in opinion, we hope that the presented arguments entice further discussions and draw a new generation of enthusiastic researchers into this vibrant field of science to bridge existing gaps for a better understanding and therapy of this fatal disease.

PRO-CON debate: valve sparing aortic root surgery. PRO: reimplantation.

The remodeling and the reimplantation procedures were described more than 25years ago with the aim of sparing, otherwise normal aortic valve in the presence of a root aneurysm. Because of its ability to reconstruct the sinuses of Valsalva, the remodeling procedure was considered to be more physiological than the reimplantation. However, because the remodeling lacked annular stabilization, the long-term stability of the procedure was questioned. However, through the years, both procedures have been significantly improved, so that is now possible to perform a reimplantation procedure with neo-sinuses reconstruction or a remodeling procedure with annular stabilization. In this way, both procedures can now guarantee an anatomical root reconstruction and an increased long-term durability. Today preference for a reimplantation procedure is based on the perception of a better reproducibility of the surgical procedure, an increased procedural safety due to the characteristic hemostatic feature of this surgical approach, and to a much larger amount of data present in the literature on long-term results.

Pro-con debate on preoxygenation: Pros: We provide optimum oxygen storage before induction of anaesthesia to facilitate airway management minimizing the risk of critical hypoxia

Pro-con debate on preoxygenation: Pros: We provide optimum oxygen storage before induction of anaesthesia to facilitate airway management minimizing the risk of critical hypoxia

Pro-con debate on preoxygenation: Cons: We shall moderate the inspired oxygen concentration or avoid the fall in the resting lung volume when inducing anesthesia

Pro-con debate on preoxygenation : Cons: We shall moderate the inspired oxygen concentration or avoid the fall in the resting lung volume when inducing anesthesia

Year in review 2015: Interstitial lung disease, pulmonary vascular disease, pulmonary function, sleep and ventilation, cystic fibrosis and paediatric lung disease.

Keywords: interstitial lung disease; lung function; paediatric lung disease; pulmonary vascular disease; sleep

Malaria prevention—keep it simple and logical

Due to various activities—including those by the World Bank and the Bill & Melinda Gates Foundation—we are happy to see a global decrease in malaria cases. But too many still suffer and die from malaria so malaria prevention or at least to prevent deaths by malaria is of paramount importance, still. And this is not true for the indigenous population only but for travellers as well. Balancing the risk of disease with that of possible side effects of chemoprophylaxis is a difficult task which mostly leads to split decisions even in experts (as was shown in a thrilling Pro-Con debate at the CISTM14 in Quebec in May 2015). This lack of guidance left and still leaves many colleagues (including qualified travel medicine practitioners) quite puzzled—not to talk about those on target—i.e. the travellers. For sustainable guidance my deep believe is: KEEP IT SIMPLE—otherwise counselling doctors (not all of whom are experts in tropical medicine or malariology) as well as travellers will get lost in confusion for sure1 (‘The compliance is inversely proportional to the complexity of the prescription’—Haynes and Sackett 1976). Insect bite precautions (IBP) from dusk until dawn are the mainstay of malaria prophylaxis—so this is of paramount importance for each traveller going to malaria endemic areas no matter how high the risk actually is. The first crucial decision of the binary decision tree is the definition of high risk of exposure (but may consider high risk of complications in vulnerable travellers as well). Whereas some sources say that there is no method of quantifying the risk2 in other sources high risk is defined by a risk …

Pro-Con Debate: Protracted Bacterial Bronchitis as a Cause of Chronic Cough in Children.

