Intravesical sequential gemcitabine and docetaxel versus bacillus calmette-guerin (BCG) plus interferon in patients with recurrent non-muscle invasive bladder cancer following a single induction course of BCG

INTRODUCTION

Repeat BCG induction remains an option for select non-muscle invasive bladder cancer (NMIBC) patients who fail initial therapy. Alternative salvage intravesical regimens such as Gemcitabine and Docetaxel (Gem/Doce) have been investigated. We aimed to compare the efficacy BCG plus interferon a-2b (BCG/IFN) and Gem/Doce in patients with recurrent NMIBC after a single prior BCG course.

METHODS

The National Phase II BCG/IFN trial database and multi-institutional Gem/Doce database were queried for patients with recurrent NMIBC after one prior BCG induction course, excluding those with BCG unresponsive disease. Stabilized inverse probability treatment weighted survival curves were estimated using the Kaplan-Meier method and compared. Propensity scores were derived from a logistic regression model. The primary outcome was recurrence free survival (RFS); secondary outcomes were high-grade (HG) RFS and risk factors for treatment failure.

RESULTS

We identified 197 BCG/IFN and 93 Gem/Doce patients who met study criteria. Patients receiving Gem/Doce were older and more likely to have HG disease, CIS, and persistent disease following induction BCG (all P < 0.01). After propensity score-based weighting, the adjusted 1- and 2-year RFS was 61% and 53% after BCG/IFN versus 68% and 46% after Gem/Doce (P = 0.95). Adjusted 1- and 2-year HG-RFS was 60% and 51% after BCG/IFN versus 63% and 42% after Gem/Doce (P = 0.68). Multivariable Cox regression revealed that Gem/Doce treatment was not associated with an increased risk of failure (HR = 0.97, P = 0.89) as compared to BCG/IFN.

CONCLUSION

Patients with recurrent NMIBC after a single induction BCG failure and not deemed BCG unresponsive had similar oncologic outcomes with Gem/Doce and BCG/IFN in a post-hoc analysis. Additional prospective studies are needed.

Comparison of Major Complications at 30 and 90 Days Following Radical Cystectomy

OBJECTIVES

To better understand the time-course in which major complications occur after radical cystectomy and to describe associations with complications at 30 and 90 days.

METHODS

A database of radical cystectomy cases was queried for preoperative, perioperative, and postoperative data. Follow-up extended to 90 days postsurgery and included major complications (Clavien III-V). Early (30-day) and late (90-day) complication rates were compared via McNemar's test, and patient characteristics were compared across complication time groups by one-way ANOVA or Fisher's exact tests. Multinomial logistic regression was used to explore associations between patient characteristics and complication timing.

RESULTS

Of 969 patients undergoing radical cystectomy, 210/969 (21.7%) experienced a complication within 90 days. The rate of major complication significantly differed at 30 and 90 days (14.4% [conflict of interest (CI): 12.4%-16.9%] vs 21.7% [CI: 19.2%-24.4%] respectively, P ≤.0001). Chronic obstructive pulmonary disease (COPD) (P = .03), Charlson Comorbidity Index (P = .02), and Indiana pouch diversion (P = .002) were significant predictors of early complication. Diabetes was the strongest predictor for late complication (OR: 2.42; P = 0.01). Diabetes was also a significant predictor for late genitourinary complications (OR 3.39; P = .01), and smoking history was a significant predictor for late infectious complications (OR 3.61; P = .01).

CONCLUSION

We identified a significant number of complications occurring after 30 days postcystectomy, including the majority of deaths and genitourinary complications. These findings suggest that assessment of complications exclusively at 30 days would fail to capture a large proportion of major complications and deaths. Understanding the time-course of complications postcystectomy will serve to better inform design of future outcome studies.

Uretero-Enteric Anastomotic Stricture Following Radical Cystectomy: A Comparison of Open, Robotic Extracorporeal, and Robotic Intracorporeal Approaches

OBJECTIVES

To compare the incidence of benign uretero-enteric anastomotic strictures between open cystectomy, robotic cystectomy with extracorporeal urinary diversion, and robotic cystectomy with intracorporeal urinary diversion. The effect of surgeon learning curve on stricture incidence following intracorporeal diversion was investigated as a secondary outcome.

