Controversies in sleep disorders medicine. Pulmonologists respond!

PURPOSE: Herein we report the results of an informal survey of approximately 350 physicians attending the American College of Chest Physicians meeting in October 1995. METHODS: With response computer technology, we polled session participants about sleep and sleep disorders. The responses to the questions were instantaneously displayed and recorded and are presented herein. RESULTS: We found considerable expertise and experience in our audience; 65% were board certified in pulmonary medicine and 12% in sleep disorders medicine. There was not agreement about expectations upon referral of a patient to a sleep center or about the definitions of either sleep apnea or hypopnea. Most sleep centers perform split-night polysomnography but there is not a single clear indication for this procedure and there is uncertainty about the efficacy of split-night studies. Most laboratories represented recognize the diagnosis of upper airways resistance syndrome, and respondents seemed well versed in the definition of this entity. There was not uniform agreement of the treatment effects of mild or positional obstructive sleep apnea. CONCLUSIONS: Pulmonologists appear to be interested in and knowledgeable about sleep disorders. There are several basic areas of controversy, emphasizing the need for clinical research in the area of sleep-disordered breathing.     

Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.     

Controversies in acetabular fractures

Open reduction and internal fixation has become the standard of care for the treatment of most displaced acetabular fractures. As surgical techniques have become refined, long term results of surgical fixation have improved. During the past 10 to 15 years, several controversies have surfaced in the orthopaedic literature regarding the treatment of acetabular fractures. The recent literature regarding acetabular fixation was reviewed. Controversies include the most efficacious surgical approach for complex acetabular fractures; the effectiveness of intraoperative sciatic nerve monitoring; the most effective method of prophylaxis against deep vein thrombosis; and the indications for and method of prophylaxis against heterotopic bone formation.     

Controversies in benign breast disease

Breast health means more than breast cancer. At least 50% of patients seen at a multidisciplinary breast center have benign conditions. Pain, nipple discharge, and a question of a mass are the usual chief complaints. This article provides contemporary information and management guidelines for the common breast conditions associated with these complaints.     

Controversies concerning calcium antagonists

PURPOSE: This report describes a female infant with stage 4 multifocal ganglioneuroblastoma with gastric involvement. PATIENT: The patient had a right cervical tumor, a left posterior mediastinal tumor, bilateral adrenal tumors, and bony and bone marrow metastases. The tumor cells were diploid and lacked N-myc gene amplification. The gastric involvement, which did not produce clinical symptoms, was only detected by meticulous exploration during laparotomy. RESULTS: Our patient achieved only a partial response to alternating cycles of cyclophosphamide, vincristine, and adriamycin; and etoposide and cisplatin. She currently has stable, unresectable disease with elevated catecholamines. CONCLUSIONS: Multifocal ganglioneuroblastomas may arise from either neuroblastic rests or aberrant deposits of neuroblasts. The latter mechanism may have accounted for our patient's gastric tumor. Patients with multifocal ganglioneuroblastomas warrant meticulous radiographic and surgical evaluation to completely document the full extent of disease, and to ensure appropriate staging and therapy.     

Controversies in the approach to ophthalmia neonatorum

Colonic obstruction is a very rare complication of gallstone disease. A case is described in a 63-year-old female patient. Radiological investigation, including plain abdominal X-ray and contrast studies, aided in the diagnosis.     

Controversies regarding radial neck fractures in children

Fractures of the radial neck in children are not uncommon, yet several aspects of their management remain controversial. Until a consensus is reached regarding the determination of displacement, acceptability of initial angulation, treatment, and outcome, the complication rate of these fractures will remain high. The authors recommend measuring the displacement as the angle between a line perpendicular to the articular surface of the radial head with a line down the shaft of the proximal radius. Fractures that are angulated less than 30 degrees require immobilization alone. Fractures angulated more than 30 degrees should be treated with an attempt at closed reduction. If closed reduction fails, a percutaneous reduction should be attempted before open reduction. Internal fixation should be performed using an oblique extraarticular Kirshner wire for all unstable fractures. Grading outcome based on range of motion and the presence or absence of pain is recommended. It is hoped that once the controversies surrounding these fractures are resolved, the long term results of these troublesome injuries will improve.     

Controversies in the management of operated pituitary macroadenomas

The medial canthal region includes several individual aesthetic units that differ in skin quality and thickness, contour, and associated landmarks. Basal cell carcinomas commonly involve the medial canthal region and extend without respecting the boundaries between units. Reconstruction of tumor-free defects is often complicated by web formation across the medial canthal concavity. To avoid this complication, we evaluate each defect according to the anatomic units involved and develop individual flaps from each component area, anchoring each flap to the medial canthal tendon or associated deep fibrous tissue. This system has been used in 58 cases with excellent results. It allows flexibility for reconstructing the many diverse defects that oculoplastic surgeons encounter and helps to minimize postoperative deformity.     

Love in the Countertransference: Controversies and Questions.

The aim of this article is to bring discussion of the analyst's loving feelings toward his or her patients into open professional dialogue. Several controversies are examined: (a) countertransference love versus love in real life; (b) purposeful self-disclosure of the analyst's loving and sexual feelings; and (c) "falling in love" with one's patients. In each of these areas a personal clinical vignette and selective relevant literature are discussed. As befitting the subject matter, the author's writing style is as close as possible to the experience of the analytic couple, with minimal use of technical and abstract language. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Controversies and realities of therapy for varicosis

Proponents of surgical eradication of varicose veins claim a high cure rate. Proponents of the conservative methods of multiple injections of sclerosing agents claim that this money-saving ambulatory method avoids hospitalization and loss of working time, that the end results are quite satisfactory and that any recurrences can be easily dealt with by reinjections. Both methods are effective. Both have their indications. Many surgeons use sclerotherapy after surgery as complementary therapy. Radical views recommending surgery or injections exclusively are contrary to the principles of good medical care and do injustice to the patient. A simple venographic technic demonstrating the status of the greater saphenous veins is described.