What is the effectiveness of surgical and non-surgical therapies in the treatment of ischemic priapism in patients with sickle cell disease? A systematic review by the EAU Sexual and Reproductive Health Guidelines Panel

Sickle cell disease (SCD) is an inherited hemoglobin disorder characterized by the occlusion of small blood vessels by sickle-shaped red blood cells. SCD is associated with a number of complications, including ischemic priapism. While SCD accounts for at least one-third of all priapism cases, no definitive treatment strategy has been established to specifically treat patients with SC priapism. The aim of this systematic review was to assess the efficacy and safety of contemporary treatment modalities for acute and stuttering ischemic priapism associated with SCD. The primary outcome measures were defined as resolution of acute priapism (detumescence) and complete response of stuttering priapism, while the primary harm outcome was as sexual dysfunction. The protocol for the review has been registered (PROSPERO Nr: CRD42020182001), and a systematic search of Medline, Embase, and Cochrane controlled trials databases was performed. Three trials with 41 observational studies met the criteria for inclusion in this review. None of the trials assessed detumescence, as a primary outcome. All of the trials reported a complete response of stuttering priapism; however, the certainty of the evidence was low. It is clear that assessing the effectiveness of specific interventions for priapism in SCD, well-designed, adequately-powered, multicenter trials are strongly required.

Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel

Surgical treatments for ischemic priapism (IP) include shunts or penile implants. Non-ischemic priapism (NIP) is usually the result of penile/perineal trauma causing an arterial fistula and embolisation may be required. We conducted a systematic review on behalf of the EAU Sexual and Reproductive health Guidelines panel to analyse the available evidence on efficacy and safety of surgical modalities for IP and NIP. Outcomes were priapism resolution, sexual function and adverse events following surgery. Overall, 63 studies (n = 923) met inclusion criteria up to September 2021. For IP (n = 702), surgery comprised distal (n = 274), proximal shunts (n = 209) and penile prostheses (n = 194). Resolution occurred in 18.7-100% for distal, 5.7-100% for proximal shunts and 100% for penile prostheses. Potency rate was 20-100% for distal, 11.1-77.2% for proximal shunts, and 26.3-100% for penile prostheses, respectively. Patient satisfaction was 60-100% following penile prostheses implantation. Complications were 0-42.5% for shunts and 0-13.6% for IPP. For NIP (n = 221), embolisation success was 85.7-100% and potency 80-100%. The majority of studies were retrospective cohort studies. Risk of bias was high. Overall, surgical shunts have acceptable success rates in IP. Proximal/venous shunts should be abandoned due to morbidity/ED rates. In IP > 48 h, best outcomes are seen with penile prostheses implantation. Embolisation is the mainstay technique for NIP with high resolution rates and adequate erectile function.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Intrauterine device migration to the urinary bladder causing sexual dysfunction: a case report

BACKGROUND

Intravesical migration represents an uncommon complication of intrauterine device (IUD) insertion. We present the case of an IUD that migrated to the urinary bladder, causing significant sexual complaints.

CASE REPORT

A 38-year-old woman presented with complaints of gradually evolving dyspareunia and recurrent urinary tract infections during the past 12 months. She reported an IUD insertion 18 months before. Further detailed evaluation revealed disorders in all sexual domains. Imaging and cystoscopy detected the presence of IUD in the urinary bladder. Under anesthesia, the IUD was removed out of the bladder without any complications. In her follow-up evaluation after six months, her sexual function was significantly improved and she had no urinary symptoms.

CONCLUSION

Sexual difficulties in a woman with an IUD should raise the suspicion of device dislodgement or dislocation. Hippokratia 2016, 20(1): 70-72.

Pre-pregnancy obesity: maternal, neonatal and childhood outcomes

Nowadays, obesity rates have an increasing tendency, since the incidence of obesity in both developed and developing countries is still rising over the years. Maternal pre-pregnancy obesity seems to have an influence on both obstetrical and neonatal outcomes. Many researchers have focused on pregnancies of obese nulliparous, non diabetic women as well as on the medical profile of their neonates, with conflicting conclusions. Additionally, several studies have followed these neonates through their childhood and adult life in order to observe them for any occurrence towards specific diseases. In our study, literature was reviewed and results are presented, into two groups. The first group summarizes the correlation of high maternal prepregnancy Body Mass Index (BMI) with the rates of hypertensive disorders, fertility, cesarean section and maternal mortality, while the second group correlates maternal BMI to neonatal Apgar score, neonatal admission to NICU, preterm delivery, congenital defects, birthweight, and weight status after birth, child morbidity, respiratory problems as asthma and children's mortality. Maternal pre-pregnancy obesity tends to have an important negative impact on the above mentioned outcomes. However, further research, in certain fields, needs to be carried out in order to gain a clear image.

