POS1049 ASSESSING TREATMENT PATTERNS WITH DISEASE-MODIFYING ANTIRHEUMATIC DRUGS AND PREDNISONE FOR PSORIATIC ARTHRITIS BY RACE/ETHNICITY

Background

Psoriatic arthritis (PsA) is a comorbidity commonly associated with psoriasis. Studies have demonstrated delays in the diagnosis and treatment of PsA[1] that may disproportionately affect racial/ethnic minority patients as indicated by one study that found Black Medicaid patients with PsA to be less likely to receive disease-modifying antirheumatic drugs [DMARDs] than White Medicaid patients with PsA [2]. Yet much remains unknown about potential racial/ethnic disparities in PsA management.

Objectives

The objective of our study was to evaluate treatment patterns for PsA by race/ethnicity.

Methods

We performed a cross-sectional study of adult (≥18 years old) patients with PsA who had at least one outpatient visit within the University of Pennsylvania health system between 2010 and 2019. Patients with PsA were identified by the presence of at least two International Classification of Diseases (ICD)-9 or ICD-10 codes for PsA associated with two different healthcare encounters. The primary outcomes were receipt of a prescription for: (i) an oral DMARD, (ii) a biologic DMARD, and (iii) prednisone. Oral DMARDs included apremilast, methotrexate, sulfasalazine, leflunomide, azathioprine, cyclosporine, tofacitinib, hydroxychloroquine, and upadacitnib. Biologic DMARDs included abatacept, adalimumab, brodalumab, certolizumab, etanercept, golimumab, guselkumab, infliximab, ixekixumab, secukinumab, ustekinumab, and risankizumab. The primary independent variable was race/ethnicity categorized as White (reference), Black, Asian, Hispanic, or other race. Multivariable logistic regression was used to assess the relationship between race/ethnicity and each treatment outcome.

Results

The study population included 1781 patients with PsA who were a mean age of 50.7 (SD 14.3), 54.6% female, and 72.5% commercially insured. The racial/ethnic distribution was 81.9% White, 5.6% Black, 4.0% Asian, 3.0% Hispanic, 2.5% other race, and 3.1% missing race/ethnicity. Of these patients, 64.3% were prescribed an oral DMARD, 55.6% were prescribed a biologic, and 44.1% were prescribed prednisone. There were no statistically significant differences across race/ethnicity for prescription of either oral or biologic DMARDs. However, prescription of prednisone did differ by race/ethnicity (p<.005) with Black (54.6%) and Hispanic (56.6%) patients being more likely to receive prednisone prescriptions and Asian (32.4%) patients being less likely to receive prednisone prescriptions than White (44.2%) patients. In adjusted logistic regression models controlling for sociodemographic and other factors, Hispanic patients were more likely to receive a prednisone prescription (OR 1.79, 95% CI 1.01 – 3.20, p=0.05) while Asian (OR 0.58, 95% CI 0.34 – 0.97, p=0.04) patients were less likely to receive a prednisone prescription compared to White patients.

Conclusion

We found Hispanic patients with PsA to be more likely to receive prednisone prescriptions than White patients with PsA but did not identify any racial/ethnic differences in prescription patterns for oral or biologic DMARDs for PsA. Greater use of prednisone among Hispanic patients may reflect different diseases trajectories (e.g., more disease flares or greater disease severity) or other factors that affect prescription patterns that require further study.

References

[1]Favier G, Gladman DD, Merola JF, Armstrong AW, Boehncke WH, Helliwell PS. Benchmarking Care in Psoriatic Arthritis - The QUANTUM Report: A Report from the GRAPPA 2016 Annual Meeting. J Rheumatol. 2017;44(5):674-678.

[2]Ogdie A, Matthias W, Thielen RJ, Chin D, Saffore CD. Racial Differences in Prevalence and Treatment for Psoriatic Arthritis and Ankylosing Spondylitis by Insurance Coverage in the USA. Rheumatol Ther. 2021;8(4):1725-1739.

