Increase Success Rates Research Articles

Effectiveness and Safety of Cryoablation in Patients With Atrial Fibrillation Episodes of

Background: Paroxysmal atrial fibrillation (AF) is closely related to pathophysiologic processes and clinical outcomes. However, it is uncertain whether cryoablation of pulmonary veins isolation is effective and safe for patients with symptomatic and drug refractory AF episodes of <24-h duration.Methods: The patients were designed into Group A (253 patients with paroxysmal AF episodes of <24-h duration) and Group B (253 patients with paroxysmal AF lasting for 24 h or longer) on a 1:1 basis by identical propensity scores. Mortality, stroke/transient ischemic attack (TIA), and complications relevant to the cryoablation procedure were compared, and recurrence of atrial tachyarrhythmia was analyzed for clinical independent predictors.Results: The rate of atrial tachyarrhythmia recurrence was 21.74% in Group A and 30.04% in Group B, respectively (P = 0.042). At 12-month follow-up from the procedure, lower incidences of stroke/TIA endpoint of the patients were observed in Group A compared with Group B by Kaplan–Meier analysis [HR 0.34 (0.13–0.87), P = 0.025]. No significant differences in mortality and complications relevant to the cryoablation procedure were observed between Group A and Group B. Moreover, adjusted multivariable Cox regression analysis showed that <24-h paroxysmal AF type (HR 0.644, 95% CI: 0.455–0.913, P = 0.014) and left atrium diameter (LAD) (>40 mm) (HR 1.696, 95% CI: 1.046–2.750, P = 0.032) were independently associated with the incidence of recurrence of atrial tachyarrhythmia in the study.Conclusion: Our findings indicated that <24-h paroxysmal AF type was obviously associated with an increased success rate of cryoablation and reduced incidence of stroke/TIA during the follow-up period. Therefore, there is superior effectiveness and similar safety in patients with AF episodes of <24-h duration compared with patients with longer paroxysmal AF duration.

The optimal subsidy scheme and technology innovation strategy considering consumers' green premium

PurposeThis paper investigates how a regulator pursuing social welfare maximization designs an optimal subsidy scheme to stimulate technology innovation in the presence of a consumer green premium. Specifically, the authors solve the following questions: (1) Does the consumers' green premium affect the design of the subsidy scheme? (2) How should the firm choose a green technology innovation strategy under the optimal subsidy scheme? (3) Does technology innovation bring higher social welfare and lower environmental impact?Design/methodology/approachThe authors first develop a game model to explore the impact of subsidy schemes on social welfare without considering technology innovation. Then the authors investigate two innovation strategies, in-house innovation and external introduction, under the optimal subsidy scheme. Finally, they illustrate the optimal choices of innovation strategy for the firm, consumers and regulators.FindingsThe results reveal that the subsidy scheme will not always increase social welfare, which depends on the environmental improvement coefficient of the unit green level. The optimal subsidy level increases with the green premium, but it is not related to the size of the consumer green segment. Moreover, the success rate of in-house innovation will raise the optimal green level, but the company benefits from an increased success rate of in-house innovation only when the green segment is large enough. The green segment size and external green level jointly determine the choice of technology innovation strategy.Originality/valueThis research is the first to analyze this problem while considering the green demand and subsidy scheme simultaneously as drivers of a firm's technology innovation, thereby providing new managerial implications for decisions by the regulator and firms.

Retrospective Comparative Analysis of Fluoroscopic-Guided Lumbar Puncture in the Routine Prone Versus Lateral Decubitus Position.

Objective: We sought to investigate patient outcomes such as success rate, fluoroscopy time, and radiation dose for fluoroscopic-guided lumbar puncture procedures performed in the prone position versus the lateral decubitus (LD) position.Methods: Retrospective chart analysis was performed at a single institution from 2013 to 2019. Cases were separated by performance in the prone or lateral decubitus positions. Data collected include patient characteristics, fluoroscopy time, radiation dose (DAP), puncture level, indication, opening pressure, and success rate. Exclusion criteria include trainee participation and procedures where positioning was unspecified. Mean fluoroscopy time, DAP, and procedure success rate were calculated and compared between groups.Results: Mean fluoroscopy time (min) was 0.97 and 1.07 in the LD and prone groups respectively (p = 0.21). Mean DAP (mGy) was 43.18 and 42.06 in the LD and prone groups respectively (p = 0.38). Success rate was 98.3% and 89.1% in the LD and prone groups respectively (p = 0.04). Room time (minutes) was 64.46 and 77.77 in the LD and prone groups respectively (p = 0.04).Conclusion: Our study found no statistically significant difference in terms of fluoroscopic time or radiation dose when comparing fluoroscopic-guided lumbar punctures in the prone versus lateral decubitus positions. Further analysis did show a statistically significant increased success rate and a shorter room time for the lateral decubitus position.