PATIENTS AND METHODS

Patients who underwent radical cystectomy at an academic hospital between 2011 and 2018 were retrospectively reviewed. The primary outcome, incidence of anastomotic stricture over time, was assessed by a multivariable Cox proportional hazards regression. A Cox regression model adjusting for sequential case number in a surgeon's experience was used to assess intracorporeal learning curve.

RESULTS

Nine hundred sixty-eight patients were included: 279 open, 382 robotic extracorporeal, and 307 robotic intracorporeal. Benign stricture incidence was 11.3% overall: 26 (9.3%) after open, 43 (11.3%) after robotic extracorporeal, and 40 (13.0%) after robotic intracorporeal. An intracorporeal approach was associated with anastomotic stricture on multivariable analysis (HR 1.66; P = .05). After 75 intracorporeal cases, stricture incidence declined from 17.5% to 4.9%. Higher sequential case volume was independently associated with reduced stricture incidence (Hazard Ratio per 10 cases: 0.90; P = .02).

CONCLUSION

An intracorporeal approach to urinary reconstruction following robotic radical cystectomy was associated with an increased risk of benign uretero-enteric anastomotic stricture. In surgeons' early experience with intracorporeal diversion the difference in stricture incidence was more pronounced compared to alternative approaches; however, increased intracorporeal case volume was associated with a decline in stricture incidence leading to a modest difference between the 3 surgical approaches overall.

Obesity induces limited changes to systemic and local immune profiles in treatment-naive human clear cell renal cell carcinoma

Understanding the effects of obesity on the immune profile of renal cell carcinoma (RCC) patients is critical, given the rising use of immunotherapies to treat advanced disease and recent reports of differential cancer immunotherapy outcomes with obesity. Here, we evaluated multiple immune parameters at the genetic, soluble protein, and cellular levels in peripheral blood and renal tumors from treatment-naive clear cell RCC (ccRCC) subjects (n = 69), to better understand the effects of host obesity (Body Mass Index "BMI" ≥ 30 kg/m2) in the absence of immunotherapy. Tumor-free donors (n = 38) with or without obesity were used as controls. In our ccRCC cohort, increasing BMI was associated with decreased percentages of circulating activated PD-1+CD8+ T cells, CD14+CD16neg classical monocytes, and Foxp3+ regulatory T cells (Tregs). Only CD14+CD16neg classical monocytes and Tregs were reduced when obesity was examined as a categorical variable. Obesity did not alter the percentages of circulating IFNγ+ CD8 T cells or IFNγ+, IL-4+, or IL-17A+ CD4 T cells in ccRCC subjects. Of 38 plasma proteins analyzed, six (CCL3, IL-1β, IL-1RA, IL-10, IL-17, and TNFα) were upregulated specifically in ccRCC subjects with obesity versus tumor-free controls with obesity. IGFBP-1 was uniquely decreased in ccRCC subjects with obesity versus non-obese ccRCC subjects. Immunogenetic profiling of ccRCC tumors revealed that 93% of examined genes were equivalently expressed and no changes in cell type scores were found in stage-matched tumors from obesity category II/III versus normal weight (BMI ≥ 35 kg/m2 versus 18.5-24.9 kg/m2, respectively) subjects. Intratumoral PLGF and VEGF-A proteins were elevated in ccRCC subjects with obesity. Thus, in ccRCC patients with localized disease, obesity is not associated with widespread detrimental alterations in systemic or intratumoral immune profiles. The effects of combined obesity and immunotherapy administration on immune parameters remains to be determined.

Multi-Institution Evaluation of Sequential Gemcitabine and Docetaxel as Rescue Therapy for Nonmuscle Invasive Bladder Cancer

PURPOSE

Rescue intravesical therapies for patients with bacillus Calmette-Guérin failure nonmuscle invasive bladder cancer remain a critical focus of ongoing research. Sequential intravesical gemcitabine and docetaxel therapy has shown safety and efficacy in 2 retrospective, single institution cohorts. This doublet has since been adopted as an intravesical salvage option at multiple institutions. We report the results of a multi-institutional evaluation of gemcitabine and docetaxel.

