Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry

BACKGROUND

The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.

METHODS

REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.

RESULTS

Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.

CONCLUSIONS

REAL-AF operators were high volume low fluoroscopy "real world" operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

Primary cesarean delivery among uncomplicated term nulliparous parturients: the influence of group practice within a community hospital

In a community hospital, the rate of cesarean delivery varied significantly for uncomplicated nulliparous patients managed by four practice groups, although the rate of shoulder dystocia did not. Among four practice groups in a single center, our objective was to discern the rate of cesarean delivery (CD) among uncomplicated, term nulliparous parturients, and the likelihood of shoulder dystocia and admission to the neonatal intensive care unit (NICU). The inclusion criteria for this retrospective study were uncomplicated nullipara > or = 37 weeks. Multivariable models were used for analysis. Over 2 years, 1217 women met the inclusion criteria. The overall rate of primary CD was 21%, with rates of 15%, 24%, 17%, and 32% for the four groups. After controlling for confounding variables, the rate of primary CD was significantly higher for group 2 (odd ratio [OR] 1.68; 95% confidence interval [CI] 1.17, 2.42) and 4 (OR 1.83; 95% CI, 1.25, 2.68) versus groups 1 and 3 combined. Shoulder dystocia and admission to NICU did not vary between groups. Among uncomplicated term nulliparous patients, the rate of primary CD varied significantly by practice groups, without an effect on rate of shoulder dystocia or NICU admission.

Diagnosis of postpartum infections: clinical criteria are better than laboratory parameter

BACKGROUND

Physiologic increases in the leukocyte count and segmental neutrophil percentage during pregnancy alter the ability of these indices to predict infection.

METHODS

Women with cesarean deliveries were assessed by leukocyte counts and segmented neutrophil percentage as well as clinical signs to detect postoperative infection.

RESULTS

In 157 consecutive patients undergoing cesarean deliveries there was a significant physiologic increase between the preoperative and postoperative leukocyte count (12.4 +/- 3.9/uL vs. 14.8 +/- 3.4/uL, P < 0.001). The leukocyte count after delivery did not discriminate whether or not the patient would develop a postpartum infection or have significant hyperpyrexia.

CONCLUSION

Due to physiologic changes associated with pregnancy, the leukocyte count and segmented neutrophil percentage do not predict infection. Therefore clinical findings are most important in diagnosing postpartum infections.

An inhibitor of CD28-CD80 interactions impairs CD28-mediated costimulation of human CD4 T cells

We have identified and characterized a microbial extract-derived inhibitor of T cell CD28-dependent costimulation, NP1835-2, utilizing an in vitro system in which anti-human CD3 antibody and a human CD80-Ig fusion protein are immobilized on protein A-coated microspheres. This system is CD28-CD80-dependent, as judged by the specific ability of anti-CD80 antibody or cytotoxic T lymphocyte antigen-4-Ig to block human CD4 T cell responses. Activation of CD4 T cells in this system in presence of NP1835-2 resulted in a concentration-dependent inhibition of T cell proliferation (IC50 of 1-4 microg/ml), surface activation marker expression, and the production of many T cell cytokines, with the exception of TGFbeta. Impairment of T cell activation correlated with a blockade of cell cycle progression at G0/G1 and was only partly restored by addition of 100 U/ml IL-2. No inhibition by NP1835-2 of T cell proliferation stimulated by plate-bound anti-CD3 antibody, phorbol 12-myristate 13-acetate + A23187, or P815 cells expressing the costimulatory molecule CD58 was observed. NP1835-2 was unable to modulate anti-IgM-stimulated B cell proliferation or LPS-induced monocyte activation. Suboptimal concentrations of NP1835-2 and cyclosporin together were able to impair T cell activation in an additive fashion. NP1835-2 was also able to inhibit the primary human MLR. These data indicate that NP1835-2 may belong to a class of molecules capable of selectively impairing CD28-mediated T cell costimulation and suggest its potential usefulness in the treatment of a variety of T cell-dependent diseases. Moreover, NP1835-2 may serve as a useful probe for investigating the mechanisms involved in T cell nonresponsiveness.

Regulation of granulocyte colony-stimulating factor gene expression by interleukin-17

Interleukin-17 (IL-17) has been previously reported to induce stromal cells to produce a number of hematopoietic and proinflammatory cytokines, including granulocyte colony-stimulating factor (G-CSF). Here, we have evaluated the mechanisms responsible for the augmentation of G-CSF gene expression by IL-17, using the murine 3T3 fibroblast cell line. Treatment of 3T3 cells, but not primary bone marrow-derived macrophages or murine monocyte/macrophage cell lines, resulted in increased steady-state G-CSF mRNA levels within 2-4 h and augmented G-CSF protein production. The combination of IL-17 and LPS enhanced G-CSF expression in an additive fashion. Stability studies revealed that IL-17 stabilized G-CSF mRNA levels, with a t1/2 of 4 h, compared to a t1/2 of less than 2 h in medium or LPS-treated cells. Induction of G-CSF expression in 3T3 cells by IL-17 did not appear to require tyrosine kinase activation or de novo protein synthesis. These studies indicate that post-transcriptional mechanisms play an important role in IL-17-induced G-CSF expression in fibroblasts and suggest that IL-17 may be useful for further delineating mechanisms of G-CSF gene regulation.

A specific stimulator of granulocyte colony-stimulating factor accelerates recovery from cyclophosphamide-induced neutropenia in the mouse

We have identified a small molecular weight compound, SCH 14988, which specifically stimulates in vitro granulocyte-colony stimulating factor (G-CSF) production from activated human peripheral blood mononuclear cells and monocytes but not other cytokines or CSFs with hematoregulatory activity. In vivo administration of SCH 14988 to mice rendered neutropenic by cyclophosphamide treatment resulted in the accelerated recovery of the peripheral neutrophil compartment. This activity correlated with increased in vivo G-CSF levels and stimulation of marrow granulopoiesis, and was comparable to that of exogenously administered recombinant human G-CSF. No alterations to other leukocyte populations in peripheral blood, spleen, or the peritoneal cavity were observed. These findings suggest that SCH 14988 may be clinically useful to enhance neutrophil granulopoiesis, as well as to study the mechanisms involved in G-CSF gene regulation.