Global Success Rate Research Articles

Esotropia management: outcomes and prognostic factors

AbstractPurposeWe aimed to study the epidemiological and the clinical characteristics of esotropia, to report the results of the medico‐surgical management, and to analyze the various factors that may influence the postoperative prognosis.MethodsMedical records of 130 patients who underwent esotropia surgery between 2000 and 2015 were retrospectively reviewed. Ophthalmological examination and complete sensorimotor assessment were performed for each patient. All surgeries were made by the same surgeon. We operated simultaneously on the horizontal and vertical elements. Total optical correction and amblyopia treatment were started before surgery. We studied the influence of certain prognostic factors on motor outcome, such as strabismus type, age at the onset, delay of surgical management, degree of amblyopia, preoperative deviation angle, and a vertical syndrome presence.ResultsThe mean age was 8 ± 4.20 years. Our patients had infantile esotropia in 52.3% of cases. The age of strabismus onset was 2 years ± 2.2 years on average. Our patients had amblyopia in 70.7% of cases. A bilateral medial rectus muscle recession was performed in half of our patients with an associated Faden operation in 46.2%. We obtained a motor success rate of 85.38% after a single operation and a global success rate of 91.54%. A stable fusion and stereoscopic vision were present in only 4.6% of cases preoperatively and 6.92% of cases postoperatively. Surgical dosage and postoperative day 1 angle were significantly associated with motor outcome (p = 0.009 and p < 0.001).ConclusionsEsotropia represents 83.3% of all strabismus. The infantile esotropia group had the worst motor and sensory status. Concerning the surgical protocol, the vertical syndrome is often operated on the same time as the horizontal deviation. Bilateral medial rectus muscle recession is the most practiced surgery. Unilateral surgery of recession/plication is indicated for deviations between 30 and 45 diopters and in the case of amblyopia. Bilateral surgery on 3 horizontal muscles is indicated in deviations of more than 45 diopters. Faden operation is indicated in angle variability of more than 15 diopters. The success rate for convergent strabismus varies between 48 to 90%.

Impact of operatoŕs experience on peri-procedural outcomes with Watchman FLX: Insights from the FLX-SPA registry.

BackgroundThe Watchman FLX is a device upgrade of the Watchman 2.5 that incorporates several design enhancements intended to simplify left atrial appendage occlusion (LAAO) and improve procedural outcomes. This study compares peri-procedural results of LAAO with Watchman FLX (Boston Scientific, Marlborough, Massachusetts) in centers with varying degrees of experience with the Watchman 2.5 and Watchman FLX.MethodsProspective, multicenter, “real-world” registry including consecutive patients undergoing LAAO with the Watchman FLX at 26 Spanish sites (FLX-SPA registry). Implanting centers were classified according to the center’s prior experience with the Watchman 2.5. A further division of centers according to whether or not they had performed ≤ 10 or > 10Watchman FLX implants was prespecified at the beginning of the study. Procedural outcomes of institutions stratified according to their experience with the Watchman 2.5 and FLX devices were compared.Results359 patients [mean age 75.5 (SD8.1), CHA2DS2-VASc 4.4 (SD1.4), HAS-BLED 3.8(SD0.9)] were included. Global success rate was 98.6%, successful LAAO with the first selected device size was achieved in 95.5% patients and the device was implanted at first attempt in 78.6% cases. There were only 9(2.5%) major peri-procedural complications. No differences in efficacy or safety results according to the centeŕs previous experience with Watchman 2.5 and procedural volume with Watchman FLX existed.ConclusionsThe Watchman FLX attains high procedural success rates with complete LAA sealing in unselected, real-world patients, along with a low incidence of peri-procedural complications, regardless of operatoŕs experience with its previous device iteration or the number of Watchman FLX devices implanted.

Lumbar Spinal Stenosis with Degenerative Spondylolisthesis Treated with Decompression Alone. A Cohort of 346 Patients at a Large Spine Unit. Clinical Outcome, Complications and Subsequent Surgery.

