Third annual Mediclinic Middle East Research Day

PODIUM ABSTRACTS

Physicians’ Understanding of Nutritional Factors Determining Brain Development and Cognition in the Middle East and Africa Abstract.

Dr Mudit Kumar, Paediatric Consultant, Mediclinic Parkview Hospital, co-author

BACKGROUND: Proper nutrition is essential for brain development during infancy, contributing to the continued development of cognitive, motor, and socio-emotional skills throughout life. Considering the insufficient published data in the Middle East and North Africa, experts drafted a questionnaire to assess the opinions and knowledge of physicians on the impact of nutrition on brain development and cognition in early life.

METHODS: The questionnaire consisted of two parts: The first focused on the responders’ demographic and professional characteristics and the second questioned the role of nutrition in brain development and cognition. Descriptive statistics were used to summarize respondents’ characteristics and their responses to questions.

RESULTS: A total of 1,500 questionnaires were distributed; 994 physicians responded. The majority of the surveyed physicians (64.4%) felt that nutrition impacts brain development in early childhood (0–4 years), with almost 90% of physicians agreeing/strongly agreeing that preventing iron, zinc, and iodine deficiency would improve global intelligence quotient. The majority of physicians (83%) agreed that head circumference was the most important measure of brain development. The majority of physicians (68.9%) responded that the period from the last trimester until 18 months postdelivery was crucial for brain growth and neurodevelopment, with 76.8% believing that infants breast-fed by vegan mothers have an increased risk of impaired brain development.

CONCLUSION: The results of this study show that practicing physicians significantly agree that nutrition plays an important role in brain and cognitive development and function in early childhood, particularly during the last trimester until 18 months post-delivery.

REFERENCES

• 1.Cusick SE, Georgieff MK. The role of nutrition in brain development: the golden opportunity of the “first 1000 days”. J Pediatr 2016;175:16–21.
• 2.Prado EL, Dewey KG. Nutrition and brain development in early life. Nutr Rev 2014;72:267–284.
• 3.Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr 1999;70:525–535.
• 4.Nyaradi A, Li J, Hickling S, Foster J, Oddy WH. The role of nutrition in children's neurocognitive development, from pregnancy through childhood. Front Hum Neurosci 2013;7:97.
• 5.Regional Committee for the Eastern Mediterranean. Regional Strategy on Nutrition 2010-2019. Geneva: World Health Organization; 2010 Sep. pp. 11.
• 6.Report No.: EM/RC57/5.
• 7.Hwalla N, Al Dhaheri AS, Radwan H, Alfawaz HA, Fouda MA, Al-Daghri NM, et al. The prevalence of micronutrient deficiencies and inadequacies in the middle east and approaches to interventions. Nutrients 2017;9:E229

Increasing the exclusive breastfeeding rate in mediclinic city hospital as part of the global strategy

Dr. Zahra Mokhber - Lactation consultant, Mediclinic City Hospital, Dubai, UAE.

BACKGROUND: Breastfeeding is a foundation of child survival and health because it provides crucial and irreplaceable nutrition for a child's growth and development. International experts recommend breastfeeding as the optimal feeding method with several documented benefits for both infants and mothers. The 5th global nutrition target by 2025 endorsed by the World Health Assembly Resolution is to increase the rate of exclusive Breastfeeding in the first 6 months up to at least 50%. WHO and UNICEF are highly encouraging hospitals to improve their support and assistance of breastfeeding mothers and infants.

Aims: To increase the rate of exclusive breastfeeding by implementing the Baby-friendly Ten Steps to Successful Breastfeeding outlined by WHO, UNICEF.

METHODS: A committee was created with a work plan to identify the areas that need improvement. An Infant Feeding Policy as a guideline for all staff, a patient education plan and a data collection plan established. Then, an education plan for staff created and more than 350 staffs including physicians, midwives, nurses, allied staff who were involved with the care of pregnant women, mothers and babies were educated to implement the Baby-friendly 10 steps. The empowered staff started to educate and support mothers during pregnancy, all through birth and hospital stay and continued the care after they went home in the clinic.

RESULTS: Breastfeeding rates over 3 years from 2016 to 2019 improved due to the practice:

• The rate of initiation of breastfeeding within first hour of birth increased from 70% to 92%

• Exclusive breastfeeding rate during hospital stay increased from 60% to 92%

• Exclusive breastfeeding rate at 6 months increased to 68% which is 28% higher than the worldwide rate published by WHO, UNICEF in 2019.

• Furthermore, the rate of skin to skin immediately after birth for minimum one hour after birth increased from 30% to 91% which prepare infants for initiation of breastfeeding

CONCLUSION: Implementing the Baby-Friendly Ten Steps to Successful Breastfeeding resulted in significant increase in initiation and exclusive breastfeeding rate at discharge and up to six months of age. This practice also worked towards the Baby- Friendly award for Mediclinic City hospital in June 2019 as the first Baby-Friendly designated private hospital in Dubai. The study showed that creative approaches and strategic education for staff and parents can create a favorable environment that breastfeeding is normal and more mothers choose breastfeeding as the optimum way of feeding their babies.

REFERENCES

• 1.WHO, UNICEF (2014), Global Nutrition Targets 2025: Breastfeeding Policy Brief, available at: https://www.who.int/nutrition/global-target-2025/en/ [accessed December 2019]
• 2.United Nations Children's Fund, UNICEF (2018). UNICEF data: Infant and young child feeding. available at: https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/ [accessed December 2019]
• 3.Riordan J, Auerbach KG. In. (2016) Breastfeeding and human lactation. 5th ed. Sudbury, Mass.: Jones and Bartlett.
• 4.UNICEF/WHO. (2009) Baby-friendly Hospital Initiative, revised, updated and expanded for integrated care [internet] Sections 1–5. Geneva, Switzerland, World Health Organization. Available at: http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse_s3/en/ [accessed December 2019]

Counselling parents of premature babies. a novel approach.

Dr. Zahreddin Abusalah - Consultant Neonatologist, Mediclinic City Hospital, Dubai, UAE.

INTRODUCTION: Counselling of parents expecting a preterm baby is a challenging experience that requires special expertise and knowledge. Despite its importance, there is no standard approved approach to conduct it.

Aims:

• To highlight the importance of effective communication with parents.

• To suggest a structured approach for counselling.

METHODS: The presentation will provide an overview of principles and contents of the counselling session. Although this has been the subject of several reviews and statements, there is a lack of a structured approach for conducting the consultation.

Colleagues in Oncology have suggested several protocols to discuss the clinical condition with their patients. Some of these protocols appear to be suitable to be adopted for use in counselling parents.

This paper will discuss the adoption of the SPIKES protocol that was originally described to disclose unfavourable clinical information to patients with cancer.

Outcomes of premature infants contribute to a major part of the consultation with parents. Therefore, the presentation will examine the latest available evidence about various aspects of outcomes of preterm babies.

The presentation will include video clips from my teaching video on counselling. The video was recorded with real parents of a premature baby.

CONCLUSION: A structured standard approach will help the healthcare professional to perform such a stressful task efficiently in a reproducible model. This may serve as a training tool too. To my knowledge, the counselling video of this presentation is the first of its kind in utilising a structured approach with the participation of real parents.

A Study to Analyse the Effectiveness of Physical Therapy and Wedged Foot Orthotic Devices on Pain in Runners with Pronated Foot

Albert Anand Udhaya Kumar, Physiotherapist, Mediclinic Al Ain Hospital, Al Ain, UAE.

INTRODUCTION: Running is one of the most popular forms of aerobic exercises and widely perceived to be beneficial to the cardiovascular and musculoskeletal endurance. In recent years, experts noted an increasing rate of injuries (24 - 65%) occurring in long distance runners and suggested that these injuries are related to the tremendous demands put on their lower extremities during running.

AIM: The Aim of study is to find out the effectiveness of Physical therapy and wedged foot orthotic devices used to reduce the pain and delay the onset of pain in runners with pronated foot.