MATERIALS AND METHODS

Each institution retrospectively reviewed all records of patients treated with intravesical gemcitabine and docetaxel for nonmuscle invasive bladder cancer between June 2009 and May 2018. Only patients with recurrent nonmuscle invasive bladder cancer and a history of bacillus Calmette-Guérin treatment were included in the analysis. If patients were disease-free after induction, maintenance was instituted at the treating physician's discretion. Posttreatment surveillance followed American Urological Association guidelines. Survival analysis was performed using the Kaplan-Meier method and risk factors for treatment failure were assessed with Cox regression models.

RESULTS

Overall 276 patients (median age 73 years, median followup 22.9 months) received treatment. Nine patients were unable to tolerate a full induction course. One and 2-year recurrence-free survival rates were 60% and 46%, and high grade recurrence-free survival rates were 65% and 52%, respectively. Ten patients (3.6%) had disease progression on transurethral resection. Forty-three patients (15.6%) went on to cystectomy (median 11.3 months from induction), of whom 11 (4.0%) had progression to muscle invasion. Analysis identified no patient, disease or prior treatment related factors associated with gemcitabine and docetaxel failure.

CONCLUSIONS

Intravesical gemcitabine and docetaxel therapy is well tolerated and effective, providing a durable response in patients with recurrent nonmuscle invasive bladder cancer after bacillus Calmette-Guérin therapy. Further prospective study is warranted.

Neurogenic bladder monitoring using the cystomanometer and cystoelastometer

INTRODUCTION

Patients with neurogenic bladder (NGB) require periodic urodynamics (UDS) to evaluate bladder function, which in turn helps guide management. At times, bladder decompensation or hydronephrosis may develop in patients between urodynamic testing intervals. Increased surveillance has improved outcomes in other chronic conditions (e.g., diabetes). Two novel devices, the cystomanometer (CM) and cystoelastometer (CEM), have been developed at the authors' institution to allow for home bladder pressure monitoring. The handheld CM can be attached to the end of any catheter and records the opening bladder pressure along with a time stamp. In addition, the CEM actively evacuates urine via a pump and records the urine volume evacuated. For safety, the pump slows and stops as it detects increasing resistance. Data are stored and transmitted wirelessly from both devices to a smartphone. A novel phone application stores, displays, and transmits data to a secure hospital server.

OBJECTIVE

This aim of this study was to validate the function of the CM and CEM and their accuracy relative to UDS.

STUDY DESIGN

Institutional review board approval was obtained. All patients with NGB managed with intermittent catheterization undergoing routine UDS were eligible for study inclusion. At the completion of UDS, the instillation port of the 6-French dual-lumen UDS catheter was connected to the CM or CEM. Bladder parameters were simultaneously recorded using the device and UDS during bladder emptying. Correlative statistics were calculated.

RESULTS

A total of 36 patients (30 children/6 adults; age range from 1.2 to 38 years [median: 7.5 years]) underwent CM testing. Strong pressure correlation with UDS was identified (R² = 0.89). A total of 42 patients (30 children/12 adults; age range of 2.9-85.2 years [median: 12.2 years]) underwent CEM testing. Again, strong pressure correlation was found (R² = 0.77). Cystoelastometer volume measurements were highly correlated with measured volumes (Fig. 4, R² = 0.98).

DISCUSSION

Both the CM and CEM functioned well and transmitted the data wirelessly to a smartphone. The data from these devices were strongly correlated with simultaneous data from the UDS. A limitation is that these devices were used by healthcare providers, and therefore, use by patients or their parents/caregivers at home has not been demonstrated.

CONCLUSION

The CM and CEM devices provide accurate bladder pressure and volume measurements. The potential for improved patient monitoring and care is promising. Reliability testing and the effects of such monitoring on patient outcomes remain to be determined.

