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

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.

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

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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.

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 .

Repurposing melanoma chemotherapy to activate inflammasomes in treatment of BRAF/MAPK inhibitor resistant melanoma

The development of resistance to treatments of melanoma is commonly associated with upregulation of the MAPK pathway and development of an undifferentiated state. Prior studies have suggested that melanoma with these resistance characteristics may be susceptible to innate death mechanisms such as pyroptosis triggered by activation of inflammasomes. In the present studies we have taken cell lines from patients before and after development of resistance to BRAF V600 inhibitors and exposed the resistant melanoma to temozolomide (a commonly used chemotherapy) with and without chloroquine to inhibit autophagy. It was found that melanoma with an inflammatory undifferentiated state appeared susceptible to this combination when tested in vitro and in vivo against xenografts in NSG mice. Translation of the latter results into patients would promise durable responses in patients treated by the combination. The inflammasome and death mechanism involved appeared to vary between melanoma and involved either AIM2 or NLRP3 inflammasomes and gasdermin D or E. These preliminary studies have raised questions as to the selectivity for different inflammasomes in different melanoma and their selective targeting by chemotherapy. They also question whether the inflammatory state of melanoma may be used as biomarkers to select patients for inflammasome targeted therapy.

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.

Air Temperature Reductions at the Base of Tree Canopies

Trees in urban settings have a significant role in regulating urban hydrologic cycles. Urban trees, either as standalone plantings or as part of a tree pit, are an increasingly popular stormwater management tool. Beyond their aesthetic contribution to urban environments, trees are widely accepted as reducing the ambient air temperature. However, there is limited long-term quantitative information regarding the temperature mitigation performed by urban trees through the use of temperature sensors over a large urban area. This study monitored air temperature at locations throughout the city of Camden, New Jersey. Sensors were installed under canopies of trees of different sizes throughout the city using a statistical experimental design. The tree size (small or large) and canopy (intersecting or nonintersecting), along with the street orientation (predominantly north-south or east-west) and time of day (daylight, nighttime, or full-day), were experimental design factors. Sensors attached to poles along the streets or in parking lots served as controls. This study recorded temperatures at 10-min intervals from early August through late November 2017 using logging thermistors mounted in radiation shields about 4 m above the ground surface. Using the maximum daily air temperature at control sites, all temperature data were categorized into three groups of hot, average, and cool days. The groups were analyzed separately using the analysis of variance to test the significance of the categorical variables. During hot days (a maximum temperature larger than 30°C), there was a meaningful statistical difference between recorded mean air temperatures under trees with intersecting canopies and the control sites. A categorical analysis of street orientation for hot and average days showed that during the daytime, east-west streets were hotter than north-south streets, while this trend reversed at night when north-south streets were hotter than east-west streets. For cool days, there were no differences for the studied categorical factors.

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.

Oncological outcomes and stoma-free survival following TaTME, a prospective cohort study

BACKGROUND

Transanal TME (TaTME) was introduced to improve access to the pelvis in difficult cases (male sex, obesity and mid to low rectal cancers) and reduce the risk of anastomotic leak by avoiding cross stapling. In April 2018 the Norwegian hospital to whom all local; recurrences for rectal cancer are referred reported an unexpected rise in early multifocal local recurrences of 9.5% following TaTME compared with 3.4% following conventional TME leading to a nationwide moratorium on the procedure and ending, in an editorial published on the British Journal of Surgery in August 2020, by saying that other countries should consider the issue in the context of local practices and results. There are limited data concerning oncological outcomes of TaTME compared to conventional TME. The aim of this study was to report perioperative and oncological outcomes for patients with rectal cancer treated with TaTME in a high-volume, experienced UK centre.

METHODS

From January 2015 to January 2020 consecutive patients with histologically confirmed rectal cancer having TaTME at Worcestershire Royal Hospital NHS were prospectively entered into an online international registry. Patients were followed according to local protocol with clinical examination, tumour markers, endoscopy and radiology.