METHODS: The study was pre-test and post-test experimental study design. All the subjects underwent a clear examination to diagnose the navicular height and pronated foot were selected and divided into two groups. The subjects were instructed clearly on the study, the potential benefits and harms of the study was adequately explained to the subjects, they were given 24 hours to confirm their participation, their willingness to participate was obtained and the subjects had permitted to withdraw from study at any point of time. Informed consent was obtained from all the participants and the study was approved by the tertiary hospital ethical committee.

The pronated foot was defined by:

• 1.Navicular height difference between weight bearing and non-weight-bearing stance > 10 mm.
• 2.Non-weight-bearing rear foot Varus > 5 or weight- bearing calcaneal valgus > 5.

The subject selection was based on the inclusion and exclusion criteria. The subjects were explained with VAS for pain and 60 minute Treadmill running test. 20 subjects were randomly selected and assigned into two groups. In Group A (Experimental) received a flat insole with 5 rear foot posting. The insole was made of -2 mm Poron, a rubber- like material with good impact absorbing capability, and the rear foot posting was made from an off-the-shelf 5 wedge of ethyl vinyl acetate (EVA). The medial wedge extended from the lon- gitudinal midline to the medial edge of the insole and was 6 to 8 cm in length depending on subject's foot size Subjects underwent a physical therapy session for 4 days per week. One session stands for duration of 30 minutes.

CONCLUSION: Thus the study concluded that physical therapy and wedged foot orthotic devices helps in reducing pain intensity and delays the pain onset of runners with pronated foot.

ACKNOWLEDGEMENTS: Authors are thankful to all the Team members of the Tertiary Hospital, Al Ain, UAE.

BIBLIOGRAPHY

• 1.Deepak Sebastian. A manual therapy approach to musculo- skeletal Dysfunction, Principles of manual therapy first edi- tion ISBN 2005) .9-504-8061-81-).
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• 10.Cole C., et al. “Platar facitis evidence based review of the di- agnosis and therapy”. American Family Physician 72 2242-2237:(2005).
• 11.Porter D., et al. “The effects of duration and frequency of Achil- les tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study”. Foot and Ankle International 624-619:(2002) 23.7.
• 12.Robroy L Martin and Todd E. “Davenport “Stephen F Reischl Heel Pain—Plantar Fasciitis: Revision”. Journal of Orthopaedic and Sports Physical Therapy 44.11.
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Dilemma of managament of Reflux;post weight loss surgery Is “Amir's UAE Repair” an answer?

K Amir, M Verheij, N Toba, A Abdalla, S Yousaf, Z Nimer, A Nisar

Obesity is one of the many factors causing reflux [1-3]. When patients undergo wright loss surgery their reflux may improve, however many continue to get reflux. There is a significant group of patients whose reflux becomes much worse after the reflux surgery due to change in anatomy and function of stomach despite a good weight loss [4-5]. Standard surgery for reflux is commonly done in the form of Nissen's fundoplication [6], which helps to prevent reflux by wrapping the fundus (upper stomach) around the lower end of oesophagus. In common weight loss operations like sleeve gastrectomy and Proximal gastric bypass operations this part (fundus) of the stomach is removed, thus leaving nothing behind to wrap the lower oesophagus to prevent reflux in the patients who have undergone weight loss surgery. These patients with a lose Lower Oesophageal Sphincter (LOS) at times with a lax hiatus and a hiatus hernia [7] suffer from reflux and fail to lose weight or maintain their weight loss [4]. The reason being that there is no cephalic restriction and the oesophagus also becomes a reservoir in addition to the gastric tube or the pouch, hence increasing the capacity of the food reservoir allowing larger portion sizes for the patients to eat.

In addition, there is an issue to reflux causing heartburn, water brash, Cough, sore throat, cough, Pharyngitis, sinusitis, exacerbation of asthma or recurrent chest infections due to aspirations [8]. The oesophagus is at an increased risk of Inflammation, Ulcers, Stricture formations, Barrett's oesophagus and Cancer of oesophagus [2,9].

This issue is topical and debated in every Bariatrics meeting across the globe and generally the proposed options are very few and unsatisfactory:

• 1.Recommendation for patients with sleeve gastrectomy:

  “To consider offering a bypass operation to those who had a sleeve gastrectomy surgery and have reflux”.

  Flaw with this advice is that these are the patients who chose not to have a bypass operation in the first instance and preferred a sleeve gastrectomy over a bypass operation [1].

  Why deal with the reflux complication of a sleeve gastrectomy with another complex bariatric operation?

• 2.Recommendation for patients with Proximal Gastric bypass operation:

  “This group of patients is offered resection of the Gastric pouch and to convert the Proximal Gastric Bypass surgery to Roux en Y Oesophago Jejunostosty”.

The issue here is that the patient will face an uncertain outcome which will probably prevent reflux but without the restrictive component of the primary weight loss operation and doubtful outcome regarding weight loss from then on. Overall portion size will be considerably more than the Proximal gastric bypass surgery.

Both options suggested are potentially failures of the initial weight loss surgery [10] and cannot be considered as corrective procedures for a complication of the first surgery but a reversal of the operation with primarily one goal; to prevent reflux.

These unsatisfactory decisions and surgery have created a feeling of uncertainty and dissatisfaction among bariatric surgeons [11].

We propose a stepwise approach to avoid such scenarios and handle the patients with post bariatric surgery patient with reflux appropriately when encountering this scenario:

• 1.Prevention in the first instance:
  • a.Appropriate assessment of the patients with reflux to be identified in the work up before performing the bariatric procedure
  • b.Appropriate testing which is performing an endoscopy and possibly oesophageal physiological studies if indicated.
  • c.Council the patient regarding the Antireflux surgery and a definitive and standard antireflux procedure while performing the primary bariatric surgical procedure.
• 2.Corrective treatment in patients presenting with reflux after weight loss surgical procedure:
  • a.Appropriate clinical assessment by surgeons with expertise in antireflux surgery.
  • b.Investigations in the form of gastroscopy and physiological studies.
  • c.Multidisciplinary approach by the antireflux surgery team to discuss the results of investigations and proposed treatment.
  • d.The surgical procedure to be carried out in the refluxers post Bariatric procedure patients by expert surgeons in antireflux surgery.

We have performed two surgeries for patients with severely debilitating reflux after sleeve gastrectomy surgery. Both had some initial weight loss but later regained some weight. Volume reflux caused sever burning sensation in chest, sore throat, cough and inability to lie flat. Poor quality of life and ongoing discomfort were common features.

The technique of Laparoscopic “Amir's UAE Repair”

After the initial success of these patients we have planned a prospective study for these patients to assess their quality of life after this surgery.

REFERENCES

• 1.Bou Daher H, Sharara A. Gastroesophageal reflux disease, obesity, and laparoscopic sleeve gastrectomy: The burning questions. World Journal of Gastroenterology 2019; 25 (33): 4805-4813
• 2.El-Serag H. The association between obesity and GERD. A review of the epidemiological evidence. Dig Dis Sci 2008; 53: 2307-2312
• 3.Hampel H, Abraham N. Meta-Analysis: Obesity and the risk of gastroesophageal reflux and it's complications. Ann Intern Med 2005; 143: 199-211
• 4.Cecily E, Dupree D O. Laparoscopic Sleeve Gastrectomy with pre-existing gastroesophageal reflux disease JAMA Surg 2014; 149 (4) 328-334
• 5.Stenard F, Iannelli A. Laparoscopic sleeve gastrectomy and Gastroesophageal Reflux. World Journal of Gastroenterology 2015; 21 (36): 10348-10357
• 6.Moore M, Afaneh C el al. Gastroesophageal reflux disease: A review of surgical decision making. World Journal of Gastrointestinal Surgery 2016; 8 (1): 77-83
• 7.Daes J, Jimenez M. Improvement of the Gastroesophageal reflux symptoms after standardizing laparoscopic sleeve gastrectomy. Obesity Surgery 2014; 24:536-540
• 8.Fisichella P, Schlottman F. Evaluation of Gastroesophageal Reflux Disease. Updates in Surgery 2018; 70:309-313
• 9.Chang J, Katzka D. Gastroesophageal reflux disease, Barrett's Esophagus and Esophageal Adenocarcimona. JAMA Int Med 2004; 164(14): 1482-1488
• 10.Peterelli R. Effect of Laparoscopic Sleeve Gastrectomy VS. Laparoscopic Roux-en-Y Gastric Bypass on weight loss at 5 years among patients with morbid obesity. The SM-BOSS Randomized Control Trial. JAMA 2018; 319: 255-265
• 11.Altieri MS, Pryor AD. Gastroesophageal reflux disease after bariatric surgery. Surg Clin North Am 2015; 95(3): 579-591