Cohort study. To study the clinical outcome, complications and subsequent surgery rate of DA for lumbar spinal stenosis (LSS) with DS. There is still no consensus regarding the treatment approach for LSS with DS. We performed a retrospectively designed cohort study on prospectively collected data from a single high productive spine surgical center. Results from the Swedish Spine Registry and a local register for complications were used for the analyses. Patients with LSS and DS (>3 mm) who underwent DA during January 2012 to August 2017 were included. Patient reported outcome measures at baseline and 2 years after surgery were analyzed. Complications within 30 days of surgery and all subsequent surgery in the lumbar spine were registered. We identified and included 346 patients with completed 2-year follow-up registration. At 2-year follow-up there was a significant improvement in all outcome measures. The global assessment success rate for back and leg pain was 68.3% and 67.6% respectively. Forty-one patients had at least 1 intra- or postoperative complication (11.9%). Nine patients (2.6%), underwent subsequent surgery within 2 years of the primary surgery whereof 2 underwent fusion. During the whole period of data collection, that is, as of June 2020, 28 patients had undergone subsequent surgery (8.1%) whereas 8 of them had had 2 surgeries. Fifteen patients underwent fusion. DA provides good clinical outcome at 2-year follow-up in patients with LSS and DS with low rate of intra- and postoperative complications and subsequent surgery. Our data supports the evidence that DA is effective and safe for LSS with DS.Level of Evidence: 3.

Epicardial course of the musculature related to the great cardiac vein: Anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion.

Mitral isthmus gaps have been ascribed to an epicardial musculature anatomically related to the great cardiac vein (GCV) and the vein of Marshall (VOM). Their lumen offers an access for radiofrequency application or ethanol infusion, respectively. The purpose of this study was to evaluate the frequency of mitral isthmus gaps accessible via the GCV lumen, to assess their location around the GCV circumference, and to propose an efficient ablation strategy when present. One hundred consecutive patients underwent VOM ethanol infusion (step 1) and endocardial linear ablation from the mitral annulus to the left inferior pulmonary vein (step 2). In cases of mitral isthmus gap, endovascular ablation of the GCV anchored wall facing the left atrium was systematically performed (step 3), while the opposite GCV free wall was targeted in case of block failure only (step 4). After VOM ethanol infusion and endocardial ablation, mitral isthmus block occurred in 51 patients (51%). Pacing maneuvers and activation sequences demonstrated an epicardial gap via the VOM in 2 patients (2%) and via the GCV in 47 patients (47%). In the latter case, block was achieved at the GCV anchored wall in 42 patients (89%) and the GCV free wall in 5 patients (11%). Global success rate of mitral isthmus block was 98%. No tamponade occurred. With the advent of VOM ethanol infusion, residual mitral isthmus gaps are mostly eliminated within the first centimeter of the GCV. Thorough mapping of the entire circumference of the GCV wall can help identify these epicardial gaps.

Our Experience with Inverted Papilloma: about 61 Patients

Introduction: Inverted papilloma (IP) is the most common type of Schneiderian papilloma originating from the mucosal lining of the nose and paranasal cavities. It is a semi benign tumor with a high tendency for recurrences and malignant transformation. Management consists of a complete tumoral resection. Objective: to analyze surgical results considering the techniques (open or endoscopic surgery), the rate and time of recurrence. Method: We present herein a cohort of 61 patients treated in the CHU-UCL Godinne between 1998 and 2019. We analyzed the demographic data, the origin of the tumor, the staging, the surgical approach and the outcomes. The patients were classified into two groups: the first one includes 48 patients operated de novo in CHU-UCL Godinne and the second group 13 patients referred to us for revision surgery. Results: We observed 8 recurrences, all groups confounded. The global success rate was 87%. The number of recurrences in the first group was 6 out of 48 and 2 out of 13 in the second group. Following these results we propose an algorithm of treatment depending on the site of attachment of the IP. Conclusion: We confirmed that more extended surgeries such as Caldwell Luc procedure, medial maxillectomy, Draf IIb/III frontal sinusotomy or type III sphenoidotomy give better outcomes than more “limited” and functional surgeries such as Draf I/IIa frontal sinusotomy or middle antrostomy. The latter should be done only for specific and limited extension of the IP in the maxillary sinus. A subperiosteal dissection is mandatory in all cases. Keywords: inverted papilloma; retrospective study; surgery; recurrence

Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage.