Disclosure of Interests

Fahad Ahmed: None declared, Alexis Ogdie Consultant of: A. Ogdie has received consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, CorEvitas (formerly Corrona), Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB., Grant/research support from: A. Ogdie has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Abbvie (University of Pennsylvania), Pfizer (University of Pennsylvania), Amgen (FORWARD), and Novartis (FORWARD)., Robert Fitzsimmons: None declared, Daniel Shin: None declared, Junko Takeshita Consultant of: JT has served as a consultant for Pfizer Inc. and Janssen Biotech receiving honoraria., Grant/research support from: JT has received a research grant (to the Trustees of the University of Pennsylvania) from Pfizer Inc.

AB0777 Influence of TNF inhibitors on subclinical atherosclerosis in Spondyloarthritis patients

Background

Spondyloarthritis is a chronic inflammatory disease associated with increased cardiovascular morbidity and mortality due to accelerated atherosclerosis. Recent studies have reported the benefit of TNF inhibitors in reducing the risk of cardiovascular events and its association with changes in lipid profile. Nevertheless, it remains controversial.

Objectives

We aimed to investigate the effect of TNF inhibitors on subclinical atherosclerosis assessed with carotid intima-media thickness (CIMT) and flow mediated dilatation (FMD) in patients with spondyloarthritis (SpA).

Methods

We performed a cross sectional study including 47 patients meeting ASAS 2009 criteria for SpA. Patients with traditional cardiovascular risk factors were excluded. We collected clinical data, therapeutic modalities and biological tests including total cholesterol, HDL, LDL and triglyceride after 12 hours of fasting. FMD and mean CIMT (mean value of right and left carotid artery) were measured with a Mindray Resona 7 ZST+ ultrasound machine by an experienced radiologist.

Results

Among the 47 subjects, 18 patients (38%) were receiving TNF inhibitors for a median duration of 36 months (IQR 25-75%: 24-72) (9 were on Etanercept, 7 were on Adalimumab, one patient was on Infliximab and one was on Golimumab). The group treated with TNF inhibitors had a median age of 43 years (IQR 25-75%: 36-46.5) and a median duration of the disease of 12 years (IQR 25-75%: 9.5-22). Median ASDAS and BASDAI scores were 2.40 (IQR 25-75%: 1.48-3.1) and 2.60 (IQR 25-75%: 1.55-3.75) respectively. On the other hand, patients naïve to TNF inhibitors had a median age of 32 years (IQR 25-75%: 55-42), median disease duration of 7 years (IQR 25-75%: 3-12.5), median ASDAS of 2.13 (IQR 25-75%: 1.61-2.91), and median BASDAI of 2.40 (IQR 25-75%: 1.55-3.75).

When comparing the two groups, there was no significant difference regarding disease activity scores ASDAS (p=0.431) and BASDAI (p=0.793) as well as biochemical variables; total cholesterol (p=0.483), HDL (p=0.395), LDL (p=0.263) and triglyceride (0.092). In contrast, patients on TNF inhibitors were significantly more aged (p=0.009) and had a significantly higher duration of the disease (p=0.004).

Doppler ultrasound examination showed a median CIMT of 0.56 mm (0.48-0.64) in patients treated with TNF inhibitors versus 0.55 mm (0.48-0.60) in patients naïve to TNF inhibitors with no significant difference (p=0.238). Patients on TNF inhibitors had lower values of FMD (with a median of 12.5 (6.7-16) versus 15.5 (10-24.5)). However this difference was not significant (p=0.182).

Conclusion

In our study, biological treatment with TNF inhibitors did not affect endothelial function and subclinical atherosclerosis in patients with spondyloarthritis. Given the small size of our study population and its heterogeneity in terms of age and duration of the disease, no conclusions can be drawn. Further longitudinal studies that involve larger samples are necessary.

Disclosure of Interests

None declared

AB0857 Increased carotid intima-media thickness is correlated with renal function in spondyloarthritis

Background

Cardiovascular diseases are the main cause of mortality in spondyloarthritis and seem to be multifactorial. Due to its easy application and reproductibility, carotid intima-media thickness (CIMT) is increasingly used for assessment of subclinical atherosclerosis and cardiovascular risk stratification.

Objectives

The aim of our study was to investigate the relationship between CIMT and renal function in patients with spondyloarthritis (SpA).

Methods

We performed a cross sectional study including 47 patients with SpA and no history of cardiovascular disease. Clinical and biological data were recorded. Data related to renal involvement and creatinine level were extracted. CIMT was measured in the right and the left common carotid artery by an experienced radiologist; than mean CIMT was calculated.