Immature granulocytes range is potential biomarker in peripheral enthesitis

Dr. Atheer Al-Ansari FRCP, Consultant Rheumatologist, Mediclinic Airport Road Hospital, Abu Dhabi, UAE

Dr. Iman Hussein, Associate Professor. Ain Shams University, Cairo, Egypt

INTRODUCTION: Immature granulocytes (IG) level in peripheral blood is used as early sign of infection. On the other hand IG could be elevated in other conditions like inflammatory or cancerous diseases and in pregnancy. Similar to CRP, we have observed a series of cases of peripheral enthesitis associated increased level of IG and correlated with CRP elevation and clinical activity.

METHOD: To test the concept of IG as a biomarker in peripheral enthesitis, we have identified 13 cases over the last 12 months at the Rheumatology clinic in our centre who have shared two features (clinical enthesitis and elevated IG) those 13 cases presented with recurrent foot and ankle pain and swelling of enthesitis nature.

RESULTS: The cohort is of equal gender distribution 46/54% respectively and age range 31-53 years (mean age 38.5), only 3 patients are known to have Psoriatic arthritis whilst the rest either undiagnosed or diagnosed Rheumatoid arthritis or gout prior to clinic visit. The rheumatologist clinical diagnoses are of enthesitis of foot, ankle, knee and hip area as shown on the table [1} apart from one patient who has spinal symptoms mainly. 4/13 patients have the history of psoriasis and after their visits we find them fit in the CASPAR criteria for psoriatic arthritis. All these cases are associated with increased absolute number of IG as well as differential (IG) number compare to 10/13 of these cases are having high CRP. The 3 cases with normal CRP do have relatively slight increase in (IG) number. The main correlation is of response to therapy and was seen in 7 cases who have followed up at the time of submission and it shows a 100% correlation between CRP, absolute (IG) and differential (IG) values. There are 3 patients who have elevated (IG) but normal CRP and it would possible indicate (IG) test has a better yield than CRP in peripheral enthesitis.

CONCLUSION: Immature granulocytes can be elevated in inflammatory disease and more notably in peripheral enthesitis of the lower limbs of inflammatory rather than mechanical nature and do correlate with CRP elevation as well as response to therapy. Larger studies are need to assess the usefulness and validity of (IG) level in clinical practice.

REFERENCE

• 1.Salvarani c et al, Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis, J Rheumatol. 1997 Jun;24(6):1106-10
• 2.Rudwaleit M et al, The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in genera, Ann Rheum Dis. 2011;70(1):25
• 3.Moots R et al, Low-density granulocytes: functionally distinct, immature neutrophils in rheumatoid arthritis with altered properties and defective TNF signaling, Translational & Clinical Immunology 2016 https://doi.org/10.1189/jlb.5A0116-022R

Capture the Fracture Program (FLS) for Osteoporosis at Mediclinic Welcare Hospital The Fracture Liaison Service (FLS)

Dr. Mustafa Al Izzi, MRCP (UK), FRCP (Edin), Professor and Consultant Rheumatologist Mediclinic Welcare & City Hospitals & Dubai Mall Clinic

Vice President of the Emirates Osteoporosis Society (EOS)

BACKGROUND: Studies have shown that as few as 10% of women with fragility fractures receive osteoporosis therapy. Patients with a recent fragility fracture after the age of 50 years are at increased risk of sustaining a subsequent fracture. Subsequent fracture risk is highest within the first 2 years after a fracture and subsequent fractures are associated with an increased morbidity and mortality resulting in a high financial burden for healthcare

METHODS: FLS are proposed as the most successful approach for secondary fracture prevention. This FLS approach starts with the identification of patients with a fragility fracture (case finding), followed by assessment of clinical risk factors for subsequent fractures and secondary osteoporosis (including bone density, imaging of spine, laboratory assessment), treatment initiation (if indicated) and adequate long-term follow-up to improve treatment adherence.

In 1999, McClellan and colleagues initiated the first fracture liaison service (FLS) in the UK, since then, several FLSs have been initiated from different medical departments in hospitals all over the world as supported by the International Osteoporosis Foundation (IOF), European League Against Rheumatism (EULAR)/European Federation of National

Associations of Orthopedics and Traumatology (EFORT) and American Society for Bone and Mineral Research (ASBMR) task force.

RESULTS: FLS workshop was conducted in Dubai on 29/11/2019 as a collaborative initiative between IOF and EOS. It was the first workshop of its kind to be held in UAE. Participants from seven different hospitals in UAE attended including Mediclinic Welcare hospital. Each FLS unit will consist of an orthopaedic surgeon, a rheumatologist or Endocrinologist with interest in Osteoporosis and a dedicated nurse who will trace fracture cases from the medical records and arrange for such patients their follow ups.

CONCLUSION: FLS unit will be functional in MWEL as the first unit in UAE of its kind to capture the osteoporotic fractures at an early stage for a better management of osteoporosis and prevention of fragility fractures.

The new Gold standard in hernia surgery? Needlescopic Mini-Scar-less (MSL) Totally Extra Peritoneal (TEP) Inguinal hernia repair

K Amir, M Verheij, A Ali, S Yousaf, Z Nimer, A Abdalla, A Nisar

Laparoscopic surgery brought a major advancement in the field of surgery by reducing the trauma to the patient and improving the immediate, short, medium- and long-term outcomes of the patient and of course better cosmesis.[1] The pain scores came from 6-8 after open surgery, down to 2-4 after minimal invasive hernia surgery.

Since the first ever Laparoscopic Totally Extra Peritoneal hernia (TEP) operation was done in 1988 by Dulucq, more than a score and ten; there has been little improvement in the surgery. The cosmesis though excellent and pain scores in the lower third of the scale still needed improvement.

Totally Extra Peritoneal repair of groin for Inguinal, femoral and Obturator hernias has become the gold standard over the last three decades. It offers far superior results than conventional open approach regarding less post-operative pain[2], early mobilisation, early return to activity, decrease length of hospital stay [3], early return to driving, early resumption of exercise, early return to work [4], lesser chance of hernia recurrence [5] and chronic pain due to surgery in unilateral, bilateral and recurrent inguinal hernia surgery.[1,4,6] This has been acknowledged by National Institute of Clinical Excellence (NICE), United Kingdom through great work and efforts of Professor Michael Bailey. Professor Bailey has been instrumental in developing, refining and popularising the technique initially in United Kingdom and later in Europe and the rest of the world. Author had the honour of working closely with him, teaching and training surgeons. Professor Amir has also contributed with his personal work and a study in hernia surgery to the National Institute of clinical Excellence (NICE) United Kingdom.

Groin hernia repairs account for over 20 million surgical procedures annually worldwide [7,8]. Nearly 85,000 groin hernia surgeries are carried out annually in United Kingdom; only less than 10% of these operations are carried out laparoscopically [3], the rest are done with open conventional technique.

One reason might be that this operation is considered to be complex and many experienced surgeons in groin hernia surgery find the adaptation of Laparoscopic Totally Extra Peritoneal (TEP) hernia challenging. The learning curve has been considered as long and surgical trainers’ fraternity considers this to be between 40-100 to perform simple hernias and between 400-600 hernia operations to handle all comers [9].