To identify the factors predicting intrauterine balloon tamponade (IUBT) failure for severe postpartum hemorrhage (PPH) after delivery, we conducted a retrospective cohort study of women who underwent IUBT for severe PPH after delivery from October 1, 2016 until September 30, 2017. The failure of IUBT was defined as the need of additional surgical procedures or uterine embolization. A total of 99,650 deliveries occurred during the study period. Among the patients, 106 cases of severe PPH were managed with IUBT, and the global success rate was 70.8% (75/106). Least absolute shrinkage and selection operator (LASSO) regression was performed to select the potential risk factors predicting IUBT failure. The associated risk factors—obesity, multiple gestation, cesarean delivery, estimated blood loss (EBL), and placenta accreta spectrum (PAS)—were included in multivariate logistic models. Ultimately, these models identified multiple gestation, EBL, and PAS as independent risk factors for IUBT failure. In conclusion, IUBT is an effective method for severe PPH. The presence of factors affecting IUBT failure should be recognized early, and other modalities of management should be anticipated.

Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital.

Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. Risk, III.

Invasive Aspergillosis (IA) in Acute Myeloid Leukemia (AML): When Is Prophylaxis Appropriate?

Introduction: management strategies for IA in patients receiving intensive chemotherapy (CT) for AML remain a matter of debate. Although most centers adopted primary prophylaxis recommendations based on few trials with less-than-ideal comparators, it appears that the option between a preemptive/early diagnosis-driven strategy and a prophylactic one should take in account the local incidence of IA, as the number needed to treat differs considerably between institutions. Until 2012 our center followed a preemptive strategy, but the finding of an alarming increase in IA cases led us to adopt primary prophylaxis. Results were prospectively evaluated in the following years and are reported here.Methods: from January/06 to March/12 308 patients received 629 first-line or subsequent CT courses (377 induction, 252 consolidation) in which only secondary antifungal prophylaxis was allowed. From April/12 to May/16 197 patients received 378 courses (230 induction, 148 consolidation) under prophylactic voriconazole. In both periods patients were nursed in rooms with positive pressure and HEPA filters, and CT regimens were unchanged. IA cases were classified according to EORTC/MSG criteria. Incidence of IA, overall mortality and attributable (specific) mortality at 12 weeks were compared between the 2 periods.Results: in the first period 82 cases of IA (79 lung, 3 sinus) were diagnosed, 6 of which were proven, 43 probable and 33 possible. Half occured in induction, 33% in consolidation, and the remaining in second-line CT courses. Most cases were treated with voriconazole (only 5 received other antifungals, in a clinical trial setting) with a global success rate of 82%. Two of the 11 failures occured in complete remission (consolidation courses). Overall mortality at 12 weeks was 23% and attributable mortality was 12%. In this period 2 cases of rhinocerebral Mucor were diagnosed. In the second period 13 cases of IA (12 lung, 1 gut) occured, of which 1 was proven, 7 probable e 5 possible. Most (77%) arose during induction. Serious (grade 3/4) adverse effects of voriconazole needing interruption were infrequent and consisted mainly of hepatic enzymes increases in 5% of the patients. Success rate (diverse antifungals) was 85%. Overall mortality at 12 weeks was 23% with no attributable mortality. Incidence of IA (27% vs 6.6%) and attributable mortality were significantly different between the 2 periods (both p < 0.001).Conclusion: preemptive/early diagnosis-driven strategy is atractive, as it spares most patients the side effects of useless antifungals. However, in centers with a high incidence of IA like ours, prophylaxis becomes highly rewarding, leading to a very significant reduction in these life-threatening fungal infections. DisclosuresNo relevant conflicts of interest to declare.

