Clinical Practice Guidelines for Bladder Cancer 2019 edition by the Japanese Urological Association: Revision working position paper

The Clinical Practice Guidelines for Bladder Cancer edited by the Japanese Urological Association were first published in 2009 and a revised edition was released in 2015. Four years has passed since the 2015 edition, and the clinical practice environment surrounding bladder cancer has drastically changed during that time. The main changes include: (i) insurance coverage of a new diagnostic method for non-muscle-invasive bladder cancer; (ii) insurance coverage of an immune checkpoint inhibitor in advanced and metastatic bladder cancer; and (iii) advances in robot-assisted radical cystectomy as a minimally invasive treatment for muscle-invasive bladder cancer. A paradigm shift in bladder cancer diagnosis and treatment is occurring day by day. Therefore, in this 2019 edition, while dealing with the above changes, we carefully selected clinical questions with clear evidence and included other clinically important points in the general statement. We also added a new chapter on rare cancers of the urinary tract. As a new method for the evaluation of study evidence level, we introduce “The Grading of Recommendations Assessment, Development and Evaluation” system modified to Japanese by the Medical Information Network Distribution Service.     

Utility of the Pentax-AWS Airwayscope and Macintosh laryngoscope for airway management during chest compressions in 27° left-lateral tilt: a manikin simulation study of maternal cardiopulmonary resuscitation

Purpose

American Heart Association (AHA) 2010 cardiopulmonary resuscitation guidelines recommend high-quality chest compressions (minimum interruption, a pace >100 compressions/min, and a depth more than 5 cm). They propose minor changes for pregnant women: manual left deviation of the uterus or a left-lateral incline of 27°–30° to alleviate pressure on the inferior vena cava. We examined the performance of the Pentax-AWS Airwayscope (AWS) and Macintosh laryngoscope (McL) for airway management during chest compressions on a 27° left-lateral tilt (27 LLT) operating table.

Methods

The study included 18 novice doctors in our anesthesia department. They performed tracheal intubation on a manikin positioned on a 27 LLT operating table using the AWS or McL with or without chest compressions. We measured the intubation time and success rate for tracheal intubation.

Results

Intubation success rate with the McL decreased with chest compressions compared to without chest compressions (12/18 vs. 18/18, P < 0.05). Intubation time with the McL was lengthened with chest compressions compared to without chest compressions (18.9 ± 4.0 s vs. 11.1 ± 1.0 s, P < 0.05). Intubation success rate was the same for the AWS with and without chest compressions (18/18 in both cases), and intubation time did not increase significantly without compressions compared to with compressions (11.6 ± 1.4 s vs. 12.6 ± 1.2 s, NS).

Conclusions

The AWS is an effective tool for airway management during chest compressions in 27 LLT in a manikin, suggesting that the AWS may be a useful device for airway management during maternal resuscitation.     

Intravenous infusion of hyperosmotic NaCl solution induces acute cor pulmonale in anesthetized rats

Intravenous hyperosmotic NaCl infusion is an effective treatment for circulatory shock. However, a fast infusion rate (2 mL/kg at the rate of 1 mL/s) induces transient hypotension. This response has been reported to be due to decreased total peripheral resistance and/or decreased cardiac performance. Although the hypotension is transient and recovers within 2 min without detrimental consequences, it is important to understand the associated hemodynamics and mechanisms. We found that the hypotensive effect was larger with intravenous NaCl infusion than with intra-aortic infusion, indicating that change in cardiac performance played a more significant role than change in peripheral resistance. NaCl infusion induced an increase in pulmonary vascular resistance and central venous pressure and a decrease in right ventricular dP/dt max, suggesting acute cor pulmonale. Diastolic ventricular crosstalk-induced left ventricular failure was also observed. Hyperosmotic NaCl-induced hypotension was therefore mainly due to a combination of acute cor pulmonale and left ventricular failure.