The effect of an initial catheter ablation with an adjunctive ethanol infusion into the vein of Marshall on persistent atrial fibrillation.

INTRODUCTION: Some previous studies have reported that a first-step ethanol infusion into the vein of Marshall (EIVOM) with touch-up radiofrequency (RF) ablation can facilitate mitral isthmus (MI) block and improves the ablation outcomes in persistent atrial fibrillation (PeAF) patients. However, the effect of an initial RF ablation with an adjunctive EIVOM has not been fully investigated. METHODS: This study enrolled 233 PeAF patients undergoing pulmonary vein isolation and linear ablation including an MI, roof line, and cavotricuspid isthmus ablation. An EIVOM was performed when endocardial ablation with or without coronary sinus ablation failed to create MI block. RESULTS: Bidirectional MI block was achieved in 224 patients (96.1%). Among them, MI block was obtained by only RF ablation in 174/224 patients (77.7%) (RF group) and an adjunctive EIVOM was needed in 50/224 (22.3%) (EIVOM group). During the follow-up, 113 (64.9%) RF group patients were free from AF/atrial tachycardia compared to 41 (82.0%) EIVOM group patients (log-rank p = .045). In a multivariate Cox regression analysis, an adjunctive EIVOM was associated with a lower recurrence rate (hazard ratio = 0.39, 95% confidence interval = 0.17-0.78, p = .006). CONCLUSION: An initial RF ablation with an adjunctive EIVOM strategy improved MI ablation's acute success rate and was associated with better clinical outcomes.

Association between induction of the self-management system for preventing readmission and disease severity and length of readmission in patients with heart failure.

OBJECTIVE: We recently developed the self-management system using the HF points and instructions to visit hospitals or clinics when the points exceed the pre-specified levels. We found that the self-management system decreased the hospitalization for HF with an increase in unplanned visits and early intervention in the outpatient department. However, it is unclear whether we managed severe HF outpatients who should have been hospitalized. In this study, we aimed to compare HF severity in rehospitalized patients with regard to self-management system use. RESULTS: We retrospectively enrolled 306 patients (153 patients each in the system user and non-user groups) using propensity scores (PS). We compared HF severity and length of readmission in rehospitalized patients in both groups. During the 1-year follow-up period, 24 system users and 43 non-system users in the PS-matched cohort were hospitalized. There were no significant differences between the groups in terms of brain natriuretic peptide levels at readmission, maximum daily intravenous furosemide dose, percentage of patients requiring intravenous inotropes, duration of hospital stay and in-hospital mortality. These results suggest that the HF severity in rehospitalized patients was not different between the two groups.

Association of the induction of a self-care management system with 1-year outcomes in patients hospitalized for heart failure.

BACKGROUND: To perform self-care in patients with heart failure (HF), we developed and implemented a new HF point self-care system, which was characterized by 1) the way weight and HF symptoms were scored ("Heart Failure Points") and 2) the timing of consultations defined for both patients and health care providers. We examined the association between the induction of the new system and 1-year outcomes in patients hospitalized for HF. METHODS: We retrospectively enrolled 569 consecutive patients into our study who were admitted for HF treatment at our hospital: 275 patients between November 2011 and October 2013 (before the induction of the self-management system) and 294 patients between November 2015 and October 2017 (after the induction). We sought to compare the clinical outcomes between patients using the self-management system and those not using the system after propensity-score (PS) matching. The primary outcome measure was a composite of all-cause death or HF rehospitalization. RESULTS: The cumulative 1-year incidence of the primary outcome measure in the use group (n = 153) was significantly lower than that in the non-use group (n = 153) (24.5% vs. 34.9%, respectively; p = 0.031; hazard ratio: 0.62; 95% confidence interval: 0.40-0.96), mainly due to a reduction in HF hospitalization. CONCLUSIONS: The induction of the new self-care system was associated with better 1-year outcomes in patients hospitalized for HF. This system may help patients with HF to achieve more efficient self-care.

Association of oral yeast carriage with specific host factors and altered mouth sensation.