Immediate Loading of Implants Placed by Guided Surgery in Geriatric Edentulous Mandible Patients.

The aim of this study was to show the clinical outcomes of the immediate loading of implants inserted by guided surgery in edentulous mandible patients. Edentulous mandible patients were diagnosed with oral examination, cone beam computerized tomography and diagnostic casts for intermaxillary relations and treated with 8–10 implants for rehabilitation with guided surgery and immediate loading. After flapless surgery, implants were loaded with an immediate acrylic temporary prosthesis. After a period of six months, a ceramic definitive full-arch prosthesis was placed. A total of 22 patients (12 females and 10 males) were treated with 198 implants. Eleven patients (50%) had a previous history of periodontitis. Six patients (27.3%) were smokers. The follow-up was 84.2 ± 4.9 months. Clinical outcomes showed a global success rate of 97.5% of implants. Five implants were lost during the healing phase with provisional prosthesis. Twenty-two fixed full-arch rehabilitations were placed in the patients over the 193 remaining implants. Mean marginal bone loss was 1.44 mm ± 0.45 mm. Six patients (27.3%) showed some kind of mechanical prosthodontic complication. Eighteen (9.3%) of the 193 remaining implants were associated with peri-implantitis. The antecedents of peri-implantitis are critical elements for the survival of the implants. The loss of implants was significant in patients who smoked up to 10 cigarettes, compared to non-smokers. Peri-implantitis is one of the key elements in the long-term follow-up of implants and it was more manifest in smoking patients, and in those with a history of peri-implantitis. Marginal bone loss was more significant in smokers. Full-arch rehabilitation is presented as a predictable alternative with minor fatigue problems that are easily solvable.

Heparin coating in biodegradable ureteral stents does not decrease bacterial colonization-assessment in ureteral stricture endourological treatment in animal model.

BackgroundWe assessed an antireflux biodegradable heparin-coated ureteral stent (BraidStent®-H) in an animal model comparative study after endoscopic treatment of ureteral strictures.MethodsA total of 24 female pigs underwent initial endoscopic, nephrosonographic, and contrast fluoroscopy assessment of the urinary tract. Afterward, unilateral laparoscopic ureteral stricture model was performed. Three weeks later, the animals underwent laser endoureterotomy and were randomly assigned to Group-I, in which a double-pigtail stent was placed for 6 weeks, or Group-II, in which a BraidStent®-H was placed. Follow-up was carried out by ultrasonography, contrast fluoroscopy, ureteroscopy, urinalysis and bacteriuria assessment at 3, 6, 12 and 5 months. Finally, a pathological study of the urinary system was performed.ResultsThere were no animals in Group-II with vesicoureteral reflux, with significance at 6 weeks with Group-I. Distal ureteral peristalsis was maintained in 50–75% in Group-II at 1–6 weeks. The 91.7% of stents in Group-II were degraded between 3–6 weeks, without obstructive fragments. Bacteriuria in Group II was 33.3–50% at 3 and 6 weeks. The global success rate by groups was 91.6% and 87.5% in groups I and II, respectively, with no statistical significance.ConclusionsBraidStent®-H has been shown to be as efficacious as current ureteral stents in the treatment of benign ureteral strictures following laser endoureterotomy. In addition, it reduces the morbidity associated with current stents and has a homogeneous and predictable degradation rate of about 6 weeks, with no obstructive fragments. Future studies are required to improve the antibacterial coating to reduce BraidStent®-H contamination in view of the results obtained with the heparin coating.