Quadruple immunotherapy of Bacillus Calmette-Guérin, interferon, interleukin-2, and granulocyte-macrophage colony-stimulating factor as salvage therapy for non-muscle-invasive bladder cancer

BACKGROUND

Bacillus Calmette-Guérin (BCG) is the most effective initial intravesical therapy for high-grade non-muscle invasive bladder cancer, but many patients still fail. Combination intravesical BCG and interferon (IFN) will salvage some patients but results remain suboptimal.

OBJECTIVE

We hypothesized that further immunostimulation with intravesical interleukin-2 and subcutaneous granulocyte-macrophage colony-stimulating factor may improve response to intravesical BCG and IFN in patient with prior BCG failure(s).

METHODS

A retrospective review was performed. Patients received 6 treatments of quadruple immunotherapy (intravesical solution with one-third dose BCG, 50 million units IFN, and 22 million units interleukin-2, along with a 250-mcg subcutaneous sargramostim injection). Surveillance began 4 to 6 weeks after treatment completion. Patients received maintenance if recurrence-free. Success was defined as no recurrence (bladder or extravesical) and bladder preservation. Analysis was performed by Kaplan-Meier method (P<0.05).

RESULTS

Fifty-two patients received treatment with a median recurrence follow-up of 16.3 months and overall follow-up of 41.8 months. All patients had at least 1 prior BCG failure and 13% had 2 or more prior failures. Only 3 patients (6%) were unable to tolerate full induction. Treatment success was 55% at 1 year, and 53% at 2 years. Thirteen patients (25%) underwent cystectomy at a median time of 17.3 months with disease progression to T2 in 1 patient and T3 in 2 patients. No patients had positive surgical margins or positive lymph nodes.

CONCLUSIONS

In patients with non-muscle-invasive bladder cancer with prior BCG failure, quadruple immunotherapy demonstrated good treatment success in some patients and warrants further evaluation.

Obesity as defined by waist circumference but not body mass index is associated with higher renal mass complexity

OBJECTIVES

Obesity, typically defined as a body mass index (BMI)≥30kg/m², is an established risk factor for renal cell carcinoma (RCC) but is paradoxically linked to less advanced disease at diagnosis and improved outcomes. However, BMI has inherent flaws, and alternate obesity-defining metrics that emphasize abdominal fat are available. We investigated 3 obesity-defining metrics, to better examine the associations of abdominal fat vs. generalized obesity with renal tumor stage, grade, or R.E.N.A.L. nephrometry score.

METHODS AND MATERIALS

In a prospective cohort of 99 subjects with renal masses undergoing resection and no evidence of metastatic disease, obesity was assessed using 3 metrics: body mass index (BMI), radiographic waist circumference (WC), and retrorenal fat (RRF) pad distance. R.E.N.A.L. nephrometry scores were calculated based on preoperative CT or MRI. Univariate and multivariate analyses were performed to identify associations between obesity metrics and nephrometry score, tumor grade, and tumor stage.

RESULTS

In the 99 subjects, surgery was partial nephrectomy in 51 and radical nephrectomy in 48. Pathology showed benign masses in 11 and RCC in 88 (of which 20 had stage T3 disease). WC was positively correlated with nephrometry score, even after controlling for age, sex, race, and diabetes status (P = 0.02), whereas BMI and RRF were not (P = 0.13, and P = 0.57, respectively). WC in stage T2/T3 subjects was higher than in subjects with benign masses (P = 0.03). In contrast, subjects with Fuhrman grade 1 and 2 tumors had higher BMI (P<0.01) and WC (P = 0.04) than subjects with grade 3 and 4 tumors.

CONCLUSIONS

Our data suggest that obesity measured by WC, but not BMI or RRF, is associated with increased renal mass complexity. Tumor Fuhrman grade exhibited a different trend, with both high WC and BMI associated with lower-grade tumors. Our findings indicate that WC and BMI are not interchangeable obesity metrics. Further evaluation of RCC-specific outcomes using WC vs. BMI is warranted to better understand the complex relationship between general vs. abdominal obesity and RCC characteristics.