Results

Our study included 33 men and 14 women with a sex ratio of 2.35, a median age of 36 years (IQR 25-75%: 28-46) and a median duration of the disease of 11 years (IQR 25-75%: 5-16). Renal involvement was found in 6 patients (13%): kidney stones (n=2), tubulo-interstitial nephritis (TIN) (n=2), IgA nephropathy (n=1) and AA amyloidosis (n=1). Median creatinine level was 63 μmol/l (IQR 25-75%: 58.5 - 64). No patient had kidney failure.

Ultrasound examination found median right, left and mean (CIMT) of 0.54 mm (IQR 25-75%: 0.50-0.63), 0.55 mm (IQR 25-75%: 0.49-0.61) and 0.55 mm (IQR 25-75%: 0.48-0.62) respectively. Increased CIMT values were found in 8 patients (17%). No patient had atherosclerotic plaque.

Patients with renal involvement had significantly higher values of CIMT (0.64 mm (IQR 25-75%: 0.56-0.70) vs 0.53 mm (IQR 25-75%: 0.47-0.59); p= 0.045). Significant positive correlation was also detected between CIMT values and creatinine level (p=0.002; r=0.445).

In multivariate linear regression, creatinine level was identified as independent predictor of increased CIMT (B=0.002; 95% confidence interval=0.000-0.005; p=0.035).

Conclusion

Although all patients included have normal creatinine level, we identified creatinine level as independent predictor of subclinical atherosclerosis in SpA patients. This finding highlights the monitoring of this parameter.

Disclosure of Interests

None declared

AB0849 Assessment of Carotid Intima-Media Thickness in Spondyloarthritis patients

Background

Cardiovascular morbidity and mortality are increased in spondyloarthritis (SpA) (1), which is attributed to accelerated atherosclerosis. Recognition of subclinical atherosclerosis in asymptomatic population is important for risk stratification and optimal management. Due to its simplicity and non-invasive nature, carotid intima-media thickness (cIMT) is actually widely used for identifying subclinical atherosclerosis.

Objectives

The aim of our study was to investigate the presence of subclinical atherosclerosis in SpA patients compared with healthy controls, by evaluating cIMT.

Methods

We performed a case control study including 47 patients and 47 age and gender matched healthy controls. All subjects were included without history of cardiovascular disease or cardiovascular risk factors. Sociodemographic features, disease characteristics, radiographic structural damage and therapeutics were recorded. cIMT was measured with Mindray Resona 7 ZST+ ultrasound machine, from the right and the left carotid artery; than mean cIMT was calculated. We considered that cIMT was increased if the measurements were between 0.7 mm and 1.5 mm. Measurements higher than 1.5 were defined as an atherosclerotic plaque.

Results

Fourty seven patients with a sex ratio of 2.35 were included in our study. Median age was 36 years (IQR: 28-46) and median duration of the disease was 11 years (IQR: 5-16). Median BASDAI and ASDAS-CRP scores were 2.6 (IQR: 1.8-3.8) and 2.18 (IQR: 1.62-2.91) respectively. Of the 47 patients, 10 (21%) had an active disease according to BASDAI and 19 (40%) had an active disease according to ASDAS. Median BASFI score for functional impairment was 3 (IQR: 1.5-5.1). Median BASRI and mSASSS scores were 3 (IQR: 2-4) and 10 (IQR: 4-15) respectively. Regarding treatment, 92% of patients were using non-steroidal anti-inflammatory drugs (NSAIDs), 51% were on csDMARDs and 38% were on anti-TNF alpha drugs.

Median right, left and mean cIMT were respectively 0.54 mm (IQR: 0.50-0.63), 0.55 mm (IQR: 0.49-0.61) and 0.55 mm (IQR: 0.48-0.62) respectively. Increased cIMT values were found in 8 patients (17%). No patient had atherosclerotic plaque.

Median values of cIMT were significantly higher in patients with spondyloarthritis than the control subjects (p<0.0001) as shown in Table 1.

Table 1.

Comparaison of carotid intima-media thickness values between spondyloarthritis patients and control subjects.