Towards Revealing Parallel Adversarial Attack on Politician Socialnet of Graph Structure

Socialnet becomes an important component in real life, drawing a lot of study issues of security and safety. Recently, for the features of graph structure in socialnet, adversarial attacks on node classification are exposed, and automatic attack methods such as fast gradient attack (FGA) and NETTACK are developed for per-node attacks, which can be utilized for multinode attacks in a sequential way. However, due to the overlook of perturbation influence between different per-node attacks, the above sequential method does not guarantee a global attack success rate for all target nodes, under a fixed budget of perturbation. In this paper, we propose a parallel adversarial attack framework on node classification. We redesign new loss function and objective function for nonconstraint and constraint perturbations, respectively. Through constructing intersection and supplement mechanisms of perturbations, we then integrate node filtering-based P-FGA and P-NETTACK in a unified framework, finally realizing parallel adversarial attacks. Experiments on politician socialnet dataset Polblogs with detailed analysis are conducted to show the effectiveness of our approach.

Impact of Operator's Experience on Peri-Procedural Outcomes with Watchman FLX: Insights from the FLX-SPA Registry

Objectives: This study compares peri-procedural results of left atrial appendage occlusion (LAAO) with Watchman FLX (Boston Scientific, Marlborough, Massachusetts) in centers with varying degrees of experience with the Watchman 2.5 and Watchman FLX devices. Background: The Watchman FLX is a device iteration of the Watchman 2.5 that incorporates several design enhancements intended to simplify LAAO and improve procedural outcomes. Methods: Prospective multicenter registry including consecutive patients undergoing LAAO with the Watchman FLX at 26 Spanish sites (FLX-SPA registry). Implanting centers were classified according to the center's prior experience with the Watchman 2.5 device. A further stratification of centers according to whether or not they had performed {less than or equal to}10 or >10 Watchman FLX implants was prespecified at the beginning of the study. Procedural outcomes of both groups of institutions were compared. Results: A total of 359 patients (mean age 75.5{plus minus}8.1, CHA2DS2-VASc 4.4{plus minus}1.4, HAS-BLED 3.8{plus minus}0.9) were included. Global success rate was 98.6%, successful LAAO with the first selected device size was achieved in 95.5% patients and the device was implanted at first attempt in 78.6% cases. There were only 9 (2.5%) major peri-procedural complications. No differences in efficacy or safety results according to the center´s previous experience with Watchman 2.5 device and procedural volume with Watchman FLX existed. Conclusions: The Watchman FLX attains high procedural success rates with complete LAA sealing in unselected, real-world patients, along with a low incidence of peri-procedural complications, regardless of operator´s experience with its previous device iteration or the number of Watchman FLX implants performed.

Single centre experience of ICD lead extraction for lead dysfunction: Procedures and results

The increase in ICD implantation has been accompanied by an increase in lead-related complications. Non-functional ICD leads extraction can be challenging with a high rate of complications. The aim of this study was to examine transvenous ICD lead extraction at the University Hospital of Grenoble-Alpes. This is a retrospective analysis of the extractions performed since May 2002, for lead dysfunction. The variables studied were extraction techniques and results. A total of 110 ICD leads were removed during 106 extraction procedures. The mean age was 61.8 ± 14.6 years and 80.2% were male. All procedures were performed in the operating room of cardiac surgery, under general anesthesia, with surgical stand-by and trans-esophageal echocardiographic monitoring. One ICD lead has been removed during the procedure in 96.2% ( n = 102) and 2 leads in 3.8% ( n = 4). These leads were double-coil in 88.2% ( n = 97) and single-coil in 11.8% ( n = 13). The extraction strategy consisted of simple traction (10%, n = 10), and in case of failure, gradual use of locking stylet (7.3%, n = 8), laser sheath (80%, n = 88) and femoral vascular approach by lasso (2.7%, n = 3). The global success rate was 97.2% ( n = 103). Complications recorded were bleeding (8.5%, n = 9) and tamponade (1.9%, n = 2). The mortality rate was 2.8% ( n = 3). All deaths were due to a vena cava injury, specifically superior vena cava in 2 cases and inferior vena cava in 1 case. Two deaths occurred during extraction and the third death after the end of the procedure. Univariate analysis has shown that lead age greater than 10 years is significantly associated with mortality (16.7% vs. 1.1%, P = 0.03). In this long-term monocentric experience, ICD lead extraction had a high success rate, but is still challenging with vena cava injury leading to death is 2.8%.