The standard operation requires three cuts in the lower abdomen with accumulative incision's length of 3-4 cm. The technique involves Balloon dissection kit for camera port and two other working ports.

We had improved this technique to Needlescopic Hernia repair with accumulative incision's length of 1.6 cm, offering much better cosmesis and less post-operative pain at the port sites in the abdominal wall since 2018. Most recently we have introduced a further improved version of the technique and now we perform the same operation through a total incision size of nearly just 1 cm. Cosmetically this is a much superior operation than its previous versions. There are scars in the lower abdomen, hence mini-scar, however the size in so small that these cannot be identified by an on looker even to some trained surgeon in the post-operative stage, thus the addition to the name of the technique; Mini-Scar less TEP repair. Though the cuts in the abdominal wall are minimal; however, the operation is carried out exactly the same way as in a standard Totally Extra Peritoneal operation. Surgeons with expertise in Totally Extra Peritoneal technique will be able to adapt this technique for better outcomes of their patients, if they followed some key steps of Needlescopic Mini-Scar less (MSL) Totally Extra Peritoneal Inguinal hernia repair for suitable patients. The technique of Needlescopic Mini-Scar less (MSL) Totally Extra Peritoneal Inguinal hernia repair Patient Position and theatre set up:

Supine as for TEP repair with arms tucked to the sides with inkopads.

Monitor towards the foot end of the patient. If two monitors available in integrated theatre then a monitor by either side of the patient at level to patient's knee.

Surgeon stands on the left side of the patient (if right- handed; or vice versa) Assistant/Camera Person stands on the left side of the patient.

Once the ports are placed then the surgeon and camera person move opposite to side of the hernia.

An Intra-Infero-Lateral 5 mm incision is made in the skin after prefiltration and raising of the skin with size 11 blade 5 mm visiport with doughnut at tip is used to enter through the cut inferolaterally at an angle of 60 degrees to reach the anterior rectus sheath. 5 mm 30 degree camera is used throughout the operation.

Anterior sheath penetrated and the rectus abdominus muscle separated and the port advanced anterior to the posterior rectus sheath for approximately 1 cm.

The trocar of the port is removed, Co2 tubing attached to trocar and pressure set to 12 mm of Hg and camera reintroduced in the port and some blunt dissection of the extraperitoneal space done and port and camera further advanced under vision. The dissection is continued posterior to the width of the rectus abdominus muscles till the pubic symphysis is reached.

1st 5 mm port is fully inserted over the camera, It's balloon at the tip is inflated with 2.5 mls of air, port retracted and secured in a position as proximal as possible.

2nd port, 3 mm in size is placed in midline 5 cms below the umbilical port after preinfiltration with local anaesthetic.

3rd and final port, 3 mm in size is placed in midline 4 cm below the second port after preinfiltration with local anaesthetic.

Right and left hand 2.5 mm instruments are placed through the working ports and dissection done in routine as for a standard Totally Extraperitoneal repair.

Hernias are reduced widely, haemostasis assured and extraperitoneal space is prepared ensuring safety in all areas especially the triangle of doom and other structures including fine nerves. Any lipomas of cord are also reduced following the principals of Totally extra Peritoneal repair.

A 15X12 cm mesh is prepared by trimming a 15X15 cm light weight mesh. A horizontal line is drawn across the mesh as a reference and the lateral edges are trimmed round for orientation of the mesh during its placement in the extraperitoneal space.

The mesh is rolled and tied with 2/0 vicryl long at its medial end.

The long 2/0 vicryl strand in introduced through the 5 mm Umbilical port and then the camera introduced by its side. The end of the tie is picked up with a grasper through the lowest port. Camera is removed and the mesh railroaded through the 5 mm port and pushed in with the camera. The tied mesh is orientated in appropriate position, held it left hand instrument and the tie cut and removed with 2.5mm scissors. The mesh is unrolled and positioned appropriately.

We do not secure the mesh in place in majority of our cases except in large direct hernias.

CO2 gas is retrieved, 3mm ports removed, balloon deflated and 5 mm port removed as well. Local anaesthetic is infiltrated on the sheath of 5 mm port and the skin closed with 5/0 absorbable Subcuticular suture.

The 3 mm ports wounds are approximated with steristrips. Opsite dressings are applied on 3 wounds.

RESULTS: We have performed 3 operations so far; one unilateral and two bilateral hernias. The recovery has been uneventful.

Patients, operating surgeons and the out patient's nursing staff are pleased with the cosmetic results and minimal, difficult to identify scars as soon as 1 week after the surgery.

A prospective study is being done to compare operative time, post-operative pain, post-operative mobilisation, cosmetic outcomes, time taken for recovery and return to work.

REFERENCES

• 1.NICE guidance: Laparoscopic surgery for inguinal hernia repair, Technology appraisal guidance [TA83] Published date: 22 September 2004
• 2.Garofalo F, Mota-Moya P et al. TEP Repair residency teaching program and outcome evaluation. World Journal of Surgery 2017; 41: 100-105
• 3.Bednarski B, Nickerson T P, You Y N et al. British Journal of Surgery 2019; Wiley Online Library 10.1002/ bjs.11223
• 4.Bobo Z, Nan W, Qin Q, Tao W, Jianguo L, Xianli
• 5.H. Meta-analysis of randomized controlled trials comparing Lichtenstein and totally extraperitoneal laparoscopic hernioplasty in treatment of inguinal hernias. J Surg Res 2014; 192: 409–420.
• 6.Schjoth-Iversen L, Refsum A, Brudvik K W. Factors associated with hernia recurrence after laparoscopic total extraperitoneal repair for inguinal hernia: a 2 year prospective cohort study. Hernia.2017; 21: 729–735
• 7.Kingsnorth, A., Controversial topics in surgery. The case for open repair. Annals of the Royal College of Surgeons of England, 2005. 87(1): p. 57-60; discussion 57-60.
• 8.Lomnicki J, Leszko A et al. Current treatment of the inguinal hernia — the role of the totally extraperitoneal (TEP) hernia repair. Folia Medica Cracovienisia 2018; 58: 103–114
• 9.Suguita FY, Futema E, et al. Learning curve takes 65 repetition of totally extraperitoneal
• 10.laparoscopy on inguinal hernias for reduction of operating time and complications. Surg Endosc. 2017; 31: 3939–3945.
• 11.Ramshaw B, Laparoscopic Inguinal Hernia Repair: Lessons learned after 1224 consecutive cases. Surg Endosc 2001; 15: 50–54

Hereditary Cancer Syndromes and development of tele genetics program in the Asia-Pacific, Middle East region

Dr. Shaheenah Dawood MD - Assoc. Professor of Clinical Oncology, Consultant Medical Oncologist - Mediclinic City Hospital, Dubai, UAE

BACKGROUND: BRCA mutations is emerging as an agnostic marker for PARPinhibitors. Accessibility to genetic counselling is limited due to shortage of manpower and access to institutions that provide it. Our aim was to look at the incidence of pathogenic germline mutations in India/UAE and develop a virtual pathway, aimed at increasing accessibility to genetic counselling.

METHODS: 864 patients(pts) were tested in the UAE and India for germline mutations. Based on discussion between physicians and patients, an urgent need for genetic counseling was identified. A virtual platform (telegenetics) was constructed for those who sought genetic counseling due to a personal or family history of malignancies. Referral of pts was either self-based or through a treating physician. Primary goals included 1) ease of access for pts, 2) increase comprehension of the indications, implications and consequences of genetic testing, 3) decrease physician time in the clinic. 10 questions were developed to determine pt and physician satisfaction.

RESULTS: 241(28.9%)pts had a pathogenic variant in BRCA1/BRCA. 115pts were enrolled in the pilot phase of the tele genetics program; all physician referred. Counselling was by a dedicated trained genetic counsellor through voice-call(43.5%), video- conferencing(47.8%) or in person when requested (8.7%). All pts completed a satisfaction survey. Majority of pts were comfortable sharing information on a virtual platform(80%), were happy with the quality of virtual connection(85%), and felt comfortable connecting with the genetic counselor(90%). Information is currently being collected from referring physicians.