SpondyloarthritisPatientsControl grouppRight cIMT (mm)*0,54 (0,50-0,63)0,45 (0,42-0,50)< 0.0001**Left cIMT (mm)*0,55 (0,49-0,61)0,47 (0,45-0,50)<0.0001**Mean cIMT (mm)*0,55 (0,48-0,62)0,46 (0,43-0,50)<0.0001**

cIMT: carotid intima-media thickness; mm: millimeters; *: median value (IQR 25-75%); **: p < 0.05 denotes statistical significance.

Conclusion

Our study demonstrated increased cIMT in patients with SpA compared with healthy population; which attests higher risk for subclinical atherosclerosis and cardiovascular atherosclerotic events.

References

[1]Bai R, Zhang Y, Liu W, Ma C, Chen X, Yang J, et al. The Relationship of Ankylosing Spondylitis and Subclinical Atherosclerosis: A Systemic Review and Meta-Analysis. Angiology. 2019 Jul;70(6):492–500.

Disclosure of Interests

None declared

Examining the Constructs of Burnout, Compassion Fatigue, Secondary Traumatic Stress in Physicians Using Factor Analyses

Background

Adverse affective experiences have been well-documented in healthcare providers. Research describes them under a variety of terms, including burnout, secondary traumatic stress (STS), and compassion fatigue (CF). The present study evaluates conflicting models of STS, CF, and burnout constructs in physicians.

Methods

Surveys were mailed to all allopathic physicians with active Rhode Island medical licenses. Three hundred and seventy-five complete responses were received. The survey included common measures of STS, CF, and burnout. Confirmatory Factor Analysis (CFA) was used to evaluate discriminant validity of the three constructs and test 5 a priori (1-, 2-, and 3-factor) theoretical models, and Exploratory Factor Analysis (EFA) was planned assess underlying factor structure in the case that CFA did not provide evidence supporting any existing model.

Results

By CFA, all five a priori models of burnout, CF, and STS fail to demonstrate adequate model fit (Standardized Root Mean Square Residual >0.10, Tucker-Lewis Index <0.90). EFA with parallel analysis extracts four factors underlying the three burnout, STS, and CF measures. The four factors describe 54.3% of variance and can be described as (1) depressive mood; (2) primary traumatic stress-like symptoms; (3) responses to patients' trauma; and (4) sleep disturbances.

Conclusion

In spite of abundant discussion surrounding burnout, CF, and STS in physicians, measures of these constructs did not uphold their theoretical factor structures in the present study. Future research might explore other constructs and measures that may describe adverse affective physician experiences.

WHO informal consultation on revision of guidelines on evaluation of similar biotherapeutic products, virtual meeting, 30 June – 2 July 2021

The WHO informal consultation was held to promote the revision of WHO guidelines on evaluation of similar biotherapeutic products (SBPs) adopted by the Expert Committee on Biological Standardization (ECBS) in 2009. It was agreed in the past consultations that the evaluation principles in the guidelines are still valid, but a review was recommended to provide more clarity and case-by-case flexibility. The opportunity was therefore taken to review the experience and identify areas where the current guidance could be more permissive without compromising its basic principles, and where additional explanation could be provided regarding the possibility of reducing the amount of data needed for regulatory approval. The meeting participants applauded the leading role taken by the WHO in providing a much-needed streamlined approach for development and evaluation of SBPs which will provide efficient and cost-effective product development and increase patient access to treatments. It was recognized that the principles as currently described in the draft WHO guidelines are based on sound science and experience gained over the last fifteen years of biosimilar approvals. However, since these guidelines when finalised will constitute the global standard for biosimilar evaluation and assist national regulatory authorities in establishing revised guidance and regulatory practice in this complex area, it was felt that further revision and clarity on certain perspectives in specific areas was necessary to dispel uncertainties arising in the current revised version. This report describes the principles in the draft guidelines, including topics discussed and consensus reached.

•

WHO guidelines serve as a basis for the development of national regulatory framework for biosimilars.

•

Revision of guidelines is to provide more flexibility and clarification on data required for regulatory approval.

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Revised guidelines would contribute to improving consistency on regulatory decision and patient access to treatments.