Endoscopic Third Ventriculostomy with or without Choroid Plexus Coagulation for Treatment of Hydrocephalus in Guinea: Analysis of 76 Cases in the Department of Neurosurgery of Kipe, Conakry

In low-income countries, endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation (CPC) is an increasingly accepted alternative to shunt therapy in adult and pediatric hydrocephalus. The authors report the result of this treatment in Conakry in a mixed population of adult and pediatric patients regardless of the etiology of the hydrocephalus. A retrospective study was conducted on 76 patients undergoing 89 ETV from January 2013 to September 2020. The predominant group of patients was infants less than one year with a mean age of 4.3 months and extremes of 1 - 8 months. The H/F sex ratio was 1.7/1. All patients presented acutely with signs of high intracranial pressure. Post-infectious causes and malformations and tumors were the main etiologies, respectively 21%, 47.3%, and 15.7%. The mean duration of the endoscopic procedures was 49.93 ± 10.9 mm, associated with a choroid plexus coagulation in 42% of cases. The complication rate in the first month was 22%, with CSF leak (5%) and death (11%) accounting for the majority. At three months, the complications rates were 45%, with 14.4% closed stroma, 6% epilepsy, and 24% mortality. The mean follow-up was 28 months (range 2 - 53), and the global success rate of 61%. Our study, with its limitations, shows that ETV with CPC is a safe primary approach for the treatment of hydrocephalus in low-income countries regardless of the etiology and the age of the patients.

Functional outcomes after robot-assisted pyeloplasty for ureteropelvic junction obstruction: A bi-centre experience.

Robot-assisted pyeloplasty (RALP) for patients with clinically symptomatic ureteropelvic junction obstruction (UPJO) is increasing and needs assessment. Patients who underwent RALP for UPJO in two academic centres were included. Demographic and perioperative data were collected retrospectively. UPJO was evaluated by imaging pre- and post-surgery. Patients had follow-up consultations 3,6 and 12 months post-surgery. Global success was defined as a clinical response plus radiographic evidence of no further obstruction 3-months post-surgery. Overall 214 patients (median age: 40 years [interquartile range:30.3-54.0]) were included. Fourteen patients (6.5%) had undergone previous surgery for UPJO. Thirty patients (14%) suffered complication: urinoma (n = 13; 6.1%), pyelonephritis (n = 15; 7%) and retroperitoneal haematomas (n = 2; 0.9%). Repeated early surgery was necessary in eight patients (3.6%). Seven patients had a recurrence of UPJO and six (2.9%) underwent repeated surgery. Radiological success rate was 96.7% whereas global success rate was 91%. RALP was a reliable, effective and safe treatment for UPJO with a high global and radiologic success rate.

Treatment outcome of percutaneous ablation in patients with supraventricular arrhythmias in Cuenca, April 2013- July 2018

BACKGROUND: Supraventricular tachycardia is commonly diagnosed in clinical practice, despite having a good prognosis, it can significantly affect the patient’s life quality. Pharmacological treatment does not result in the total absence of the arrhythmia, which is why ablation therapy has become the treatment of choice, due to its high success rate, and for offering a definitive solution. The aim of this study was to determine the frequency of each supraventricular tachycardia type, according to age and sex, the rate of success of percutaneous ablation and its related factors, and the frequency of complications due to the procedure. METHODS: A cross-sectional, descriptive, correlational study was conducted, including 156 patients diagnosed with supraventricular tachycardia and ablated, from five hospitals where the procedure was performed, based on their clinical records. RESULTS: From the 156 patients in this study, 51.9% were women and 48.1% men, the age ranged between 10 and 80 years. The most commonly reported arrhythmias were nodal reentrant tachycardia, atrioventricular reentrant tachycardia and atrial flutter, being the atrioventricular reentrant tachycardia the most frequent of all. The global success rate was 93.5%, no complications were reported, and none of the studied factors had significant statistical association with the success rate. CONCLUSION: Ablation treatment had a high success rate, with cero complications in this study, demonstrating the efficacy and safety of the procedure.

