En bloc transurethral resection of bladder tumors: A review of current techniques

IntroductionGrowing interest surrounds the concept of en bloc transurethral resection of bladder tumors (ERBT). Theoretical advantages include improved adherence to oncological principles and potential yield of superior pathological specimens. Multiple ERBT methods exist. This review summarizes the current evidence regarding application of differing techniques and technologies to ERBT.MethodsA systematic review of MEDLINE/EMBASE/Scopus databases was performed, using terms “en bloc,” “ERBT,” “bladder,” and “urinary bladder neoplasm.” Template-based data extraction included technique of ERBT, feasibility, tumor size, activation of obturator nerve reflex, operative complications, detrusor muscle sampling rate, and recurrence data.ResultsMultiple approaches to ERBT have evolved, using a variety of energy sources. The feasibility of electrocautery, laser, combined waterjet/electrocautery, and polypectomy snare techniques have been confirmed in achieving ERBT. ERBT appears safe, with a low complication rate. The use of laser energy sources reduces the risk of activating the obturator nerve reflex during lateral wall resections. Otherwise, no energy source is unequivocally superior in achieving ERBT. The rate of detrusor muscle sampling is high with use of ERBT and appears superior to that achieved with conventional TURBT (cTURBT) in multiple comparative studies. A limited number of largely non-randomized trials assess bladder tumor recurrence; current evidence suggests this is similar between ERBT and cTURBT groups.ConclusionsERBT using a variety of technologies is feasible and safe, with a high detrusor muscle sampling rate. Further research is required to determine whether rates of residual disease or recurrence can be reduced with ERBT vs. cTURBT.     

Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption During Pregnancy

Alcohol consumption during pregnancy has negative implications for maternal and child health. Appropriate early universal Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant women is necessary to identify women at risk and reduce the likelihood of continued drinking. Because SBIRT is not consistently used, the development and use of performance measures to assure implementation of SBIRT are key steps towards intervention and reduction of alcohol consumption during pregnancy. Practice guidelines provide ample support for specific instruments designed for SBIRT in prenatal care. An examination of existing performance measures related to alcohol consumption during pregnancy, however, reveals no comprehensive published performance measure designed to quantify the use of SBIRT for alcohol use in prenatal care. Process performance measures were developed that can determine the proportion of pregnant women who are screened during the course of prenatal care and the proportion of women requiring either brief intervention or referral to substance use disorder treatment who received those interventions. The measures require use of screening instruments validated for use with pregnant women. The two proposed measures would represent a significant step in efforts to assure appropriate intervention for women who drink during pregnancy, hold accountable providers who do not employ SBIRT, and provide a basis from which necessary systemic changes might occur. Pregnancy is a time when many women are motivated to stop drinking. That opportunity should be seized, with timely intervention offering assistance for pregnant women who have not stopped drinking of their own accord.     

Isolation and synthesis of antiproliferative eupolauridine alkaloids of Ambavia gerrardii from the Madagascar Dry Forest

Investigation of the Madagascan endemic plant Ambavia gerrardii for antiproliferative activity against the A2780 ovarian cancer cell line led to the isolation of the three new alkaloids 8-hydroxyeupolauridine (1), 9-methoxyeupolauridine 1-oxide (2), and 11-methoxysampangine (3) and the three known alkaloids 4-6. The structures of 1 and 2 were confirmed by synthesis. Compounds 3, 4, and 6 showed moderate to good antiproliferative activities, with IC50 values of 10.3, 3.5, and 0.60 μM, respectively, against the A2780 human ovarian cancer cell line and with IC50 values of 0.57, 1.77, and 0.58 μM, respectively, against the H460 human lung cancer cell line.     

Effects of verapamil on activation of arachidonic acid metabolism in guinea-pig lungs

The effects of (±)-verapamil and its optical isomers on the activation of arachidonic acid (AA) in guinea-pig isolated perfused lungs were investigated. The calcium ionophore A23187 (6–15 nmol), histamine (20–50 nmol) and leukotriene E₄ (1–2 nmol) induced the release of thromboxane A₂ (TxA₂), which was detected by bioassay and by radioimmunoassay of the stable metabolite TxB₂. Racemic (±)-verapamil (0.4–40 μM) caused concentration-dependent inhibition of A23187-induced release of TxA₂ without affecting the conversion of exogenous AA to TxA₂. Both (+)-verapamil and (−)-verapamil (1–10 μM) caused concentration-dependent inhibition of histamine-induced release of TxA₂. In contrast, racemic (±)-verapamil did not inhibit leukotriene E₄ (LTE₄)-induced release of TxB₂. Calcium depletion (with 2 mM ethylenediamine tetra acetate) significantly reduced both histamine-induced release of TxB₂ from 8.6 ± 2.6 to 1.8 ± 0.8 ng/min (P < 0.05) and LTE₄-induced release of TxB₂ from 4.9 ± 0.9 to 0.5 ± 0.2 ng/min (mean±S.E.M.)(P<0.05). Since histamine stimulates phospholipase A₂ in guinea-pig lungs, these results suggest that (±)-verapamil inhibits phospholipase A₂ and that A23187 activates AA metabolism by stimulating phospholipase A₂. Although all three agents activate AA metabolism by calcium-dependent processes, LTE₄ may stimulate calcium entry via separate mechanisms because it is not inhibited by (±)-verapamil.     

The presence or absence of fetal breathing movements as a predictor of outcome in preterm labor

The presence or absence of fetal breathing movements may be helpful in differentiating between true and false preterm labor. We attempted to demonstrate the clinical utility of this simple ultrasonic observation in predicting short-term delivery outcome during suspected preterm labor. A total of 50 pregnancies between 26 and 34 weeks' gestation with presumed preterm labor were observed in a prospective manner. During 20 minutes of observation with real-time ultrasound at the time of admission, fetal breathing movements were observed in 33 patients and considered absent in the remaining 17 patients. In those pregnancies with absent fetal breathing movements, true labor with subsequent delivery occurred in 16 patients. Of the 33 pregnancies with fetal breathing movements present, 29 continued for greater than 48 hours. It appears that the absence of fetal breathing movement is a reliable indicator of imminent preterm delivery, irrespective of fetal membrane status (p less than 0.0001). The observed mean sensitivity and specificity of this phenomenon in predicting short-term delivery outcome are 96.6% +/- 3.3% (mean +/- SD) and 80.0% +/- 8.9%, respectively. A multivariant statistical model based on the frequency of contractions, white blood cell counts, initial cervical examination results, and premature rupture of membranes could successfully predict delivery outcome in 40% to 75% of cases. The addition of fetal breathing movement analysis to the model allowed for the correct prediction of outcome in 90% of the cases.