Post-Acute Covid Neurological Symptoms among Doctors and Nurses in A Tertiary Care Hospital: An Observational Study from Bangladesh

A good number of patients experience post-Covid complications. Doctors and nurses are the front liners who are at greater risk of having this disease. Neurological symptoms are frequent in patients with post-COVID-19 infection. The study aims to observe the post-acute neurological symptoms among doctors and nurses of Mymensingh Medical College Hospital, a tertiary care hospital in Bangladesh, after they recover from initial infection or among the asymptomatic cases. It was a retrospective observational study among the doctors and nurses who became RT PCR positive from late April to mid-September 2020. A total of 100 subjects were interviewed over the phone for the presence or absence of neurological symptoms four weeks post Covid-19 infection. Total 54 doctors and 46 nurses were evaluated; the male-female ratio was 1:1.77, the mean age was 35.6±7.6 years. Post-acute COVID neurological symptoms (PACNS) were present in 60% of respondents. Fatigue (51%) was the most common symptom, followed by sleep disturbance, headache, myalgia, loss of taste and smell. PACNS were more in symptomatic patients at the initial Covid infection than asymptomatic cases.

Sweet's syndrome in the setting of newly initiated risankizumab therapy for pre-existing psoriasis

Sweet's syndrome (acute febrile neutrophilic dermatosis) is a rare disorder of unclear aetiology characterised by painful cutaneous lesions, sometimes accompanied by systemic symptoms. It has been associated with several autoimmune conditions, drugs, malignancies and infections, though many cases are idiopathic. We describe a case of Sweet's syndrome in a 49-year-old man with pre-existing psoriasis following recent initiation of risankizumab therapy. There are very few reported cases of Sweet's syndrome in association with psoriasis and no existing reports in association with an IL-23 inhibiting medication. Further investigation of the potentially overlapping immunologic pathways implicated in cutaneous reactions to biologic agents and autoimmune conditions such as psoriasis may yield insights into the pathogenesis of such conditions and guide advancements in the rapidly evolving field of targeted biologic therapies.

Preliminary experience using the VITOM-3D system for microvascular anastomosis in DIEP free flap breast reconstruction

Free tissue transfer has become routine practice in modern plastic surgery. The technique permits surgeons the flexibility to transfer the most suitable tissue for reconstruction. This has become possible largely due to the continued advances in microscope technology. There are however several drawbacks with even the newest traditional operating microscopes. They are usually large, heavy and although highly adjustable often require surgeons to adopt an unnatural and uncomfortable position which many of us have simply learned to live with. We describe the use of a new high-definition 3D camera system (Stortz VITOM 3D) in place of a traditional microscope to perform DIEP flap breast reconstructions in two patients. The use of this equipment has been described in other surgical specialities where a number of its benefits, including improved ergonomics for surgical team, have been highlighted. We explore the specific benefits and considerations for its use in free flap reconstruction of the breast .

Social media influencer marketing to build a counter-narrative for promoting sexuality education

Background

A recent cross sectional community readiness assessment carried out in Islamabad, Pakistan indicated that the community is at the denial or resistant stage for implementing school-based sexuality education in Pakistan. The resistance was attributed to lack of awareness and prevalent misconceptions regarding sexuality education. This study aims at qualitatively exploring strategies for targeting misconceptions and increase awareness regarding sexuality education with stakeholder involvement.

Methods

35 in-depth interviews and a focus group discussion was conducted to discuss the results of the readiness assessment comprising of community members, researchers, NGO representatives, and social media influencers. Discussion guide included topics on engagement strategies, intervention modes of delivery, target audience, misconceptions, community support, and optimizing sexuality education in local context. Qualitative content analysis was conducted for analyzing the data.

Results

Results indicate that current community support is usually passive in nature and digital or social media platforms are mostly used to talk about sexuality education. Participants believed social media can be used as a platform for disseminating information by involving social media influencers with careful narrative building around sexuality for rebranding the topic, as talking about sexuality is seen as a taboo in the society. Targeting misconceptions through counter narratives and scientific evidence was considered as a way forward for increasing community acceptability and readiness. Violence, staying safe, and age appropriateness were identified as some of the key features of sexuality education that need to be highlighted for garnering community support.

Conclusions

For promoting sexuality education in Pakistan, it is essential to tackle resistance by sensitizing the community and digital social media platforms offer an opportunity to do this through influencer marketing.

Key messages

Digital and social media offer an opportunity for promoting sexuality education in conservative settings like Pakistan. Social media influencer marketing might be useful in building counter narrative and for community engagement.