OBJECTIVES: The aim of this study was to determine if there was a significant association between the presence of altered mouth and taste sensations with oral carriage of yeasts and to assess the factors that influence the yeast carriage. STUDY DESIGN: The oral and dental status including unstimulated (USFR) and stimulated (SSFR) whole salivary flow rates of a total of 509 subjects was recorded. Saliva specimens were collected for microbiologic examination. Multiple logistic regression analysis was performed to identify any factors that were significantly associated with the prevalence of oral yeasts. RESULTS: Old age, clinical signs of oral dryness, denture wearing, and a reduction in USFR increased the prevalence of yeasts, whereas patient gender, levels of dentition, the sensation of dry or burning mouth, taste disorders, and SSFR were not associated with increased prevalence of oral yeasts. CONCLUSIONS: An increased prevalence of oral yeasts was not found to relate to changes in mouth sensation alone. Other factors, most notably patient age, the wearing of dentures, clinical signs of oral dryness, and salivary flow rate under rest conditions, were, however, found to be closely associated with oral yeast carriage.

Proteinase activity of prevotella species associated with oral purulent infection.

Prevotella intermedia and Prevotella nigrescens are often regarded as principal causes of acute dentoalveolar infection; however, other species within the genus are also known to be associated with such infection. The aim of this study was to determine the in vitro proteolytic activity of these different Prevotella species that have been implicated with dentoalveolar infection. A total of 234 strains were obtained from pus specimens from dentoalveolar infection and from the plaque of healthy volunteers. Prevotella loescheii, Prevotella oralis, Prevotella melaninogenica, Prevotella buccae, and Prevotella denticola were all shown to have a proteolytic activity (8.5-10.5 x 10(-8) A-units) lower than that of P. intermedia and P. nigrescens (21.1-23.5 x 10(-8) A-units). In the case of P. loescheii, P. melaninogenica, and P. intermedia, the level of proteolytic activity for clinical strains was significantly (P < 0.05) higher than that recorded for commensal strains. Proteolytic activity for all species of Prevotella examined was inhibited by N-ethylmaleimide and phenymethylsulfonyl fluoride. This study suggests that Prevotella species associated with oral purulent infection produce cysteine and serine proteinases and that in certain species of Prevotella, the strains involved in infection exhibit higher proteolytic activity when compared with strains from healthy sites.

Detection of cfxA and cfxA2, the beta-lactamase genes of Prevotella spp., in clinical samples from dentoalveolar infection by real-time PCR.

While most bacteria involved in dentoalveolar infection are highly susceptible to penicillin, some Prevotella strains exhibit resistance to this agent through the production of beta-lactamase. The production of beta-lactamase by Prevotella spp. is in turn associated with the expression of the genes cfxA and cfxA2. The aim of the present study was to determine the prevalence of cfxA and cfxA2 in Prevotella strains by use of real-time PCR and to assess the performance of this molecular method for the direct detection of the genes in 87 clinical samples (pus and root canal exudates) from dentoalveolar infection. Production of beta-lactamase by each isolate was determined using a nitrocefin disk. beta-Lactamase production was seen in 31% of Prevotella isolates, while all isolates of other species were beta-lactamase negative. The penicillin resistance of isolates strongly correlated with the production of beta-lactamase. Real-time PCR was found to detect the cfxA and cfxA2 genes from at least five cells per reaction mixture (5 x 10(3) CFU/ml of pus). Using real-time PCR, the presence of cfxA and cfxA2 was evident for all 48 beta-lactamase-positive Prevotella strains. In contrast, neither beta-lactamase-negative Prevotella (n = 91) or non-Prevotella (n = 31) strains were positive for the genes. In this study, 31 of the 87 samples yielded beta-lactamase-positive Prevotella results, and cfxA and cfxA2 were detected in all 31 samples. Of the 56 culture-negative samples, 8 (14%) were positive for cfxA and cfxA2 by the real-time PCR. This sensitive and specific molecular method offers a rapid clinical test for aiding in the selection of an appropriate antibiotic for treatment of dentoalveolar infection. Although penicillin remains largely effective in the treatment of dentoalveolar infection, beta-lactamase-stable antibiotics should be considered in cases in which beta-lactamase-positive Prevotella strains are involved.

Incidence and bacteriology of bacteremia associated with various oral and maxillofacial surgical procedures.