Pro: Children with chronic cough present a diagnostic challenge. Protracted bacterial bronchitis (PBB) is a chronic, persistent bacterial infection of conducting airways defined by the presence of cough for longer than 4 weeks that resolves with antimicrobial therapy and without an alternative diagnosis. The diagnosis is made by the findings of increased bronchial secretions and edema of the lower airways on flexible bronchoscopy and positive cultures on bronchoalveolar lavage. It is speculated that an initial respiratory insult such as viral infection disrupts normal surface morphology and ciliary function, which leads to chronic self-perpetuating inflammation with the formation of bacterial biofilms, leading to PBB. PBB is often misdiagnosed as asthma, leading to inappropriate and excessive use of steroids. The importance of timely diagnosis should be emphasized due to the potential that PBB may be a precursor to chronic suppurative lung disease or bronchiectasis if left untreated; however, every patient should be adequately assessed to exclude other causes of chronic cough. Con: Clinical criteria for the diagnosis of PBB are nonspecific and may not distinguish it from other known causes of chronic cough, including viral infections. Benefits from antibiotic therapy (particularly prolonged therapy) have not been demonstrated. Respiratory conditions are the most common reason for antibiotic prescriptions during ambulatory visits in the United States, and many of these prescriptions are inappropriate and/or unnecessary. The proposed diagnostic criteria and recommendations for the treatment of PBB will lead to unnecessary overuse of antibiotics.

Moderator's View: Should we diagnose CKD using the 'one-size fits all' KDIGO 2012 guideline or do we need a more complex age-specific classification system?

The KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease was published January 2013 [1]. Based on evidence provided by meta-analyses including >1.5 million subjects, this document proposed a new classification system for chronic kidney disease (CKD). This classification system is meant to be universal and is independent of age. Recently, Moynihan et al. [2] expressed strong concern in the BMJ series ‘Too much medicine’ about the harms of overdiagnosing CKD in low-risk elderly due to the use of a single eGFR threshold for all age groups. This leads to a brisk debate in the weeks thereafter showing very different views on this topic. We therefore invited two leading experts to debate the pros and cons of using age-specific cutoffs for diagnosing CKD. Conte, Minutolo and De Nicola present data showing that the relationship between GFR and morphological changes in the elderly is inconsistent. Reduced kidney function in this age group is the result of a mixture of physiological senescence, subclinical vascular disease and initial kidney structural changes which are difficult to separate from each other, thereby rendering the histopathological kidney function association less suited for defining kidney disease. They therefore focus on how to use the association between kidney measures and hard clinical outcomes like end-stage renal disease (ESRD) and death for diagnosing and classifying CKD. They describe how relative and absolute risk changes with age and draw parallels to traditional risk factors like blood pressure, cholesterol and glucose, which also have lower relative risks but higher absolute risks in the elderly. Still, nobody recommends age-specific thresholds for these risk factors today. Conte et al. argue that there is no reason to treat CKD different from other risk factors and conclude that the current thresholds defining CKD should not be changed in the elderly. Glassock has long advocated against the K/DOQI classification system for several reasons, but particularly its consequences for the elderly. In this elegant debate contribution he guides us through the potential problems with a definition using one threshold for all ages. He stresses the view that a decline in GFR is often a normal phenomenon associated with normal aging referring to cohorts with a substantial proportion of apparently healthy elderly having eGFR <60 mL/ min/1.73 m. There are also studies describing histological signs of nephrosclerosis in the majority of kidney donors aged 70–77 years. Proteinuria is highlighted as an essential finding of clinical relevant kidney disease leading to the dilemma whether the large group of elderly with GFR stage 3A and normal albuminuria has kidney disease or not. He also highlighted the fact that a 25% increased mortality risk (compared with eGFR 80 mL/min) is found at eGFR levels ranging from 74 mL/min/1.73 m in the youngest to 50 mL/min/1.73 m in those 75+ years. Glassock strongly concludes that a reduced GFR has different implications in different age groups, and the KDIGO guidelines should therefore be revised to include thresholds defining CKD that are age dependent. The current pro-con debate clearly shows that there is no universal agreement on CKD diagnosis and classification. However, national guidelines, hospitals and individual physicians need to decide on how to deal with this clinical problem. We would therefore like to add some general comments to broaden the previous discussion with the hope to facilitate the choice of how CKD should be diagnosed. First, is the term CKD a useful concept at all? Most kidney disease diagnosis is based on histopathological classifications which are often immature, complex and confusing with overlapping clinical features. This has seriously hampered kidney research and cooperation with non-nephrologists. Although P O L A R V IE W S IN N E P H R O L O G Y

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.