1556 Does Surgical Intervention Improve Quality of Life for Patients with Chronic Ear Disease in Nepal?

Aim

To assess change in quality of life (QoL) pre- and post-surgery for patients with chronic ear disease (CED) in Nepal. Hearing loss is the fourth leading cause of disability world-wide with 90% of those affected living in low and middle-income countries. A huge yet treatable contributor to this is chronic suppurative otitis media (CSOM). The Chronic Ear Survey is a sensitive and disease specific QoL measurement tool in patients with CSOM exploring activity restriction, symptoms and utilisation of medical services.

Method

This study was conducted at the Brinos Ear Care Centre in Nepalgunj, Nepal. A modified Chronic Ear Survey (mCES) was translated into Nepali and administered to patients before surgery and at post-operative follow up by community ear care assistants. The Mann-Whitney U test was used for statistical analysis.

Results

The mCES was administered to 64 patients pre-operatively and 28 patients post-operatively. Disease specific QOL in patients with CSOM was demonstrated to be better overall in patients post-surgery and specifically in the domains of activity limitation and symptoms. No significant change was demonstrated in utilisation of medical services (p &lt; 0.1)

Conclusions

Surgical intervention for patients with CSOM in Nepal improves ear specific QOL. This manifests specifically in a reduction in severity of symptoms and fewer restrictions on activity. Surgery in this population does not significantly change healthcare seeking behaviour and this must be explored further in the context of access to surgery and attitudes towards healthcare in this population.

387 Plastics Surgery and the COVID-19 Pandemic: How Our Practice Has Improved as A Consequence

Aim

Plastic trauma cases were impacted by the COVID-19 pandemic. Multiple plastic trauma theatres were lost due to redeployment and redistribution of staff and resources. Plastic surgery was essentially left with an emergency list to manage trauma cases. This retrospective study aims to highlight the pitfalls and solutions realised during COVID times and how different strategies can be implemented should a third national lock down occur.

Method

Plastic surgery data (trauma, elective) was analysed from the first national lockdown due to COVID-19 in 2020. This data was compared against plastic surgery trauma data from 2019. Theatre time, the number of trauma surgeries, anaesthetic used and delay to theatre were all analysed.

Results

There was a 47% reduction in plastic surgery trauma cases and a 42% reduction in delay to surgery during the national lockdown (2020) when compared with data from 2019. A significant increase in the use of Local Anaesthetic (LA) and Regional Anaesthetic (RA) during COVID times with a decrease in General Anaesthetic when compared with pre-COVID data of 2019 was also identified.

Conclusions

This study identified that the majority of plastic cases could be performed under RA/LA. This would lead to decreased aerosol generating procedures (GA) thus limiting the transmission of COVID, and decreased delay to surgery and theatre time. As a third national lockdown may be on the horizon, it would be prudent to implement these strategies into current practice and by doing so optimising theatre usage and assisting in curtailing the COVID-19 transmission rate.

750 An Unusual Presentation of a Rare Clinical Entity – A Case Report of Spontaneous Common Bile Duct Perforation in an Adult

Spontaneous or non-traumatic perforation of the extrahepatic biliary system is a rare clinical phenomenon, with few cases reported since its first mention in medical literature by Freeland in 1882. Given the rarity, misdiagnosis is common with the diagnosis almost always made during urgent exploratory laparotomy. We describe a case of spontaneous common bile duct (CBD) perforation in an 83-year-old female with no associative underlying disease process identified.

The patient presented with sudden onset abdominal pain with no identifiable trigger, with minimal past medical history. Examination was remarkable for findings of epigastric tenderness and guarding. Haematological investigation was remarkable only for hyperamylasaemia and leucocytosis. Pneumoperitoneum was ruled out and following contrast CT abdomen and pelvis a working diagnosis of mild pancreatitis was made. US Abdomen and MRCP found no evidence of cholelithiasis, with minimal biliary duct dilatation. The patient continued to deteriorate on the ward, with aspiration of new intrabdominal fluid collection raising suspicion of perforated viscus. Exploratory laparotomy revealed a 1-cm defect in the CBD with frank bile leak. A T-tube was placed in the common bile duct defect, with an abdominal robertson drain also inserted. No further bile leak was identified via Tubogram, with the patient successfully discharged following multidisciplinary rehabilitation in intensive care and the ward setting.