The limitations of the Cepheid GeneXpert® Mtb/Rif assay for the diagnosis and management of polyresistant pulmonary tuberculosis

Abstract Background Tuberculosis (TB) is the leading world-wide cause of death caused by a single infectious agent. The global treatment success rate for multi-drug resistant (MDR) TB, defined as resistance to at least rifampicin and isoniazid, is estimated at 56%. Mutations in the rpoB gene predict resistance to rifampicin, and are used as a marker of MDR-TB, with standard quadruple therapy recommended in patients testing rpoB wildtype. Case report A 30-year old woman from Moldova had smear-positive pulmonary TB and was started on standard quadruple therapy after Cepheid GeneXpert® testing detected no mutations in the rpoB gene predictive of rifampicin resistance. After 14 days in hospital, she was considered to be non-infectious despite persistently smear-positive sputum samples and was discharged to continue TB medications in the community. Whole genomic sequencing (WGS) available 8 days after discharge subsequently predicted polyresistant TB (resistance to more than one first-line anti-TB drug apart from rifampicin). Results The patient was readmitted for treatment modification and required a further 82 days in hospital before sputum samples became culture-negative and respiratory isolation was lifted. Conclusions This case highlights the limitations of using the absence of mutations in the rpoB gene to predict fully susceptible TB. In cases of polyresistant TB, testing solely for rifampicin resistance may result in inadequate treatment, as resistance to first-line medications apart from rifampicin will not be detected. The lack of guidelines on appropriate de-escalation from respiratory isolation pertaining to pulmonary smear-positive polyresistant TB was also emphasised in this case. Our patient was removed from respiratory isolation when two consecutive sputum samples were culture-negative at 42 days. As sputum samples may remain smear-positive but be culture-negative, this raises the question of whether smear-positivity alone should be used as a measure for de-isolation.

P1188Oral antibiotic treatment for local cardiac implantable electronic device infections: our 6-year experience

Abstract INTRODUCTION Cardiac implantable electronic device (CIED) infection is a severe disease with an increasing incidence due to the rise in the number of CIEDs implanted world-wide. Complete hardware removal is the treatment of choice, but there is little clinical data about the best antimicrobial strategy, such as the best choice of antibiotics, treatment duration and when to switch to oral administration in cases of local CIED infections. PURPOSE In 2013, we designed a new protocol for CIED infection management, by which local infections were treated with complete hardware removal followed by empiric parenteral antibiotic during the first 72h, which was replaced to an oral agent (in case of negative blood cultures) and continued for 10 days. The oral antibiotic was selected according to the local cultures when positive, or to Clindamicin, Levofloxacin or Cotrimoxazole when no germ was identified. Our purpose is to describe our experience and results after the implementation of this strategy. METHODS We retrospectively reviewed all consecutive local CIED infection cases from the implementation of the protocol until September 2019, and evaluated the population characteristics, type of infection, rate of positive cultures and outcomes. RESULTS We identified 74 cases of CIED infection, of which 46 (62%) were local. The average age of this population was 75.3 ± 13.2 yo and 65% (30) were male. The predominant comorbidities were diabetes (41%), congestive heart failure (30%), and malignancies (22%). Eighteen patients (39%) had previous local infection treated medically without hardware removal. Mean number of previous procedures was 2.65 ± 1.8, and 34 (74%) of the devices were pacemakers (single and dual chamber), 5 (11%) ICDs, 6 (13%)CRT-P and 1 (2%) CRT-D. Blood cultures were negative in all cases, whereas local cultures (exudate or intraoperative tissue) were positive in 32 (70%). The most frequent microorganisms were Staphylococcus epidermidis in 18 (56%) and Staphylococcus aureus in 8 (25%), including 1 case of meticillin-resistance. Intravenous Vancomycin was administered in all cases during 72 h, followed by oral antibiotics for a mean duration of 8.8 ± 3.3 days. Hardware removal was intended in all cases, with complete or clinical success in 42 and 3 cases respectively (global success rate 97.8%), and in one case (2.2%) an epicardial lead was not removed. During a mean follow-up of 30 months, 1 infection-related death occurred (2%) due to a side effect of intravenous antibiotic therapy, and there was 1 infection relapse (2%) in the only patient without complete hardware removal, related to the remnant epicardial lead. CONCLUSIONS Oral antimicrobial treatment with good bioavailability agents, associated with complete hardware removal is an effective strategy for the management of local CIED infections, with a low recurrence rate, and avoiding long hospitalizations and potential side effects of intravenous antibiotic therapy.