Evaluating a novel biodegradable lattice structure for subtropical seagrass restoration

While attention in coastal ecosystem restoration has increased over the last two decades, the success rate of efforts remains relatively low. To increase success rates, physical restoration techniques often utilize supporting or protective materials to provide a stable surface for transplantation, and in some cases reduce herbivory and hydrodynamic disturbances. In this study, we evaluated the effectiveness of traditional (staples, burlap) and novel (BESE- elements, a biodegradable potato starch lattice) physical restoration techniques on the growth of transplanted Halodule wrightii seagrass. A first experiment revealed that seagrass planted in both two-stacked BESE structure without planting holes and four-stacked BESE with holes had significantly higher shoot count and blade length than four-stacked BESE without holes, with the latter design losing all seagrass shortly after deployment as shoots could not float through the structure. In a second experiment, the BESE lattice treatment (four-stacked with holes) had three times the shoot count and equal to greater blade length compared to traditional methods of physical restoration (staples and burlap), likely due to BESE providing some protection from hydrodynamic activity. However, disturbances, possibly including herbivory and hydrodynamic activity (culminating with Hurricane Irma), prevented long term study, illustrating the importance of stochastic abiotic factors in seagrass planting success. Overall our study demonstrates the effectiveness of using BESE lattice designs and similar physical techniques in the restoration of seagrass beds.

Preimplantation genetic testing for aneuploidies does not increase success rates in fresh oocyte donation cycles: a paired cohort study.

To determine whether in vitro fertilization cycles using fresh oocyte donations benefit from preimplantation genetic testing for aneuploidies. A paired cohort study compared 44 fresh oocyte donation cycles with or without preimplantation genetic testing for aneuploidy (PGT-A). The sibling oocyte study analyzed fertilized oocytes, blastocyst development, and euploidy rate. Only frozen embryo transfers were performed. Pregnancy, implantation, biochemical pregnancy, miscarriage, stillbirth, live birth, and twin pregnancy rates were analyzed between groups. Fresh oocyte donation cycles between PGT-A and non-PGT-A groups were similar in all laboratory and clinical outcomes. A euploidy rate of 74.2% was observed in the PGT-A group. Although a slight trend was observed for implantation rate in the PGT-A group, it was not statistically significant. No difference was observed for live birth between groups. PGT-A associated with fresh oocyte donation cycles does not improve clinical outcomes and can be seen as over-treatment for patients.

Quantitative assessment of self-treated canalith repositioning procedures using inertial measurement unit sensors.

Low success and high recurrence of benign paroxysmal positional vertigo (BPPV) after home-based self-treated Epley and Barbeque (BBQ) roll maneuvers is an important issue. To quantify the cause of low success rate of self-treated Epley and BBQ roll maneuvers and provide a clinically acceptable criterion to guide self-treatment head rotations. Twenty-five participants without active BPPV wore a custom head-mount rotation monitoring device for objective measurements. Self-treatment and specialist-assisted maneuvers were compared for head rotation accuracy. Absolute differences between the head rotation evaluation criteria (American Academy of Otolaryngology guidelines) and measured rotation angles were considered as errors. Self-treatment and specialist-treated errors in maneuvers were compared. Between-trial variations and age effects were evaluated. A significantly large error and between-trial variation occurred in step 4 of the self-treated Epley maneuver, with a considerable error in the second trial. The cumulative error of all steps of self-treated BBQ roll maneuver was significantly large. Age effect occurred only in the self-treated BBQ roll maneuver. Errors in specialist-treated maneuvers ranged from 10 to 20 degrees. Real-time feedback of head movements during simultaneous head-body rotations could increase success rates of self-treatments. Specialist-treated maneuvers can be used as permissible rotation margin criteria.