Surgeons should seek out this uncommon diagnosis in patients with hyperamylasaemia and suspected cholelithiasis who do not conform to normal biliary/pancreatic disease progression patterns.

158 Effect of Preoperative Continuation of Aspirin on Postoperative Bleeding After Off-Pump Coronary Artery Bypass Grafting (OPCABG)

Background

Despite ample evidence of continued preoperative aspirin to improve outcomes in coronary artery bypass surgery, practice for routine continued preoperative aspirin use is still inconsistent due to concern for increased postoperative bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on postoperative bleeding after off-pump coronary artery bypass grafting (OPCABG).

Method

This cohort study involved patients (n = 74) who underwent OPCABG at a single center between August 2017 to January 2018. After considering the inclusion and exclusion criteria, they were divided into two groups: one (n = 37) received tablet Aspirin 75mg till the day of surgery and for the other group (n = 37) aspirin was stopped 5 days before surgery. Postoperative bleeding was recorded in both groups. After considering preoperative, intraoperative, and postoperative variables statistical analysis was done.

Results

There was no significant difference between the two groups concerning preoperative and peroperative variables. No significant difference was also observed between the two groups in chest tube drainage at 1sthour, 2ndhour, 3rdhour, 24thhour, next 24 hours (at 48th hour), and next 24 hours (at 72nd hour) (p = 0.845, 0.126, 0.568, 0.478, 0.342 and 0.717 respectively). No significant difference was seen in the transfusion requirement of blood and fresh frozen plasma (FFP).

Conclusions

Continuation of preoperative aspirin till the day of surgery is not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of blood and FFP.

Patterns of Health Care Utilization during Breast Cancer Diagnosis and Treatment: A Cross Sectional Study in Bangladesh

Female breast cancer can be diagnosed easily; but due to inappropriate health care utilization, health-seeking is lag behind. The objectives of the study were to find out the pattern of utilization of health care during breast cancer diagnosis and treatment and their health seeking time. We conducted this cross sectional study for one year; from July 2017 to June 2018 among 200 newly diagnose patients with breast cancer whose were selected randomly from National Institute of Cancer Research and Hospital, Dhaka, Bangladesh from the listed patients who attended at the outpatient department of chemotherapy day care center for treatment. Delay in reporting, wrong reporting, double reporting, delay in hospital admission, long queue for administrative work and delay to reach cancer specialist play a role in utilization of health care. Results showed that health care service delivery and utilization was found to be significant by (p<0.05) associated with the provider delay (p=0.010), total delay (p=0.017), delay to consult with cancer specialist (p<0.0001). By logistic regression it analyzed that utilization of health care there had 2 times more likely to cause provider delay (OR=2.5; 95% CI 1.087-5.762) p=0.03. Utilization of health care influenced stage of cancer with delay help seeking and diagnostic institution also. As low middle income country, like Bangladesh, delays in seeking consultation, late presentation and the availability of breast cancer management for all patients, represent major challenges.

Vaccination against COVID-19 in Bangladesh: Perception and Attitude of Healthcare Workers in COVID-dedicated Hospitals