RESULTS

Seventy patients underwent TaTME for rectal cancer. The median distance of the tumour from the anorectal junction was 4 cm (IQR 2-5). The mesorectal margin was involved in 20 (1%) patients, all of whom received neoadjuvant chemoradiotherapy. Overall survival was 94% at a median follow-up of 15 months (IQR 9-31 months). Distant recurrence occurred in 12 (17%) of patients at a median of 14 months (IQR 10-17 months). The 18-month stoma-free survival rate was 66%.

CONCLUSIONS

A local recurrence rate of 5.7% supports the oncological safety of TaTME for rectal cancer.

Cross-sectional Study on Assessment of First-pass Success of Video Laryngoscope Intubation in General Anesthesia Patients

Traditional Direct laryngoscope (DL) has been used by anesthesiologist during intubation for general anesthesia patients for more than a century. Video laryngoscope (VL) helps in better visualization of laryngeal orifice during intubation and reduces intubation time. This was a cross sectional study conducted in two Asian Hospitals Queen Elizabeth II hospital of Kotakinabalu, Malaysia and King Faisal Hospital Taif of Saudi Arabia to assess the first-pass success of video laryngoscope and to compare with direct laryngoscope from July 2015 to December 2017. Random lottery technique was applied for sampling. Participants of both groups (VL and DL) were enrolled by simple lottery method. Total 146 patients were enrolled with a set inclusion criterion. Mallampati class, mouth opening, thyromental distance and mobility of atlantooccipital junction were set as predictors of first-pass success. The first-pass success was 98.7% in mallampati II patients and 92.8% in mallampati III patients. Average success rate was 95.75%. The mean success rate of VL and DL was compared and was found VL had a significantly better first-pass success rate than DL (p<0.05).

Coronary Artery Revascularization with the Left Internal Mammary Artery (LIMA) to Diagonal (D) & Left Anterior Descending (LAD) Sequential and LIMA-LIMA "Y" Graft, Our Experiences at National Heart Foundation Hospital and Research Institute

The Left internal mammary artery (LIMA) is considered the conduit of choice for the surgical treatment (CABG, coronary artery bypass grafting) of Coronary artery disease (CAD) due to its superior long term potency than the other conduits. Sequential anastomosis with the LIMA in CABG increases the number of arterial graft and more completeness the arterial revascularization. To increase the number of arterial graft and improved long term potency, an alternative technique is sequential anastomosis of LIMA to Diagonal (D) & left anterior descending artery (LAD) and LIMA-LIMA "Y" Graft play a vital role in patients with tight proximal lesion. Perioperative data were prospectively collected from all patients with isolated CAD with tight proximal LAD lesion, who underwent off-pump CABG from November 2013 to October 2015 at a single Centre. A total of 321 patients had LIMA to D & LAD sequential and LIMA-LIMA "Y" grafts pattern with severe proximal LAD lesion. The mean age was 54.7±8.4 years, male & female ratio was 29.7:7.5. Left main involvement was in 25% & triple vessel disease was 89% with LVEF 53.6±8.6%. Sequential LIMA to diagonal (side to side) & LAD (end to side) done in all 294 cases and LIMA-LIMA"Y" grafts in 27 cases. Thirty days mortality was 0.935% (3 patients). Postoperative myocardial infarction (MI) occurred in 2 patients (0.623%). Two sequential LIMA graft failed and both the diagonal & LAD bypassed coronary arteries were very narrow, about 1mm in diameter. All the patients underwent postoperative NYHA class evaluation at 3-6 months follow up & found normal and none of the patients suffered for angina. Revascularization with skeletonized sequential LIMA anastomosis to D, LAD & LIMA-LIMA "Y" graft is a safe, feasible with improve overall long-term potency and reproducible alternative in the presence of severe proximal LAD lesion to the complete revascularization of the anterior& lateral myocardial wall. Long term follow-up with coronary angiogram is essential to recommend this technique as standard one.