WILLINGNESS TO BE VACCINATED AGAINST COVID-19 AMONG HIGHER EDUCATION INSTITUTION

Background: The increasing COVID-19 cases worldwide ignite pharmaceutical companies’ effort to discover safe vaccines have been eyed globally. Informed perspectives across medical profession explaining beneficial effects of inoculation, however, various personal views persist which lead to confusion among general public. Objectives: To describe demographic characteristics among education institutions and their willingness to be vaccinated. Methods: Data were collected by google forms, in February 2021. The online form was then pre-tested on 10 respondents to refine questions prior to commencing the survey. Convenience sampling was administered for the selection of voluntary respondents. Data cleaning was done prior to the data analysis. Recoding of string variables and omittion of invalid responses were also done. Descriptive statistics was undertaken in a genuine licensed software of IBM SPSS Statistics version 26. Results: A total of 401 respondents answered the survey. More than half of the respondents are female constituting 62.1% of the sample, whereas males constitute 37.9%, mostly faculty members, single (63.1%), earning 20,000 (54.2%) per month. More than half of the respondents are willing to get vaccinated against COVID-19 (54.6%) and have no preference for a specific type of COVID-19 vaccine (54.9%). Around 30.4% are still unsure if they should get vaccinated or not and 15% have indicated negatively. Comparing both sexes, a larger frequency of males is willing to get vaccinated constituting 69.1% and females (45.8%). Conclusion: Males showed more willingness to be inoculated regardless of COVID-19 vaccine types. Education and continuous campaign on the importance of vaccination program is a must to increase success rate to end the health crisis.

3D transvenous radiofrequency ablation of manifest epicardial posterior-septal accessory pathways in children: Can technology innovations improve the outcome?

The aim of the study was to revise our more recent experience about epicardial posterior-septal accessory pathways radiofrequency transcatheter ablation in children and young patients using a transvenous approach through the coronary sinus, to understand if new mapping and ablation technologies can increase success rate and safety. Twenty children (mean age 13 ± 3 years) with epicardial posterior-septal accessory pathways (14 in coronary sinus and 6 in the middle cardiac vein) underwent radiofrequency transcatheter ablation with CARTO-3® system with help of the CARTO-Univu® module. Acute success rate was 73%. No patient was lost to follow-up (mean time 11.4 ± 9 months). The recurrence rate was 19%. Two patients underwent a successful redo-procedure; the overall long-term success rate was 65%. Navistar® catheter presented the highest acute success rate in the coronary sinus. Navistar SmartTouch® was the only catheter that did not present recurrences after the acute success, and it was successfully used in two patients previously unsuccessfully treated with a Navistar ThermoCool®. Acute success rate was 79% without image integration with angio-CT, while it was 63% after the introduction of CARTO-Merge®. Epicardial posterior-septal accessory pathways can be definitively eliminated by transvenous radiofrequency transcatheter ablation in more than half of the cases in children. Acute success rate does not seem to depend on catheters used, but contact-force catheter seems to be useful in cases with recurrences. Image integration with cardiac-CT does not increase success rate, but it is useful to detect coronary sinus alterations to better guide ablation strategy.

Third Ventricular Floor Bowing Indicates Surgical Success in Patients Undergoing Endoscopic Third Ventriculostomy—Systematic Review and Meta-Analysis

This meta-analysis aimed to evaluate the prognostic performance of third ventricular floor bowing (TVFB) as a marker for surgical success in patients undergoing endoscopic third ventriculostomy (ETV). We performed a comprehensive literature search for studies comparing ETV success in patients with TVFB compared with those without using PubMed, SCOPUS, Embase, and EuropePMC. TVFB was defined as inferior bowing or bulging deformation or convex third ventricular floor. Surgical success was defined as resolution of symptoms post surgery and requires no further intervention for hydrocephalus. The outcome was surgical success in patients with TVFB compared with those without TVFB. The effect estimate was reported as odds ratio (OR). Five studies comprising 439 patients were included in this meta-analysis. The prevalence of overall surgical success was 42%. The prevalence of surgical success was 85% in patients with TVFB. TVFB was associated with increased success rates (OR 5.94 [95% confidence interval 3.07, 11.5], P < 0.001; I2: 26.04%, P= 0.248). TVFB was associated with sensitivity 0.83, specificity 0.54, positive likelihood ratio 1.8, negative likelihood ratio 0.32, diagnostic OR 6, and area under curve 0.81 (0.77-0.84) for surgical success. Presence of TVFB confers to a 56% rate of surgical success, and no TVFB confers to a rate of 19% surgical success. The association between TVFB and surgical success was not affected by age (coefficient:-0.03, P= 0.474) and aqueductal stenosis (P=-0.05, P= 0.237). This meta-analysis showed that the presence of TVFB was associated with increased ETV success.