간호윤리교육에서 간호윤리상황극과 찬반토론이 간호대학생의 도덕지능, 도덕적 민감성과 도덕 판단력에 미치는 영향*

This study was designed to compare the effects of two teaching methods, i.e., ‘Theatre of Situations’ and ‘Pro-Con Debate’ on moral intelligence, moral sensitivity and moral judgment of students taking nursing ethics classes. Two-group pretest-posttest design was used. The subjects, 87 nursing students, were randomly allocated to two groups, i.e., experimental group A, ‘Theatre of Situations’ consisting 45 students and experimental group B, ‘Pro-Con Debate’ consisting 42 students. The same four nursing hypotheticals dealing with ethical issues or dilemmas were used for both groups. Each of ‘Theatre of Situations’ and ‘Pro-Con Debates’ was conducted for 150 minutes after 450 minutes of regular nursing ethics lectures. Data were collected before and after the classes to measure moral intelligence, moral sensitivity and moral judgment of the subjects. The data were analyzed by a paired t-test using SPSS. The findings from this study are as follows: (1) in group A, moral meaning perceived by the subjects (a sub-domain of moral sensitivity) was significantly improved; (2) in group B, kindness and tolerance (sub-domains of moral intelligence) were significantly improved. Both methods are recommendable for enhancing nursing ethics education.

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

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

Videolaryngoscopy: should it replace direct laryngoscopy? a pro-con debate

Although it is universally recognized that the advent of videolaryngoscopy has revolutionized airway management, there is considerable disagreement over the future role of direct laryngoscopy and whether direct laryngoscopy should be relegated to a legacy technique. Arguments against the continued relevance of traditional intubation methods include increased success and decreased complications when videolaryngoscopy is utilized, as well as the fact that videolaryngoscopy enhances the performance of nonanesthesia providers. However, proponents of direct laryngoscopy cite technical issues, as well as instances in which intubation by videolaryngoscopy fails despite successful visualization. This argument serves as the rationale for the continued use of direct laryngoscopy, particularly for airway management experts.

Administration of ketamine to children with pulmonary hypertension is safe: pro-con debate: Pro Argument.

Administration of ketamine to children with pulmonary hypertension is safe: pro-con debate: Pro Argument.

Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients

When caring for critically ill children, airway management remains a primary determinant of the eventual outcome. Airway control with endotracheal intubation is frequently necessary. Rapid sequence intubation (RSI) is generally used in emergency airway management to protect the airway from passive regurgitation of gastric contents. Along with a rapid acting neuromuscular blocking agent, sedation is an essential element of RSI. A significant safety concern regarding sedatives is the risk of hypotension and cardiovascular collapse, especially in critically ill patients or those with pre-existing comorbid conditions. Ketamine and etomidate, both of which provide effective sedation with limited effects on hemodynamic function, have become increasingly popular as induction agents for RSI. However, experience and clinical investigations have raised safety concerns associated with both etomidate and ketamine. Using a pro-con debate style, the following manuscript discusses the use of ketamine versus etomidate in RSI.