Obesity-induced changes to the immune landscape in human renal cell carcinoma subjects

Immunotherapy for advanced renal cell carcinoma (RCC) has shown tremendous promise. However, clinical responses remain &lt;30% and the reasons are unclear. Obesity affects ~35% of U.S. adults and is a major risk factor for RCC. We reported previously that obesity impairs immunotherapeutic efficacy in a murine renal cancer model, due to increased myeloid suppressor cells and weakened effector CD8 T cell responses. Based on these results, we hypothesized that obesity would also induce detrimental shifts in the immune landscape in treatment-naive subjects with confirmed RCC. In an IRB-approved study, we consented 86 RCC subjects with obesity (mean BMI = 38.4) and 77 normal to over-weight RCC subjects (mean BMI = 25.0), plus tumor-free controls, into a prospective study to examine intra-tumoral and systemic leukocytes by multi-parameter flow cytometry, plasma proteins via multiplex, and tumor gene expression by Nanostring. Numerous systemic cell populations (ex: CD45RO+ PD1+ CD4 or CD8 T cells, and HLA-DR- CD14− CD11b+MDSC, all p&gt;0.05) were unaltered by obesity in RCC subjects. Peripheral CD14+ inflammatory monocytes and Foxp3+ Tregs were decreased in RCC subjects with obesity (both p&lt; 0.05). However, obesity altered plasma proteins to favor RCC progression, with increased angiopoietin, VEGF-A and –C, and IL-8 (all p&lt; 0.05). Within renal tumors, obesity did not alter CD4 or CD8 T cell percentages or phenotypes (CD45RO, PD1, CD56). Nanostring analysis of renal tumors revealed multiple obesity-related changes in pro-tumorigenic genes. Thus, obesity in RCC subjects had surprisingly few effects on cellular immunity, but multiple effects on protein mediators that may shift the overall immune landscape toward one that favors tumor progression.

Experience with Sequential Intravesical Gemcitabine and Docetaxel as Salvage Therapy for Non-Muscle Invasive Bladder Cancer

Patients with high-grade muscle invasive bladder cancer (NMIBC) receive intravesical therapy with bacillus Calmette-Guérin (BCG) as the well-established standard-of-care. However, even with prompt induction of intravesical therapy, approximately 40 % of patients will recur within 2 years. For patients who fail BCG, options include radical cystectomy, repeat BCG therapy, or alternative intravesical salvage therapy. In this review, we will discuss the most recent published evidence on salvage intravesical therapy with an emphasis on a more in-depth report of our therapeutic strategy with sequential gemcitabine and docetaxel intravesical therapy for this treatment-refractory population. In addition, we will provide practical advice on our approach to this challenging patient population including the use of operative staging to aid early identification of treatment failures.

Bacillus Calmette-Guérin (BCG) Treatment Failures with Non-Muscle Invasive Bladder Cancer: A Data-Driven Definition for BCG Unresponsive Disease

Objective: To create the first data-driven definition for those unlikely to benefit from further BCG treatment.

Materials and Methods: The database created for the Phase 2 BCG-Interferon-α 2B (IFN) study was queried and BCG failure patients were identified (n = 334). Full study protocols have previously been published. Separate models were constructed for analysis of patients with any CIS (pure or concomitant) and pure papillary disease. Variables considered included age, gender, stage, grade, tumor size and focality (for papillary only), number of prior BCG courses, and prior BCG failure interval.

Results: Patients with recurrent CIS within 6 months of their most recent prior BCG course (HR 2.56, p <  0.01) and ≥2 prior BCG failures (HR 1.54, p <  0.01) responded worst to repeat intravesical therapy. Those with CIS recurrence at 6–12 months did not differ from those recurring within 6 months (HR = 0.88, p = 0.71). Patients with recurrent papillary disease within 6 months (HR 1.82, p = 0.02), ≥2 BCG failures (HR 1.54, p = 0.03), and multifocal disease (HR 2.05, p <  0.01) responded worst to therapy. Patients with T1 disease remained disease free in 38% of cases (24–51% 95% CI) at 2 years with low rates of progression.