Comparison of Procedure and Fluoroscopy Time Between Left Bundle Branch Area Pacing and Right Ventricular Pacing for Bradycardia: The Learning Curve for the Novel Pacing Strategy.

Background: Left bundle branch area pacing (LBBAP) is a novel physiological pacing approach.Objective: To assess learning curve for LBBAP and compare the procedure and fluoroscopy time between LBBAP and right ventricular pacing (RVP).Methods: Consecutive bradycardia patients who underwent LBBAP or RVP were prospectively recruited from June 2018 to June 2020. The procedure and fluoroscopy time for ventricular lead placement, pacing parameters, and periprocedural complications were recorded. Restricted cubic splines were used to fit learning curves for LBBAP.Results: Left bundle branch area pacing was successful in 376 of 406 (92.6%) patients while 313 patients received RVP. Learning curve for LBBAP illustrated initial (1–50 cases), improved (51–150 cases), and stable stages (151–406 cases) with gradually increased success rates (88.0 vs. 90.0 vs. 94.5%, P = 0.106), steeply decreased median procedure (26.5 vs. 14.0 vs. 9.0min, P < 0.001) and fluoroscopy time (16.0 vs. 6.0 vs. 4.0min, P < 0.001), and shortened stimulus to left ventricular activation time (Sti-LVAT; 78.7 vs. 78.1 vs. 71.2 ms, P < 0.001). LBBAP at the stable stage showed longer but close median procedure (9.0 vs. 6.9min, P < 0.001) and fluoroscopy time (4.0 vs. 2.8min, P < 0.001) compared with RVP.Conclusion: The procedure and fluoroscopy time of LBBAP could be reduced significantly with increasing procedure volume and close to that of RVP for an experienced operator.

Dispositivos de modificación de placa en oclusiones coronarias crónicas totales: estudio PLACCTON

Introduction and objectivesSevere calcification is present in> 50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context. MethodsPatients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs. ResultsAmong 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967). ConclusionsFollowing successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

Self-Efficacy in Coping Behaviors of Cancer Patients: Who Am I and What Can I Accomplish?

Cancer symptoms make patients less able to cope with their health conditions, more vulnerable to negative outcomes, and more likely to develop negative self-efficacy. Self-efficacy is one’s judgment and belief in how successfully one can overcome possible future challenges. The self-efficacy theory holds that people are likely to engage in activities which they believe they can accomplish and avoid those in which they perceive themselves to be incompetent. Self-efficacy is of paramount significance for cancer patients to cope with treatment-related physical, social, and psychological problems and to adapt to new life situations. It should, therefore, be considered an integral part of well-being and success in symptom management. Nurses play a significant role in health-promoting behavior development. Nurses also manage such variables as maintaining activities of daily living, increased success rates, adaptation to change, involving family and social support mechanisms in the process, and encouraging and informing patients. Thus, nurses also support patients to increase their self-efficacy perceptions. The purpose of this review is to present the literature on the concept of self-efficacy, which is a determinant of the coping behaviors of patients with cancer.

DOES HARVESTING OVARIAN TISSUE TO DELAY REPRODUCTIVE AGING HAVE A NEGATIVE IMPACT ON THE NATURAL AGE OF MENOPAUSE IN HEALTHY WOMEN?

Given the increasing success rates of ovarian tissue cryopreservation and autologous transplantation, ASRM has removed this approach from the list of experimental fertility preservation procedures. The advances in ovarian cryopreservation and transplantation techniques led to the question of whether it can also be used to delay reproductive aging and provide a natural form of hormone replacement therapy. However, it is currently unknown if ovarian biopsies obtained for elective purposes will cause a reduction in reproductive lifespan not matched by the longevity of the transplanted tissue.