CONCLUSION: Our ongoing pilot phase reveals improved pt satisfaction and understanding of the information provided. A mobile application has been developed to enhance pt accessibility/convenience and physician connectivity with the testing phase of the app currently on going. To our knowledge this is the first tele genetics program to target the middle east/Asia pac region that is targeted to cope with increase in pt volumes, expand appropriate referrals, starting with pts who have a personal or family history of cancers, expanding to more complex high risk diseases over time.

A prospective Comparison of New-generation Fecal Immunochemical Test (FIT) With Guaiac Fecal Occult Blood Test (FOBT) in Detecting Colorectal Cancer

Villanueva J, Tomagan J, Alimagno A, Santos E, Noble D, Santos A, Sonejee K, Al-Thahyabat M, Aljabiri M

INTRODUCTION: Colorectal cancer (CRC) is the third most common cancer, and is the second leading cause of UK cancer deaths, killing 16,000 people each year, And It is estimated that 51,020 deaths in the USA. Screening aims to detect colorectal cancer at an early stage, in people with no symptoms, and can detect non-cancerous polyps and adenomas, which could develop into cancer over time, which can then be easily removed and reduce the risk of cancer developing. Thus, regular colorectal cancer screening can significantly reduce the risk of mortality.

AIM: The aim of the present study was to compare fecal immunochemical tests (FITs) for colorectal cancer (CRC) screening with the traditional guaiac-based FOB tests (gFOBT).

METHODS: Prospective study in a Single Centre in a large Private hospital (Mediclinic Parkview) for the period of 1st November -31st December 2019 for patients living in United Arab Emirates. Ages between 15-55 years, for a period of 2months. A standard FOBT test provided in addition to the FIT test at the same time for 60 patients during this period. Laboratory analysis performed on same day on both tests

RESULTS: Sixty-nine patients over this short period screened with FIT and FOBT. Patient with FOBT test positive were 16% (10/69) and FIT were 30%(18/69). Within these patients, we picked up 3-colon cancer patients on FIT. There was 1 false negative in the FOBT arm and 5 /69 false positive (7.2%) and this makes it less specific for CRC screening

CONCLUSION: In our prospective study, the Fecal Immunochemical Test (FIT) indicated that the introduction of this test as the first line- screening test is likely to increase pick up rate of adenoma by an extra 50% and this led to subsequent colon cancer prevention. As it has shown FIT, test positive was 30% compared to the guaiac fecal Occult Blood Test (FOBT) 16% that is currently used. The current study also showed that participants reported much higher intentions to complete and return the new fecal Immunochemical Test (FIT) versus the current guaiac fecal Occult Blood Test (FOBT). Furthermore, we have noticed that when the FIT test is highly positive the FOBT is negative this gives an indication that this loses its sensitivity when there is a large amount of blood in the stool. Further study should be conducted on this to find the cut off level for positive FIT test. We recommend that Mediclinic Middle East initiate FIT test for bowel Cancer screening as a standard method for all associated hospitals and clinics due to the high sensitivity and specificity

Comparison of biomarkers among 34855 GI cancer samples shows heterogeneity of tumor types.

DR. SALIM CHAIB RASSOU

Dr. Shaheenah Dawood MD - Assoc. Professor of Clinical Oncology, Consultant Medical Oncologist - Mediclinic City Hospital, Dubai, UAE

BACKGROUND: Recent data indicate that biomarker driven use of targeted therapy and I/O-therapy among patients with GI cancer is associated with improved outcome. The presence of biomarkers varies broadly between different GI tumor types, highlighting the importance of comprehensive molecular profiling. To analyze the presence of various alterations in GI cancer samples of a large database, comparing congruency between various tumor types.

METHODS: A retrospective data analysis of 34855 GI cancer patients profiled at CARIS Life Sciences obtained from Jan 1, 2010 till Sep 14, 2018 was performed. GI tumors were classified as CRC, esophageal/gastric/GIST, small intestine, pancreatic/hepatobiliary/liver. Technologies used to analyze the biomarkers: IHC for PD-L1, MMR and Her2, and DNA-NGS for EGFR, BRAF, KRAS, NRAS, MET- CNV, TMB, MSI, POLE and BRCA1/2.

RESULTS: Median age was 61 range (18-89 years). 51.5% was CRC (n=18047), 15.5% was esophageal/Gastric/GIST (n=5470), 3% was small intestinal cancer (n=886) and 30% was pancreatic/hepatobiliary/liver cancer (n=10452). Information on biomarkers was available from 2931 cases for MET amplification to 28536 for RAS mutation. Overall, the most common finding was a pathogenic RAS-mutation in 7650 cases (26.81%), the rarest one was a mutation in EGFR in 12 cases (0.06%). Higher rate of HER2 amplification was observed among pts with esophageal/gastric/GIST tumors (6.5%) in comparison to tumors at other GI sites ( ∼1.5%). High TMB was seen among patient with CRC and small intestine tumors (∼7%) while it was lowest among pancreatic cancer (1.8%). Compared to other GI sites lower MSI /MMR deficiency rates were observed in pancreatic / hepatobiliary tumors, significantly higher PD-L1 positivity was observed in gastrooesophageal cancer types, increased MET- amplifications in gastrooesophageal and small intestinal cancer types and lower RAS-mutation rate in gastrooesophageal cancer.

CONCLUSION: Molecular profiling analyzing druggable biomarkers can help identify patients with increased likelihood for benefit from immune-checkpoint-inhibitors and targeted therapies. Further investigations are needed to evaluate the different findings in various GI cancer types.

Clinical Benefits of Implementing DIBH in Breast Radiotherapy

DR. SALIM CHAIB RASSOU

• EBCTCG use of RT after Breast Conservative Surgery (BCS) or after mastectomy in N+

• Not only reduces Local Recurrence (LR), but also improves long-term survival.

• Absolute reduction in the 5-year rate of LR was proportional to the absolute reduction in 15-year breast cancer mortality with a 4:1 ratio.

• RT for breast cancer inadvertently delivers ‘excessive’ dose to the heart,

• Increased rate of late cardiac deaths closely linked to mean cardiac doses > 5Gy

• Technical innovations in radiotherapy minimize cardiac irradiation.

Full benefit in overall survival requires radiotherapy's technique that minimizes cardiac dose and avoids the late cardiac mortality seen with older techniques and irradiation of large cardiac volumes (14)

What is considered an acceptable treatment plan?

Target coverage with respect to dose to (OAR) and good dose distributions

• There is lack of consistency among institutions or individuals

• To improve patient standard of care:

• There is a need to define a consistent and transparent TRT path for all patients

• Reduces significance variations in the acceptability of treatment plans.

• DIBH, facilitated by respiratory gating, significantly reduced:

• The volume of heart and abdominal contents treated to high dose,

• Well tolerated,

Highly reproducible and accomplished within acceptable treatment times in a busy radiation therapy department. (12) Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients (13)

So far we have treated near 1000 with this technique in two centers, our preliminary analysis consist of 319 breasts Cancer,

• 144 left-sided DIBH and

• 175 free-breathing (FB) (83 L and 92 R).

DIBH plans show large reductions of dose to the heart compared with left-sided FB plans

• UV20 Gy for the heart is reduced from 7.8% to 2.3% (70%, p < 0.0001),

• V40 Gy from 3.4% to 0.3% (91%, p < 0.0001)

• Mean dose from 5.2 to 2.7 Gy (48%, p < 0.0001).

• Lung V20 Gy reduced (p < 0.04)

• Median target coverage is slightly improved (p = 0.0002).

CONCLUSION: Implementation of DIBH in daily clinical practice results:

• In reduced irradiation of heart and lung, without compromising target coverage.