Osmotherapy in Brain Edema

Despite the fact that it has been used since the 1960s in diseases associated with brain edema and has been investigated in >150 publications on head injury, very little has been published on the outcome of osmotherapy. We can only speculate whether osmotherapy improves outcome, has no effect on outcome, or leads to worse outcome. Here we describe the action and potentially beneficial and adverse effects of the 2 most commonly used osmotic solutions, mannitol and hypertonic saline, and present some critical aspects of their use. There is a well-documented transient intracranial pressure (ICP)-reducing effect of osmotherapy, but an adverse rebound increase in ICP after its withdrawal has been discussed extensively in the literature and is an expected pathophysiological phenomenon. From side effects related to renal and pulmonary failure, electrolyte disturbances, and a rebound increase in ICP, osmotherapy can be negative for outcome, which may explain why we lack scientific support for its use. These drawbacks, and the fact that the most recent Cochrane meta-analyses of osmotherapy in brain edema and stroke could not find any beneficial effects on outcome, make routine use of osmotherapy in brain edema doubtful. Nevertheless, the use of osmotherapy as a temporary measure may be justified to acutely prevent brain stem compression until other measures, such as evacuation of space-occupying lesions or decompressive craniotomy, can be performed. This article is the Con part in a Pro-Con debate in the present journal on the general routine use of osmotherapy in brain edema.

Uraemic toxins versus volume and water as the major factor that matters with dialysis

In this pro-con debate, we will analyse the relevance of data supporting the prime role of uraemic toxins versus salt and volume overload as the main driver for the impressive mortality and morbidity characteristic of any end-stage re- nal disease patient. Firstly, we are going to review the circumstantial evidence and associated studies/clinical observational data which only weakly suggest that uraemic solutes are indeed linked to damage to the body and its constituents, especially the car- diovascular (CV) system. At the same time, we will equally thoroughly discuss the 'fact' that decreasing salt and fluid load is essential for any dialysed patient. Evidence in favour of a prominent role for uraemic toxins is appealing from a pathophysiological point of view, but unfortunately is mis- leading in real life practice. Evidence in favour of salt and water reduction is overwhelmingly stronger. This difference in apparent evidence strength notwith- standing the weaker support for uraemic toxins does not take away from clinical importance of minimizing uraemic tox- icity load in the large majority of the dialysis population. filtration (HDF) or more frequent/longer dialysis, was only partially associated with better results. Moreover, in the ma- jority of the positive studies, alternative interpretations of the results is possible, including a contribution of better volume control achievable with these particular dialysis techniques. Some 'observational' studies (2-7) showed a beneficial effect of high-flux versus low-flux synthetic dialysis mem- branes on survival, whereas prospective random controlled trials (RCTs) were inconclusive. In the Haemodialysis (HEMO) study, the largest random- ized clinical trial conducted in haemodialysis (HD) so far, patients were randomized to either a high-dialysis dose (achieved eKt/V ¼ 1.53 � 0.09, sp Kt/V ¼ 1.71 � 0.11) or a standard-dose goal (achieved eKt/V ¼ 1.16 � 0.08, sp Kt/V ¼ 1.32 � 0.09) and to dialysis with either high-flux dialysers (b2-microglobulin clearance of > 20 mL/min) or to low-flux dialysers—(b2-microglobulin clearance < 10 mL/ min). The results showed that a higher HD dose was not associated with a lower mortality risk compared with con- ventional HD dose (8). Thus, while a minimumKt/V ,a ccord- ing to the guidelines, is mandatory, the HEMO study clearly demonstrated that there are no advantages in further increas- ing the urea Kt/V, even in the high-flux membrane group. At the same time, each 10 mg/L increase in b2-M level was associated with an 11% increase in mortality, even after ad- justment for years on dialysis and residual kidney function. These results deserve further specifically designed studies in order to clarify if it is a matter of larger molecule removal or better fluid removal. In the other large trial in the field, the Membrane Perme- ability Outcome study, there was no significant difference in survival between high- and low-flux groups when all patients were included in the analysis (9). However, patients with serum albumin � 40 g/L on enrolment and with diabetes had a significantly better survival in the high-flux arm. High-flux dialysis was associated with a significantly lower accumulation of b2-microglobulin. Again, it is important to clarify if the better outcome was related to larger molecule removal or better fluid removal. Compared with conventional HD, HDF could theoretically offer some advantages: better clearance of middle- and