OBJECTIVE: The aim of this study was to determine the incidence and bacteriology of bacteremia associated with various oral and maxillofacial surgical procedures. METHODS: A total of 237 patients who underwent oral and maxillofacial surgery were included in this study. Blood samples were obtained for bacteriological examination immediately after the essential steps of the surgical procedure had been performed. RESULTS: Bacteremia was detected in patients who underwent surgery for tumor, infection and trauma, and surgical reconstruction of jaw. In particular, decortication for osteomyelitis and tooth extraction resulted in a higher incidence of bacteremia compared with other surgical procedures. The incidence of bacteremia was not affected by oral hygiene, gingival inflammation, blood loss, and duration of surgery. Furthermore, concerning tooth extraction, there was no statistical difference in the incidence of bacteremia with respect to the number of teeth extracted and the method of extraction. Extraction of teeth with odontogenic infection (periodontitis, periapical infection, and pericoronitis) did however produce a significantly increased incidence of bacteremia compared with infection-free teeth (P < .01). Viridans streptococci were the predominant group of bacteria isolated from the bacteremias. CONCLUSION: Oral and maxillofacial surgery involving transoral incision produces bacteremia, regardless of the extent and degree of surgical invasion. In particular, surgical procedure at infected sites is more likely to result in bacteremia compared with infection-free sites.

Detection of Candida in concentrated oral rinse cultures by real-time PCR.

The incidence of oral candidosis has increased in recent years, largely as a result of the emergence of human immunodeficiency virus infection and the more widespread use of immunosuppressive chemotherapy. This development has been associated with a need for more reliable methods for the detection of Candida. The present study assessed the performance of a real-time PCR and two block-based PCRs for the detection of Candida in 193 concentrated oral rinse culture (CRC) specimens. A total of 102 CRC specimens were positive by culture for Candida; and 96, 90, and 75 of these were also positive by real-time, N18-specific, and internal transcribed spacer (ITS)-specific PCRs, respectively. The five false-negative results by the real-time PCR were all non-Candida albicans positive by culture. Of the 91 culture-negative CRC specimens, 20, 41, and 44 were positive by the real-time PCR and the N18- and ITS-specific PCRs, respectively. All three PCRs detected fungal DNA in 8 culture-negative CRC specimens, with a further 30 being positive by two of the three PCRs. A total of 32 CRC specimens were Candida free by all methods. In summary, a real-time PCR that provides a sensitive, specific, and rapid alternative technique for detection of Candida in the mouth is described.

Molecular characterization of clinical and environmental isolates of vancomycin-resistant Enterococcus faecium and Enterococcus faecalis from a teaching hospital in Wales.

The present study describes the first molecular characterization of environmental and clinical isolates of vancomycin-resistant enterococci (VRE) in Wales. Over a 3-month period (May-July 2000), 134 isolates of VRE (89 Enterococcus faecium and 45 Enterococcus faecalis) were isolated from the patient environment of the University Hospital of Wales (UHW) in Cardiff, Wales, UK. In addition, over the same time-period, 24 clinical isolates of VRE (20 isolates of E. faecium and four isolates of E. faecalis) were obtained from 14 patients. All study isolates were subjected to PFGE typing and their van genotypes were determined by using multiplex PCR. The vanA PCR product (231 bp) was evident in 146 (92 %) of 158 VRE isolates; the remaining 12 isolates (8 %) were positive for the vanB gene. All isolates of E. faecalis were found to be vanA-positive. In total, 16 PFGE banding profiles (pulsotypes) were observed for environmental isolates of E. faecium, whilst eight pulsotypes were found for isolates of E. faecalis. Some of these pulsotypes were isolated from multiple sites, whereas others were more restricted in their distribution. Eleven pulsotypes were evident for clinical isolates and eight of these (representing 11 isolates) were also encountered in environmental isolates. Eleven clinical isolates of E. faecium (55 %) shared an identical pulsotype that was not detected in environmental isolates. These results demonstrate a heterogeneous environmental population of VRE and an association of certain strains with clinical isolates. Predominance of a single pulsotype (not detected in the environment) amongst clinical isolates suggests non-environmental transmission between patients.