• Provides an unequivocal benefit

• 1.Reduction in cardiac dose for left-sided with (DIBH) compared (FB)
• 2.Same for (FB-IMRT) and (3D-DIBH) reduce cardiac irradiation
• 3.At 20 years cumulative risk of cardiac death of 6.4% compared with 3.6% for patients with right-sided breast cancer. (1)
• 4.IMRT used for adjuvant treatment of breast cancer has shown improved target coverage as well as lower doses to cardiac structures. (2,3)
• 5.The use of (DIBH) during tangential breast radiation therapy has also proved to be a high-quality means of reducing the cardiac volume that receives the radiation dose

• 1.J.Clin.Oncol.24: 4100–6; 2006
• 2.Radiat.Oncol.6: 5; 2011
• 3.Med. Dosim.33: 71–7; 2008
• 4.CARO 2005, Abstract book (195)
• 5.Radiotherapy and Oncology 106 (2013) 28–32 6. The Breast 18 (2009) S3, S103–S111

Somatic mutation and copy number variation(CNV) characterisation of patients receiving (neo)adjuvant therapy for early breast cancer in a multi ethnic Middle-Eastern cohort

Dr Shaheenah Dawood Mediclinic City Hospital, Dubai UAE; Dr Darren Korbie, XING Technologies Pty Ltd Brisbane; Dr Mike Pheasant XING Technologies, Pty Ltd Brisbane, Australia; Dr Houriya Kazim Mediclinic City Hospital, Dubai UAE; Dr Annett Al Hamadi Mediclinic City Hospital, Dubai UAE; Dr Zulfaqqar Jaffar Ali Mediclinic AbuDhabi; UAE Mr Charles Lloyd XING Technologies, Pty Ltd Brisbane, Australia; Dr Rebecca A Dent, National Cancer Centre Singapore, Singapore; Dr Paul N Mainwaring, Canossa Private Hospital, Brisbane, Australia.

INTRODUCTION: Cancer arises from a series of well-known causes: Aging (the clock mechanism of cellular turnover and daily DNA repair), Tobacco smoke, betel nut, diesel fumes, alcohol, cured meats, viruses e.g. HBV, HPV, EBV, sunlight, background radiation. These carcinogens induce DNA and epigenetic DNA changes which can be measured using DNA signatures e.g. DNA Damage & repair as well as meDNA signatures. These signatures can be categorized into carcinogenic processes such as kaetegis, chromothrypsis & chromoplexy amongst others. Finally, cancers are heterogenous meaning that as they evolve from one cell they undergo a variety of evolutionary growth patterns that mean not all cells carry the same molecular make-up.

Breast cancer in women from the Middle East is characterized by younger age, more advanced stage at presentation and a higher proportion with TNBC. In TCGA and ICGC molecular data of pts from the Middle-East is under-represented. The objective of this study was to define the molecular parameters of breast cancer in a prospective cohort of women diagnosed in a Middle Eastern breast cancer referral centre receiving (neo)adjuvant systemic therapy. We examined the association between primary biopsy and pathological tissue response (RCB criteria) integrating molecular pathology using massive parallel sequencing analyses.

METHODOLOGY: We designed a custom 1000 gene panel using Illumina IDT capture-based assay design and sequenced tumour samples to greater than 500X coverage with matched tumour normals. Sequencing analysis and variant calling were performed using Broad GAKT best practice; BWA, Mutect2, Oncotator pipeline. CNV data was analysed using panelcn.MOP and seqCNV.

RESULTS: 57 women were enrolled(June 2016-October 2017). Median age was 45yrs.10.5% were of middle-eastern origin, 24.5% from North Africa, 42.1% from Asia and 22.9% from Europe/North America. 4%, 53%, 44% had stage I, II and III disease respectively. 16%, 70%, 14% had TNBC, HR+/HER2neg and HER2pos disease respectively. 15.7% had germline BRCA1/2 mutation. We found 367 somatic mutations in 217 significantly mutated genes(SMG). Most commonly seen mutations:TP53(26%),PIK3CA(21%),KMT2C(12%),JAK1 (11%). 5% had POLE mutation. 20pts who received neoadjuvant chemotherapy 7(35%) was RCB0. Differences in PAX3,BRCA2,CHD2 and FGFR4 were observed among pts who did and did not achieve RCB0. CNV analysis is below:

IMPLICATIONS: Using a novel 1000 gene hybrid-capture technology including SMG, CNV, small indwells we describe a spectrum of aberrations with common features to be expected in a multiethnic Middle-Eastern breast cancer cohort. The incidence of TP53 and PIK3CA mutations was similar to those reported for Caucasian women with breast cancer in the cBioprtal data sets. Interestingly we observed JAK1 to be the 4th most commonly mutated gene. Compared to cBioportal published breast cancer datasets we observed higher rates of MYC amplification as well as TP53 pathway aberrations. Germline& therapy-induced CNV changes also allude to significant chromosome instability within this cohort. Our preliminary data has demonstrated that in the population there were a) common SNV and CNV changes recognised across the world as being pathogenic, but also b) unique changes on crucial cancer cell growth pathways hinting that there are unique changes associated with patients of non-Caucasian origin that merit further exploration

Fatma.mubarak. (2019). Prevalence of Anxiety and Depression in Abu Dhabi residents in Year 2019. Family Medicine Department, Mediclinic Al Noor Hospital, Abu Dhabi, UAE.

INTRODUCTION: In recent Medical researchers in UAE, the Mental Health care became one of the most important subject to focus on human health being in UAE.

In past, inattentively the mental health disorder was not addressed properly due to several factors. Despite that; Depression and Anxiety are commonly seen in the general practice; and there is no statistical data reflects the impact of this problem.

The study titled as Prevalence of Anxiety and Depression in Abu Dhabi residents in Year 2019. It's a Pilot Study that aims to reveal the percentage of depression and anxiety among the general population of Abu Dhabi.

Also; it aims to increase the awareness of mental health issues among the stakeholders to facilitate further management of this global health issue.

METHODS: It is a cross sectional, pilot study with sample size of 176 and the P value is set to be 0.05, CI is 95%. The data tool is self- administered questionnaire focusing on Patient Health Questionnaire 2 and 9, and General Anxiety Disorder 7 scale distributed to visitors attending Mediclinic Hospitals. Data analysis was done by using Statistical Package for Social Science (SPSS).

RESULTS:

• The study showed that 53.98% of Abu Dhabi residents screened were negative for depression while 46.02% were positive.

• 62.50% of Abu Dhabi residents screened and found to have mild anxiety, 31.25% as moderate anxiety and 6.25% had severe anxiety.

CONCLUSION: This study concludes the emerging cases of depression and anxiety among Abu Dhabi residents and requires further wide screening programs to be implemented in order to reduce the mental health related sicknesses and empower the human nature with positive thinking attitude & well-being.

Anthropometric measurements and prevalence of obesity related diseases: A cross-sectional study of overweight and obese patients in a novel multi-disciplinary weight management program

MARIAM ELSABAN, FAISAL NAWAZ, MONA JOUMAA, AMAR HASSAN KHAMIS, USAMA WARSHOW, RAHILA BHATTI

BACKGROUND: According to world health organization (WHO), United Arab Emirates (UAE) has one of the highest prevalence rates of obesity in the Middle East at 33%. There is a paralleled rise in the incidence of related metabolic conditions, particularly type 2 diabetes, metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Through dietary, pharmaceutical, endoscopic and surgical options, multidisciplinary weight reduction programs offer a comprehensive approach to obesity management.

AIM: Study the prevalence of obesity related diseases in a weight management program and determine the relationship to obesity anthropometric indices.

METHODS: This is a cross-sectional study conducted at Mediclinic Parkview Hospital in Dubai, UAE. 311 patients have been evaluated from January 2019 until September 2019 as part of a multi-disciplinary weight management program. Key demographics, anthropometric, and clinical data was analyzed using Statistical Package for Social Sciences (SPSS) software (Version 24). Correlations were assessed by Mann-Whitney test (significance p < 0.05).