Healthcare professionals are the crucial and influencing source of information for vaccines and their communication among patients and communities that can accelerate successful vaccination in a country. This cross-sectional study was one of the first and foremost ones in Bangladesh to observe the basic perception and attitudes towards vaccination against COVID-19 among the healthcare workers (HCWs) - doctors, interns, nurses, ward boys, cleaners, and medical technologists of major COVID-dedicated hospitals. The cross-sectional questionnaire-based study was conducted in February 2021 among 550 HCWs to assess the perception and attitude towards vaccination against COVID-19. The study participants were targeted as the priority group for COVID-19 vaccination, working in two major COVID-dedicated hospitals, Holy Family Red Crescent Medical College Hospital (HF-center), and Sheikh Russel National Gastro-liver Institute and Hospital (SR-center) in Dhaka, Bangladesh during the pandemic. The questionnaire was structured with a three-point scale of responses from 'true', 'false', and 'do not know'. The responses were calculated on point-score as +1 for the correct response, -1 for the wrong response, and 0 for 'do not know' with an overall highest and the lowest possible score of +5 to -5. Absolute (n) and relative frequencies (%) were presented for qualitative variables, while quantitative variables were presented as mean (± standard deviation). Chi-square test was done for univariate analysis of qualitative variables and Student's t-test for quantitative variables. With the 95.27% response rate, including 204 males and 320 were female and the male: female ratio was 1: 1.56. The majority of the participants were doctors (45.8%) followed by nurses (27.9%), and MLSS (26.3%) respectively. The respondents were between 18 to 64 years of age with a mean of 36.17±10.94 years. Most of the respondents (95.99%) responded correctly about the cost-free availability of a vaccine against COVID-19 in the country, 87.40% preferred vaccination as safe and effective. Again 29.77% HCWs think the vaccine might not be safe or effective due to emergency authorization. Only 38.93% of respondents could respond correctly about the necessity of vaccines for children, 31.10% think the vaccination was not required instead of natural immunity. The positive perception and attitude of the frontline HCWs in COVID-dedicated hospitals in Bangladesh are crucial which will positively influence motivation and wide acceptance among the general population for the attainment of the nationwide vaccination program, and adopt effective strategic modification to minimize the gaps for a low-middle income country like Bangladesh with its resource constrain.

Prevalence of ESBL Encoding Genes in Acinetobacter baumannii Strains Isolated from Various Samples of a Tertiary Care Hospital in Mymensingh

The aim of this study was to find the prevalence of ESBL genes among A. baumannii isolates. In this cross sectional study, 49 Acinetobacter spp. were isolated from various clinical samples from March 2019 to February 2020 conducted in the department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh. Clinical samples including endotracheal aspirates, wound swab/pus, urine and blood. A total of 380 samples were analyzed. Growth was obtained in 34.21% of the samples yielding 130 organisms. Out of 130 organisms, 49(37.69%) were Acinetobacter spp. Among 49 Acinetobacter spp, 39(79.59%) were Acinetobacter baumannii which was identified by PCR targeting OXA-51 like gene. Amplification of the ESBL encoding genes, namely CTX-M, TEM, SHV done by molecular technique PCR. The most antibacterial resistance was against ceftriaxone (79.48%) and lower resistance only showed in colistin (12.82%). All the isolates were sensitive to tigecycline. The distribution of ESBLs genes such as TEM 20(51.28%), CTX-M 16(41.02%) and SHV 0(0%). The high resistance to most of the antibiotics among the studied strains and also a high prevalence of TEM gene in A. baumannii strains found in our study gives alarming sign towards the treatment complexity of these strains.

Frequency of Eosinophilic Esophagitis among Patients with Gastroesophageal Reflux Symptoms in an Academic Hospital of Bangladesh: A Cross Sectional Study

Eosinophilic esophagitis (EoE) is a disease of modern era. It was first described 40 years back. Since then it has drawn an immense interest among the clinicians. It is diagnosed by the presence of eosinophils count ≥15/HPF on esophageal biopsied mucosa in patients with symptoms of esopohageal dysfunction. It is more prevalent among patients with gastroesophageal reflux disease. As its symptoms overlap with that of gastroesophageal reflux disease (GERD), it is frequently overlooked & misdiagnosed which increases patients' sufferings. No data is available in Bangladesh. The objective of the study was to find out the frequency of eosinophilic esophagitis among patients with gastroesophageal reflux symptoms. The study was conducted at the Outpatient department of the department of Gastroenterology of Dhaka Medical College Hospital, Dhaka, Bangladesh from September 2018 to April 2019. One hundred and thirty three (133) consecutive patients with symptoms suggestive of gastroesophageal reflux disease based on validated questionnaire underwent upper GI endoscopy. Biopsies were taken from proximal and distal esophagus as well as any other endoscopically abnormal esophageal mucosal lesion. Among 133 patients with gastroesophageal reflux symptoms, 7 patients (5.3%) were found to be positive for eosinophilic esophagitis. Mean age at diagnosis was 37.28±13.38 years. It was more common in younger age group. Female patients (56%) were more than male patients (44%). Heart burn was the major symptom followed by acid regurgitation. Nocturnal cough showed statistically significant relationship with eosinophilic esophagitis. Although the frequency is low, it may be considered as a differential diagnosis among patients with GERD.