CROSSED VASOEPIDIDYMOSTOMY: A STEP-BY-STEP GUIDE

To date, there is no standardized technique for crossed vasoepididymostomy because of its unpredictable indication. We present a step-by-step procedure of a crossed vasoepididymostomy using a 4K3D video microscope and introduce principles of abdominal vas deferens measurement to increase success rate.

Withdrawal: Prospective randomized comparison between upgraded "2C3L" versus PVI approach for catheter ablation of persistent atrial fibrillation: PROMPT-AF trial design.

Background In randomized studies, the strategy of pulmonary vein (PV) antral isolation (PVI) plus linear ablation has failed to increase success rates for persistent atrial fibrillation (PeAF) ablation when compared with PVI alone. Peri-mitral reentry related atrial tachycardia due to incomplete linear block is an important cause of clinical failures of a first ablation procedure. Ethanol infusion (EI) into the vein of Marshall (EI-VOM) has been demonstrated to facilitate a durable mitral isthmus linear lesion. Objective This trial is designed to compare arrhythmia-free survival between PVI and an ablation strategy termed upgraded '2C3L' for ablation of PeAF. Study design The PROMPT-AF study is a prospective, multicenter, randomized trial involving blinded assessment of outcomes. Patients (n = 276) undergoing their first catheter ablation of PeAF will be randomized to either the upgraded '2C3L' arm or PVI arm in a 1:1 fashion. The upgraded '2C3L' technique is a fixed ablation approach consisting of EI-VOM, bilateral circumferential PVI and three linear ablation lesion sets across the mitral isthmus, left atrial roof, and cavo-tricuspid isthmus. The follow-up duration is 12 months. The primary endpoint is the rate of documented atrial tachycardia arrhythmias of >30 seconds, without any antiarrhythmic drugs, in 12 months after the index ablation procedure (excluding a blanking period of 3 months). Conclusions The PROMPT-AF study will evaluate the efficacy of the fixed '2C3L' approach in conjunction with EI-VOM, compared with PVI alone, in patients with PeAF undergoing de novo ablation. This article is protected by copyright. All rights reserved.

Smoking Cessation at the Community Pharmacy: Determinants of Success from a Real-Life Practice.

The objectives of this study are to report the contribution of pharmacists to smoking cessation and study the determinants of smoking cessation success in eight pharmacies in Portugal (south) between 2009 and 2019. A real-life study was conducted with a sample of smokers who participated in pharmacist consultations. The sample included 135 smokers (average age of 47.9 ± 1.21 years), 79 (58.5%) of whom were male. In parallel with the motivation and behavioral approach, 116 (85.9%) smokers received pharmacological therapies: 108 (80.0%) were treated with nicotine replacement products and eight (5.9%) with non-nicotine medications. The interventions resulted in 70 (51.9%) smokers complying with the quit day, of whom 59 (43.7%) were smoking-abstinent at the end of the first month. Success rates were reduced to 32.6%, 28.1%, and 20.7% at the end of the 3rd, 6th, and 12th months, respectively. Smoking cessation was more successful for the participants receiving pharmacological therapies (Fisher’s exact test, p < 0.001) and those who participated in more pharmacist consultations (χ2 = 59.994, p < 0.001) and more telephone sessions (χ2 = 17.845, p < 0.001). Pharmacists can contribute significantly to the promotion of smoking cessation. Smokers who are more thoroughly followed up by pharmacists showed increased success rates when compared with smokers having fewer sessions with pharmacists.

Endoscopic ultrasound-guided biliary drainage: Are we there yet?

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.

Plaque modification in calcified chronic total occlusions: the PLACCTON study

Introduction and objectivesSevere calcification is present in> 50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context. MethodsPatients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs. ResultsAmong 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967). ConclusionsFollowing successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