Dual inhibition of aromatase and epidermal growth factor receptor in non-small cell lung cancer

e22189

Background: Recent evidence suggests that estrogen signaling is important in the progression of cancers expressing estrogen receptors (ERs) and may also be involved in the pathogenesis of non-small cell lung cancer (NSCLC). Aromatase is an enzyme complex that catalyses the final step in estrogen synthesis and is present in several tissues, including the lung. In view of a possible functional interaction between the ER and the epidermal growth factor receptor (EGFR) pathways in NSCLC, we investigated the dual inhibition of aromatase and EGFR in NSCLC cell lines. Methods: In the current study we used exemestane, an irreversible steroidal aromatase inactivator, and erlotinib, an EGFR tyrosine kinase inhibitor. The in vitroexperiments were performed using H23 and A549, two NSCLC cell lines with low and high levels of aromatase, respectively. Cell proliferation was measured by MTT assay. Metalloproteinase (MMP) levels were detected by zymography and cell migration was determined by boyden chamber assay. EGFR protein levels detection was performed by immunofluorescense assay. Results: Exemestane and erlotinib inhibited H23 and A549 cell proliferation either alone or in combination, 48 hours after their application. However, the combination of exemestane and erlotinib was more effective than each agent alone, in H23 cells. Furthermore, exemestane decreased MMP-2 and MMP- 9 levels in H23 cells, whereas erlotinib did not. The combination of exemestane and erlotinib had the same effect on MMPs, as exemestane alone. The effect on cell migration was in line with the results in MMPs levels. In A549 cells, no changes in MMPs levels or cell migration were demonstrated. In addition, exemestane altered the location of EGFR protein in H23 cells, but not in A549 cells. Conclusions: Our findings suggest an antiproliferative effect of exemestane and erlotinib in both cell lines, as well as synergy for the combination in H23 cells. The activity of the combination in these cells with low levels of aromatase might involve an additional effect of exemestane on EGFR protein location. Erlotinib did not enhance the effect of exemestane on MMPs secretion and migration in H23 cells.

No significant financial relationships to disclose.

Global initiative for chronic obstructive lung disease for chronic obstructive pulmonary disease: GOLD opportunity for lung disorders

BACKGROUND

The purpose of this study was to assess the agreement of asthma and chronic obstructive pulmonary disease (COPD) treatment prescribed by physicians and pulmonologists in comparison to asthma and COPD guidelines and the need of the implementation of COPD guidelines in primary health care physicians.

METHODS

Eighty-three asthma patients and 100 COPD patients were chosen and classified in relation to the agreement of their treatment prescribed by a health care physician and that mentioned by global initiative for chronic obstructive lung disease (GOLD) The COPD patients were classified according to their stage of the disease too.

RESULTS

Both pulmonologists and primary health care physicians manage asthma patients following asthma guidelines, while great proportion of COPD patients are undertreated by primary health care physicians. The proportion of undertreated COPD patients is decreased as the stage of disease is progressing.

CONCLUSIONS

COPD patients mainly are undertreated by primary health care physicians when they are in the primary stages of the disease. The overtreatment of some patients consists of high doses of inhaled steroids prescribed by both pulmonologists, and mainly, primary health care physicians. Therefore, it can be concluded that there is the need of the implementation of COPD guideline by primary health care physicians and the need of COPD patients to be diagnosed in early stages by performing spirometry.

Synthesis, molecular structure determination, and antitumor activity of platinum(II) and palladium(II) complexes of 2-substituted benzimidazole

The complexes of 2-aminomethyl benzimidazole, 2-(beta-aminoethyl)benzimidazole, and 2-(alpha-aminoethy-l)benzimidazole with Pt(II) and Pd(II) have been prepared. The molecular structure of the free ligands and their complexes were studied by IR and 1H NMR. It was concluded that the substituted benzimidazole derivatives behave as bidentate ligands, being bound to the metal atoms via the nitrogen of the -N = group and the amino group of the side chain of the benzimidazole ring. The metal complexes were tested for antineoplastic activity both in cultures of neoplastic cells (MEL-745, K-562, Colon 205, IMP-32, SK-N-SH) and in vivo in rodents bearing L-1210 leukemia. The antiproliferative activity of these agents was compared to that of cis-platin.

Analysis of early lymphocyte activation events by fluorescence polarization flow cytometry

After short-term (up to 4 h) stimulation with mitogen or antigen, lymphocytes were incubated with fluorescein diacetate and the polarization of fluorescence from intracellular fluorescein was measured on a specially adapted FACS II. This flow cytofluorimetric method to assay early changes in activated lymphocytes gave a reproducible response to the mitogens phytohaemagglutinin (PHA), concanavalin-A and the monoclonal antibody OKT3, recognized at 1 h by decreased polarization. A response by immune spleen cells to the antigen dinitrophenyl-ovalbumin was revealed at 4 h. The calcium ionophore A23187 induced an increase in polarization after only 10 min. The PHA polarization response was shown to be dependent on PHA binding, PHA dose, T cells, calcium ions and an intact cytoskeleton. The cellular events monitored by the polarization change are presumably altered fluidity of the probe's microenvironment due to conformational change in macromolecules to which the probe has bound or to dissociation of the probe into the aqueous phase. The fluorescein fluorescence polarization assay is a reliable and sensitive monitor of early lymphocyte activation events and, coupled with the use of a flow cytometer, permits study of particular subpopulations of responding cells.

Flow cytofluorimetry of fluorescein fluorescence polarization to assay lymphocyte activation

Change in fluorescence polarization of intracellular fluorescein measured with a specially adapted flow cytometer reliably reflected subtle biophysical changes in cells, such as those accompanying increased temperature or osmolality of the suspending medium. This system was developed to monitor changes in lymphocytes one hour after stimulation with the mitogen phytohaemagglutinin, and provided a sensitive and rapid assay of lymphocyte activation.

Fluorescence polarization assay by flow cytometry

Fluorescence polarization measurement on cell suspensions provides a highly sensitive means for detecting subtle changes in the cells, such as occur early after lymphocyte activation or on malignant transformation. We review here the principles of fluorescence polarization, its measurement by a commercially available flow cytometer and application of such assays especially in cellular immunology.