Conclusions: Patients who fail two courses of BCG with either persistent or recurrent multifocal papillary disease within 6 months or CIS within 12 months of their prior BCG should be considered BCG unresponsive. Recurrent T1 disease respond reasonably well to another course with low progression rates but further investigation is warranted.

Intravesical and alternative bladder-preservation therapies in the management of non-muscle-invasive bladder cancer unresponsive to bacillus Calmette-Guérin

Intravesical Bacillus Calmette-Guérin (BCG) remains the standard of care in the treatment of bladder carcinoma in situ and as adjuvant therapy after thorough transurethral resection of high-grade non-muscle-invasive bladder cancer. Despite BCG therapy, in up to 40% of patients it would recur and 60% to 70% of those would fail repeat BCG induction be deemed BCG unresponsive. For such patients, cystectomy remains the preferred treatment option per the American Urological Association and European Association of Urology, though some patients would be medically unfit or refuse radical surgery. Further intravesical therapy for bladder-preservation therapies may preserve quality of life in these patients and in some cases can be curative. There are numerous non-BCG intravesical salvage options available, including immunotherapy, single-agent chemotherapy, combination chemotherapy, and device-assisted chemotherapy. In addition, investigation of radiation-based treatment and other novel therapies including checkpoint inhibitors (programmed death-1/programmed death ligand-1), are currently underway. In this review, we examine the current status of alternatives to BCG in salvage therapy for bladder preservation.

Bacillus Calmette-Guérin (BCG) Treatment Failures in Non-Muscle Invasive Bladder Cancer: What Truly Constitutes Unresponsive Disease

Bacillus Calmette-Guérin (BCG) remains the most effective intravesical therapy for non-muscle invasive bladder cancer but will fail in up to 40% of patients. The ability to identify patients who are least likely to respond to further BCG therapy allows urologists to pursue secondary treatments more likely to convey a recurrence or survival benefit to the patient. We examined the literature to determine what constitutes BCG unresponsive disease. After review, we believe that BCG unresponsive disease should be defined as (1) patients with recurrent high grade T1 disease within 6 months of their primary tumor after at least one course of BCG or patients who have failed at least 2 courses of BCG with either (2) persistent or recurrent pure papillary (Ta) disease within 6 months or (3) persistent or recurrent carcinoma in situ (CIS) within 12 months.

Sequential Intravesical Gemcitabine and Docetaxel for the Salvage Treatment of Non-Muscle Invasive Bladder Cancer

Background:

Bacillus Calmette-Guerin (BCG) is the most effective intravesical therapy for non-muscle invasive bladder cancer (NMIBC), but patients can fail or supply shortages can develop. For BCG failures, radical cystectomy is recommended. However, in patients who desire bladder preservation or are poor surgical candidates, alternative salvage intravesical therapies should be explored.

Objective:

To determine whether dual sequential intravesical gemcitabine and docetaxel is effective in treating NMIBC.

Methods:

We evaluated our initial experience with 45 patients treated with intravesical gemcitabine and docetaxel between June 2009 and May 2014. Patients were treated with 6 weekly instillations of gemcitabine (1 gram of gemcitabine in 50 ml of sterile water) followed immediately by docetaxel (37.5 mg of docetaxel in 50 mL of saline). Treatment success was defined as no bladder cancer recurrence and no cystectomy. Intention-to-treat analysis was performed using the Kaplan Meier method.

Results:

Forty-five patients received treatment with a median overall follow-up of 15 months. Median follow up for treatment success was 6 months in all patients and 13 months for responders. Five patients were unable to tolerate a full induction course. Treatment success was 66% at first surveillance, 54% at 1 year, and 34% at 2 years after initiating induction. Ten patients received cystectomy (median of 5.6 months from starting induction) with no positive margins or lymph nodes on final pathology.

Conclusions:

Sequential dual intravesical gemcitabine and docetaxel can salvage some patients in a challenging NMIBC cohort.