SY4.3. Therapeutic considerations in myasthenia gravis

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by fatigable muscle weakness. Treatment of MG has depended largely on high-dose corticosteroids for decades. Although this procedure remarkably reduced the mortality rate of MG, it highlighted issues such as the adverse effects of steroids and reduction in quality of life. A number of alternative therapeutic options have become available. Disease-modifying therapies for MG include immunosuppression with azathioprine, cyclosporine, or tacrolimus other than oral prednisolone (PSL). More aggressive exacerbation of generalized MG often requires additional immunomodulatory treatments with intravenous immunoglobulin (IVIg), plasma exchange (PE)/plasmapheresis (PP) and steroid pulse therapy. The Japanese clinical guidelines for MG were published in 2014, and they proposed a novel treatment strategy utilizing these therapeutic options, which might replace high-dose steroids. In the Japanese clinical guidelines, the first goal in MG treatment is minimal manifestations (MM) with PSL 5 mg/day or below (MM-or-better-5mg). Immunotherapy should be initiated from early stages in order to shorten the period of time during which MG symptoms interfere with daily activities. One suggested strategy to increase success rate is reduction of oral steroid dose and early initiation of calcineurin inhibitors, followed by fast-acting treatments such as IVIg, PE/PP and steroid pulse therapy to resolve remaining symptoms quickly. Despite the availability of an increasing variety of disease-modifying therapies for use in the new strategy, the proportion of patients with generalized MG who achieved MM-or-better-5mg remained approximately 50-60% in our latest survey. Therefore, we need further development of new treatment to increase the success rate of generalized MG patients to the treatment goal. In this symposium, I will review positive clinical trials in the previous literatures and guidance/guideline for management of MG in individual countries. In addition, I will introduce further development of new treatment options based on novel mechanisms of action for MG treatment. Especially, I will discuss monoclonal antibodies to prevent complement-mediated damage at the endplate of neuromuscular junction in MG with acetylcholine receptor antibody (Eculizumab, Ravulizumab and Zilucoplan) and neonatal Fc receptor antibodies which would be rational therapeutic agents for decreasing the levels of pathogenic autoantibodies with IgG isotypes (Efgartigimod and Rozanolixizumab).

Road to becoming Y-90 authorized user as an integrated vascular and interventional radiology resident (NRC alternate pathway)

Yttrium-90 (Y-90) radioembolization, also called transarterial radioembolization (TARE), is a catheter-directed therapy for direct delivery of internal radiation to tumors in the form of microspheres. It is currently available in two forms, either as a constituent of glass microspheres called TheraSphere® (BTG Ltd., London, UK [now Boston Scientific, Marlborough, MA, USA]) or as a biocompatible resin-based microsphere called SIR-Spheres® (Sirtex Medical Ltd., Woburn, MA, USA). Once these microspheres are delivered to the tumor through an arterial pathway, they are embedded within the tumor microcirculation and emit β-radiation at therapeutic levels. TARE is a commonly used treatment for unresectable primary or secondary hepatic malignancies and has led to improved survival rates and increased success rates in downstaging patients before liver resection or transplantation. Immediately following the pre-treatment angiogram, each patient undergoes a nuclear medicine study, otherwise known as technetium (99mTc) macroaggregated albumin scan, to determine the amount of radiotracer that has accumulated in the lungs (lung shunt fraction). Finally, after several calculations, the appropriate radiation dose to be delivered to the tumor is determined. While the technical aspects of radioembolization are quite complex, the collective clinical experience presented in the literature supports the use of Y-90 radioembolization for unresectable hepatic malignancies. Those ordering and administering radioembolization particles must be deemed an authorized user (AU) by the Nuclear Regulatory Commission (NRC). The NRC defines an AU as the individual responsible for ensuring that radioactive materials are handled and used safely and following NRC regulations and the terms and conditions of the NRC license. The NRC has published licensing guidance on Y-90 brachytherapy with the 10th revision released on November 8, 2019. This guidance has outlined specific requirements for obtaining a license for the use of TheraSphere and SIR-Spheres. Following the revised licensure guidelines from the NRC on Y-90 usage, a conditional authorization has been obtained at our institution by the PGY-6 interventional radiology/diagnostic radiology (IR/DR) resident. While the full guidelines and extensive alternative requirements can be found online, we will highlight the specific guidelines applicable to and fulfilled by IR/DR residents. The traditional ABR pathway takes approximately 18 months after graduation, including passing the ABR certification examination to become an AU. With the proposed alternate pathway, trainees will potentially become AU immediately after graduation. The primary aim of this submission is to describe the process for obtaining conditional authorization for Y-90 microspheres for PGY-6 IR/DR residents.