RESULTS: 311 patients taking part in the weight management program were studied. The population was constituted of 103 (33%) males and 208 (67%) females. The mean age was 41 years (±9.6) with a median BMI of 34 (±6.5) and 32.4 (±7.8) for males and females respectively. Mean waist circumference was 116 cm (±23.4) and 104 cm (±17.5), fat percent was 41.9% (±6.7) and 42.6 (±7.75), fat mass was 39.7 kg (±13.3) and 41.5 (±15.5), and visceral fat was 6.7 kg (±3.4) and 3.2 (±1.9), for males and females respectively. The population was heterogeneous with 38 nationalities. In relation to associated metabolic diseases, diabetes had the highest prevalence at 20.3% (n = 63/310) (3.3% type 1, 50% type 2, 46.7% pre-diabetes). Other co-morbidities were dyslipidemia at 31% (n = 97/261), hypertension at 20% (n = 63/311) & NAFLD at 10% (n = 34/229). BMI correlated with waist circumference (r = 0.62, p < 0.01) and was significantly associated with diabetes, hypertension, and NAFLD.

CONCLUSION: The study has confirmed the high prevalence rates of obesity related diseases in a private hospital setting in a multinational cohort of obese patients. BMI and waist circumference are the most representative measure of obesity in our population and obesity related diseases. Further studies will play a part in assessing the benefit of these measures during weight reduction interventions.

Meta-analysis comparing combined use of Eicosapentaenoic acid and statin to statin alone

Rajkumar Doshi, MD, MPH, Ashish Kumar, MBBS, Samarthkumar Thakkar, MD, Mariam Shariff, MBBS, Devina Adalja, MBBS, Abhi Doshi, MBBS, Mohamed Taha, MD, Rajeev Gupta, MD∗, DM, Rupak Desai, MBBS, Jay Shah, MD, and Nageshwara Gullapalli, MD, MPHAm J Cardiol 2020;125:198 − 204∗ Mediclinic Al Jowhara Hospital/Mediclinic Al Ain Hospital, Al Ain, UAE.

BACKGROUND: Role of omega-3-Fatty acids, especially eicosapentaenoic acid (EPA), in reducing cardiovascular events is not clear. We conducted a meta-analysis including trial sequential analysis (TSA) of all available randomized controlled trials (RCTs) assessing the impact of EPA + statin on cardiovascular risk reduction.

AIM: To appraise cardiovascular risk reduction with EPA and statin taken together. A comprehensive search of PubMed and EMBASE databases was conducted for all RCTs that compared EPA + Statin versus placebo + statins and included outcomes related to cardiovascular health. We calculated a comprehensive odds ratio (ORs) and 95% confidence intervals (CIs) using a random- effects model. We included 5 RCTs totaling 27,415 patients.

RESULTS: Demonstrated that EPA + statin resulted in 18% reduction in the incidence of MACE (OR = 0.78; 95% CI: 0.65–0.93, I2 = 54%, P value < 0.01) and 30% reduction in myocardial infarction (MI) (OR = 0.71; 95% CI: 0.61–0.82, I2 = 0% P value < 0.01,) as compared to statin alone. With respect to MACE, the number needed to treat was 49. The statistical significance for reduction in the incidence of MACE with EPA + statin was further augmented with trial sequential analysis. However, combined therapy of EPA + statin demonstrated no significant association on incidence of stroke when compared to statin alone or all-cause mortality.

CONCLUSION: The meta-analysis demonstrated that EPA significantly reduced the incidence of MACE when combined with statin therapy, which is mainly driven by a significant reduction in myocardial infarction.

REFERENCES

• 1.Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-1389.
• 2.Aung T, Halsey J, Kromhout D, Gerstein HC, Marchioli R, Tavazzi L, Geleijnse JM, Rauch B, Ness A, Galan P, Chew EY, Bosch J, Collins R, Lewington S, Armitage J, Clarke R and Omega-3 Treatment Trialists C. Associations of Omega-3 Fatty Acid Supplement Use With Cardiovascular Disease Risks: Meta-analysis of 10 Trials Involving 77917 Individuals. JAMA Cardiol 2018;3:225-234.
• 3.Wetterslev J, Jakobsen JC and Gluud C. Trial Sequential Analysis in systematic reviews with meta-analysis. BMC Med Res Methodol 2017;17:39.
• 4.Yokoyama M, Origasa H, Matsuzaki M, Matsuzawa Y, Saito Y, Ishikawa Y, Oikawa S, Sasaki J, Hishida H, Itakura H, Kita T, Kitabatake A, Nakaya N, Sakata T, Shimada K, Shirato K and Japan EPAlisI. Effects of eicosapentaenoic acid on major coronary events in Hypercholesterolaemic patients (JELIS): a randomized open-label, blinded endpoint analysis. Lancet 2007;369:1090-1098.
• 5.Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, Doyle RT, Jr., Juliano RA, Jiao L, Granowitz C, Tardif JC, Ballantyne CM and Investigators R-I. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med 2019;380:11-22.

Analysis of neonatal screening data of commonly screened newborn disorders in mediclinic city hospital, dubai, 2013-2017: a cross-sectional study

Ms Donia Ahmad - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Professor Riad Bayoumi - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Zahreddin Abusalah - Department of Neonatology, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: This study aims to address the prevalence of a group of conditions (inborn errors of metabolism, hemoglobinopathies, congenital hypothyroidism, glucose-6-phosphate dehydrogenase deficiency, congenital adrenal hyperplasia, cystic fibrosis) that are part of the newborn screening program in a multi-disciplinary hospital in Dubai, United Arab Emirates.

METHODS: A cross-sectional analysis was performed on newborn screening data in Mediclinic City Hospital, Dubai, between October 2012 and December 2014. A total of 6421 newborns were included in this study. The data was analysed for the following variables: gender, gestational age, birth weight, and birth year, as well as the diseases and their different subtypes.

RESULTS: Amino acid profile was detected in 4 newborns with a prevalence of 1:1,605 live births. Congenital hypothyroidism has a prevalence of 1:3,210 live births. The prevalence of cystic fibrosis is 1:6,421 live births. No cases were detected for acylcarnitine profile, congenital adrenal hyperplasia, or biotinidase deficiency. 1.1% of the newborns were positive for glucose-6-phosphate dehydrogenase deficiency, whereas 1.2% of the newborns were only carriers. 2.15% of the newborns were detected to have some form of hemoglobinopathy.

CONCLUSION: Out of a sample size of 6,421 newborns, a total of 74 positive cases and a total of 222 carrier cases were recorded. Compared to other studies conducted in the United Arab Emirates and Pakistan, this study showed a higher prevalence rate for carrier hemoglobinopathies but a lower prevalence rate for positive hemoglobinopathies, glucose-6-phosphate dehydrogenase deficiency, congenital hypothyroidism, congenital adrenal hyperplasia, cystic fibrosis, and biotinidase deficiency. The results from this study may have been influenced by the multi-ethnic population in the United Arab Emirates, the small sample size, and societal factors such as consanguinity.

The association between body mass index and the development of gout and hyperuricemia amongst adults in the united arab emirates between january 2018 and december 2018: cross-sectional study

Ms Hessa Al Mazrooei - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Amel Ginawi - Department of Rheumatology, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: The core objective is to explore the association between serum uric acid (SUA) and obesity amongst UAE residents diagnosed with gout in a one-year time frame, from the 1st of January 2018 to the 31st of December 2018.

METHODS: In order to conduct this cross-sectional study, 76 subjects were analysed. Body mass index (BMI) was calculated and used as an obesity marker. The participants were classified into 4 groups according to their BMI by implementing the WHO classifying system. Descriptive analysis was then used to show trends between BMI and SUA levels. Spearman's Rho test was applied to examine the association between BMI and SUA levels.

RESULTS: There was a total of 60 males (mean age, 45.8 ± 11.8 years) and 16 females (mean age, 40.6 ± 10.8 years) in this study. A positive association between obesity and SUA was determined in the female population, however, the association was statistically insignificant with regards to the male participants. None of the patients were categorized as underweight.

