Atrial fibrillation catheter ablation complications in obese and diabetic patients: Insights from the US Nationwide Inpatient Sample 2005–2013

BackgroundObesity and diabetes are risk factors for atrial fibrillation (AF) incidence and recurrence after catheter ablation. However, their impact on post‐ablation complications in real‐world practice is unknown.ObjectivesWe examine annual trends in AF ablations and procedural outcomes in obese and diabetic patients in the US and whether obesity and diabetes are independently associated with adverse outcomes.MethodsUsing the Nationwide Inpatient Sample (2005–2013), we identified obese and diabetic patients admitted for AF ablation. Common complications were identified using ICD‐9‐CM codes. The primary outcome included the composite of any in‐hospital complication or death. Annual trends of the primary outcome, length‐of‐stay (LOS) and total‐inflation adjusted hospital charges were examined. Multivariate analyses studied the association of obesity and diabetes with outcomes.ResultsAn estimated 106 462 AF ablations were performed in the US from 2005 to 2013. Annual trends revealed a gradual increase in ablations performed in obese and diabetic patients and in complication rates. The overall rate of the primary outcome in obese was 11.7% versus 8.2% in non‐obese and 10.7% in diabetic versus 8.2% in non‐diabetic patients (p < .001).ConclusionsObesity was independently associated with increased complications (adjusted OR, 95% CI:1.39, 1.20–1.62), longer LOS (1.36, 1.23–1.49), and higher charges (1.16, 1.12–1.19). Diabetes was only associated with longer LOS (1.27, 1.16–1.38). Obesity, but not diabetes, in patients undergoing AF ablation is an independent risk factor for immediate post‐ablation complications and higher costs. Future studies should investigate whether weight loss prior to ablation reduces complications and costs.     

Lymph node metastasis in soft tissue sarcoma in an extremity

For patients with soft tissue sarcoma in an extremity, the outcome is thought to be poor if lymph node metastasis develops. The purpose of this study was to examine the impact of lymphatic involvement from soft tissue sarcoma on patient survival. Thirty-nine (3.7%) of 1066 patients who had surgery for soft tissue sarcoma in an extremity had lymph node metastases develop. Three (20%) of 15 patients with epithelioid sarcoma, four (19%) of 21 patients with rhabdomyosarcoma, two (11.1%) of 18 patients with clear cell sarcoma, and two (11.1%) of 18 patients with angiosarcoma had lymphatic involvement. Thirty patients who had resection of involved lymph nodes had an estimated 5-year survival of 57%, whereas nine patients treated without surgery all died within 30 months. An estimated 4-year survival of 71% for patients with isolated lymph node metastases was significantly better than 21% for patients with synchronous systemic and lymph node involvement. There was no difference in outcome for patients with isolated lymphatic involvement compared with patients with American Joint Committee on Cancer Stage III extremity sarcomas. These results suggest that long-term survival is possible after surgical resection of lymphatic metastases from soft tissue sarcoma. The American Joint Committee on Cancer should consider separating isolated nodal metastases from systemic involvement in patients with Stage IV sarcoma.     

Thimerosal induces micronuclei in the cytochalasin B block micronucleus test with human lymphocytes

Thimerosal is a widely used preservative in health care products, especially in vaccines. Due to possible adverse health effects, investigations on its metabolism and toxicity are urgently needed. An in vivo study on chronic toxicity of thimerosal in rats was inconclusive and reports on genotoxic effects in various in vitro systems were contradictory. Therefore, we reinvestigated thimerosal in the cytochalasin B block micronucleus test. Glutathione S-transferases were proposed to be involved in the detoxification of thimerosal or its decomposition products. Since the outcome of genotoxicity studies can be dependent on the metabolic competence of the cells used, we were additionally interested whether polymorphisms of glutathione S-transferases (GSTM1, GSTT1, or GSTP1) may influence the results of the micronucleus test with primary human lymphocytes. Blood samples of six healthy donors of different glutathione S-transferase genotypes were included in the study. At least two independent experiments were performed for each blood donor. Significant induction of micronuclei was seen at concentrations between 0.05-0.5 micro g/ml in 14 out of 16 experiments. Thus, genotoxic effects were seen even at concentrations which can occur at the injection site. Toxicity and toxicity-related elevation of micronuclei was seen at and above 0.6 micro g/ml thimerosal. Marked individual and intraindividual variations in the in vitro response to thimerosal among the different blood donors occurred. However, there was no association observed with any of the glutathione S-transferase polymorphism investigated. In conclusion, thimerosal is genotoxic in the cytochalasin B block micronucleus test with human lymphocytes. These data raise some concern on the widespread use of thimerosal.     

Postpartum cerebral angiopathy: an important diagnostic consideration in the postpartum period

A 32-year-old woman, gravida 4, para 2, presented with a severe headache 5 days after she had a vaginal delivery with epidural anesthesia. Nine days later she had neurologic symptoms develop. Magnetic resonance imaging and cerebral angiogram were abnormal with evidence of a vasculitis consistent with postpartum cerebral angiopathy. The patient received both methylprednisolone and cyclophosphamide pulses with improvement of her symptoms. This is an important diagnosis for obstetricians to consider because it may result in serious neurologic damage if it is not diagnosed and treated early.