A Hybrid Adversarial Attack for Different Application Scenarios

Adversarial attack against natural language has been a hot topic in the field of artificial intelligence security in recent years. It is mainly to study the methods and implementation of generating adversarial examples. The purpose is to better deal with the vulnerability and security of deep learning systems. According to whether the attacker understands the deep learning model structure, the adversarial attack is divided into black-box attack and white-box attack. In this paper, we propose a hybrid adversarial attack for different application scenarios. Firstly, we propose a novel black-box attack method of generating adversarial examples to trick the word-level sentiment classifier, which is based on differential evolution (DE) algorithm to generate semantically and syntactically similar adversarial examples. Compared with existing genetic algorithm based adversarial attacks, our algorithm can achieve a higher attack success rate while maintaining a lower word replacement rate. At the 10% word substitution threshold, we have increased the attack success rate from 58.5% to 63%. Secondly, when we understand the model architecture and parameters, etc., we propose a white-box attack with gradient-based perturbation against the same sentiment classifier. In this attack, we use a Euclidean distance and cosine distance combined metric to find the most semantically and syntactically similar substitution, and we introduce the coefficient of variation (CV) factor to control the dispersion of the modified words in the adversarial examples. More dispersed modifications can increase human imperceptibility and text readability. Compared with the existing global attack, our attack can increase the attack success rate and make modification positions in generated examples more dispersed. We’ve increased the global search success rate from 75.8% to 85.8%. Finally, we can deal with different application scenarios by using these two attack methods, that is, whether we understand the internal structure and parameters of the model, we can all generate good adversarial examples.

Rendering A Chiral Screening Step In Supercritical Fluid Chromatography Mass-Spectrometry Compatible

Nowadays, sensitive chiral methods are required for the determination of chiral impurities and for assays in biological samples. Supercritical fluid chromatography (SFC), one of the main techniques to separate chiral molecules, can be coupled to MS to provide such sensitive methods. Moreover, chiral separation strategies are very useful to reduce the development time and cost of such methods. This study investigates the transfer of an existing non-MS compatible screening step (as part of a separation strategy) into an MS-compatible one. The initial step had a cumulative success rate of 100 % for 57 tested compounds using methanol or 2-propanol as mobile phase modifier on one of four chiral stationary phases. The additives applied in the original mobile phases, i.e. isopropylamine and trifluoroacetic acid, negatively affect the ionization in SFC-MS and thus need to be replaced. Formic acid, acetic acid, water, ammonia, ammonium acetate and ammonium formate were investigated as MS-compatible additives in different combinations and concentrations. Only methanol-based mobile phases were considered in this study because high system pressures were obtained with isopropanol. The other experimental parameters remained the same as in the initial screening step. The effects of the alternative additives on the obtained resolutions as well as on the global success rate were investigated. The best alternative MS-compatible mobile phase contained 0.5 % CH3COOH and 40 mM NH3 as additives. This mobile phase provided the highest number of separations and rather high resolutions. An MS-compatible screening step was defined with this alternative mobile phase. Compared to the original additives, a similar success rate was obtained.