Application of ultrasound-based velocity estimate statistics to strain-rate estimation

Quantification of the relative myocardial deformation rate, or strain rate, is an emerging capability to aid a cardiologist in assessing myocardial function. Ultrasound Doppler techniques can be used to compute tissue motion relative to a transducer. The myocardial strain rate can be computed as the localized spatial derivative of the tissue velocity. Such a strain-rate estimate is typically numerically noisy. We present the relevant speckle statistics to faciliate the computation of the strain rate based on a weighted least squares regression, with statistically appropriate weights.

Carboxyhemoglobin levels in patients with sickle-cell anemia: relationship to hemolytic and vasoocclusive severity

BACKGROUND

When carbon monoxide binds to hemoglobin, it increases the affinity of hemoglobin for oxygen and shifts the oxygen dissociation curve to the left. The resulting decrease in sickling tendency could have clinical benefit, and carbon monoxide has been suggested as a treatment for sickle-cell disease. Furthermore, in sickle-cell disease, as in other hemolytic diseases, endogenous carbon monoxide production is increased because of increased heme catabolism.

METHODS

In the present study, we measured carboxyhemoglobin levels in sickle-cell patients and compared them with estimates of the hemolytic and the vasoocclusive severity of the disease.

RESULTS

Significant correlation was found between carboxyhemoglobin (HbCO) levels and hematocrit, reticulocyte count, unconjugated bilirubin level, and percentage of irreversibly sickled cells. However, there was no significant correlation between carboxyhemoglobin levels and measures of the vaso-occlusive severity of the disease.

CONCLUSIONS

The correlations between HbCO levels and measures of hemolytic severity are best explained by the known relationship between hemoglobin catabolism and CO production. The lack of correlation with vaso-occlusive severity may be due to the complex changes involved and the difficulty of quantifying vasoocclusive severity.

Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial

OBJECTIVE

To examine the efficacy of digoxin for decreasing operative time, difficulty, and pain of late second-trimester surgical abortions.

METHODS

We performed a randomized, double-masked, placebo-controlled trial of intra-amniotic digoxin for second-trimester dilation and evacuation (D&E) involving 126 consecutive women at an inner-city public hospital. Eligible women had gestational ages of 20-23.1 weeks, spoke English or Spanish, and were at least 16 years old. Digoxin (1 mg) or saline was injected intra-amniotically 24 hours before the procedure, at cervical laminaria insertion. The primary outcome was procedure duration. Sample size was based on 80% power to detect a difference of 3.5 minutes between groups.

RESULTS

The two groups were similar in demographic factors, obstetric histories, and gestational duration. The average gestational length was 22.5 weeks. There was no difference in procedure duration (mean +/- standard deviation) between groups (placebo 14.7 +/- 7.0, digoxin 15.4 +/- 8.0). There were no differences in blood loss estimated by surgeons, pain scores, procedure difficulty scores, or complications between groups. Vomiting was significantly more common in those who received digoxin (placebo 3.1%, digoxin 16.1%). Most subjects (91%) reported that they preferred their fetuses were dead before the abortions.

CONCLUSION

Although digoxin did not increase efficacy of late second-trimester abortion, patient preference might justify its use.

Vaccine-induced antibodies inhibit CETP activity in vivo and reduce aortic lesions in a rabbit model of atherosclerosis

Using a vaccine approach, we immunized New Zealand White rabbits with a peptide containing a region of cholesteryl ester transfer protein (CETP) known to be required for neutral lipid transfer function. These rabbits had significantly reduced plasma CETP activity and an altered lipoprotein profile. In a cholesterol-fed rabbit model of atherosclerosis, the fraction of plasma cholesterol in HDL was 42% higher and the fraction of plasma cholesterol in LDL was 24% lower in the CETP-vaccinated group than in the control-vaccinated group. Moreover, the percentage of the aorta surface exhibiting atherosclerotic lesion was 39.6% smaller in the CETP-vaccinated rabbits than in controls. The data reported here demonstrate that CETP activity can be reduced in vivo by vaccination with a peptide derived from CETP and support the concept that inhibition of CETP activity in vivo can be antiatherogenic. In addition, these studies suggest that vaccination against a self-antigen is a viable therapeutic strategy for disease management.