CONCLUSION: It was evident that female SUA levels were positively associated with obesity in both the overweight and obese group. Nonetheless, the association was weak in the male category which could be related to confounding factors that might have influenced SUA levels.

Assesing the value of respiratory pathogen panel on antibiotics prescribing and the length of hospital stay for patients admitted to a tertiary care hospital, Dubai, United Arab Emirates; a cross-sectional study

Ms Maryam Alshamsi - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Ali Mekki Elsheikh - Department of Pulmonology and Internal Medicine, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: Assess the value of Respiratory Pathogen Panels (RPP) on antibiotic prescribing and length of hospital stay (LOS) for in- patients admitted with a respiratory tract infection in a tertiary-care hospital in Dubai emirate, United Arab Emirates (UAE).

METHODS: Cross-sectional data from 428 in-patients who had received an RPP test at a multispeciality hospital in Dubai (UAE) between 1st of July and 31st of December 2018 were analysed. Sociodemographic variables were age, gender and nationality, and RPP event variables were RPP result and pathogen type. Outcome variables were antibiotic prescribing and LOS. Other variables include quantitative-CRP and final diagnosis.

RESULTS: The value of a positive RPP decreased antibiotic prescribing by 18.3% (294) and LOS by 1.2 days, when compared to the value of a negative RPP. The majority of antibiotic prescribing and increased LOS were seen with older age groups. RPP events of bacterial origin are seen to have the highest impact with 100% antibiotic prescribing. A final diagnosis of LRTI carries 70.5% of antibiotics prescribed and 4.57 LOS (all p-values ≤0.05). Gender and sociodemographic variables were not significantly different between positive and negative RPP.

CONCLUSION: The value of RPP on antibiotic prescribing and LOS were lower with a positive RPP result. Main outcomes were decreased for patients who were younger and had a positive RPP result. The findings may help to inform clinicians and healthcare practitioners on the impact of RPP on antibiotic prescribing and LOS in the UAE.

POSTER ABSTRACTS

EPIDEMIOLOGY OF BREAST CANCER IN DUBAI, UNITED ARAB EMIRATES, 2013-2018: A RETROSPECTIVE CROSS-SECTIONAL STUDY

Ms Farah Awadhalla - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Annett Al Hamadi - Department of Oncology, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: Investigate the epidemiology of breast cancer in the UAE and determine the onset of breast cancer and the stage of diagnosis in the UAE and compare it to other regional and western countries.

METHODS: This is a retrospective cross-sectional study that was conducted on 112 patients in Mediclinic City Hospital in Dubai, UAE between the time period of 1 January 2018 and 31 December 2018. The data obtained in the study was collected from the patients’ electronic medical records in Mediclinic City Hospital and was then analysed on SPSS. A literature review was then performed on relevant journals and articles to allow for the comparison of the results obtained in the study to results obtained in other regional and western countries.

RESULTS: This study shows that the median age of the diagnosis for breast cancer in the female population in the UAE is 42.5 years. The majority of cases 53.6% (N = 60) fell between the ages of 40-49 years old. Stage 1 was diagnosed in 5.4% of the patients, stage 2 in 45.0% of the patients, and stage 3 in 49.6% of the patients.

CONCLUSION: This study showed that the mean age of breast cancer patients in the UAE was lower than other regional and Western countries. It also showed that the majority of breast cancer patients are diagnosed at stage 2 and 3 of the disease. These results show that it is time to call for breast cancer screening at an earlier age.

CREATING AND SUSTAINING A HEALTHY WORKPLACE ENVIRONMENT

Jenny Eastaugh - Deputy Nursing Director, Mediclinic Welcare Hospital, Dubai, UAE.

BACKGROUND: Hospitals today are facing many challenges; from regulatory limitations, aggressive competition, increased patient demands and continual economic restraints. These challenges have required Healthcare facilities to utilize a lean approach in providing quality services efficiently. Redesigning nursing care models, job profiles and transforming work processes are all principal strategies for many healthcare providers.

At Mediclinic Welcare Hospital we studied the direct and indirect cost of working in an unhealthy work environment and its impact on staff satisfaction, customer satisfaction and business financial performance.

AIM: To prove that by creating a sustainable and healthy workplace environment we could reduce direct and indirect operational costs, increases performance efficiencies and positively impact on customer and employee satisfaction.

METHODS: Over a two year period we used the FOCUS - PDCA methodology to examine current practices, uncover service provision deficiencies and redesign our workforce models.

RESULTS: Over the study period we showed a 25% escalation in staff engagement rates, a 20% increase in customer satisfaction markers and a total of DH 8 million reduction in nursing costs which was a saving of 1.4% against revenue.

CONCLUSION: Creating a healthy work environment is a complex project t that can take years of hard work and effort. However, the benefits of such can produce powerful efficiency outcomes that positively impact on financial performances as well as creating a happy and healthy workforce.

ANTIMICROBIAL RESISTANCE PATTERNS OF URINARY PATHOGENS AMONG ADULTS IN THE UNITED

ARAB EMIRATES BETWEEN 2012-2018: A CROSS- SECTIONAL STUDY

Ms Maryam Jafari - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Guzanfar Choudry - Department of Urology, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: To estimate and identify the trends in antimicrobial resistance of urinary tract infectious pathogens at a private hospital in Dubai (United Arab Emirates) between 2012-2018.

METHODS: Retrospective data of patients 18 years and older with a positive urine culture result between 01 January 2012 and 31 December 2018 was obtained from the Microbiology Department of a private hospital in Dubai, United Arab Emirates and analysed.

Sociodemographic variables were age and gender of patients, and the variables associated with the urine culture results were the positive bacteria and their antibacterial resistance to a panel of commonly used antibiotics. Data were analysed using the “Statistical Package for the Social Sciences” software version 24. A Chi-square test was employed to measure the association between different variables in this study.

RESULTS: The most common urinary pathogens found were Escherichia coli (80.1%) followed by Klebsiella Pneumoniae (13.4), Pseudomonas aeruginosa (4%), Proteus mirabilis (1.8%), and Acinetobacter baumannii (0.7%). The highest overall resistance rate observed in Escherichia coli isolates were to Trimethoprim/Sulfamethoxazole (81.5%) and Ciprofloxacin (80.6%) whereas, the highest sensitivity was to Imipenem (34.4%) and Nitrofurantoin (32%). In contrast, Klebsiella Pneumoniae was highly resistant to Nitrofurantoin (37%) and was found to be most sensitive to Ciprofloxacin (7.8%). Resistance was significantly higher amongst males and the elderly (all p's≤0.05), with an increased resistance to Trimethoprim/sulfamethoxazole among both groups.

CONCLUSION: This study explored the trend and pattern of antimicrobial resistance in the United Arab Emirates, and found a high resistance rate among urinary pathogenic strains between 2012 and 2018. Resistance was higher among males and the elderly patients. These findings may help to inform clinicians on the proper empiric treatment options for patients, in order to improve their prognosis

COLORECTAL CANCER SCREENING, THE OPTIMUM AVERAGE WITHDRAWAL TIME TO INCREASE ADENOMA DETECTION RATE IN COLONOSCOPY. COLONOSCOPY WITHDRAWAL: IT TAKES TIME TO DO IT WELL

Villanueva J, Tomagan J, Alimagno A, Santos E, Noble D, Santos A, Aljabiri M

Mediclinic Middle East, Mediclinic Parkview Hospital digestive disease, Hepatology and intervention endoscopy centre, Department of gastroenterology and endoscopy, Dubai- UAE.

INTRODUCTION: Increasing colonoscopy withdrawal time (CWT) has previously been shown to be associated with increasing adenoma detection rate (ADR). For most colonoscopies, the goals are to identify neoplasia and reduce the risk of colorectal cancer. Therefore performing a high-quality colonoscopy is essential indicator for ADR. Evolving data support a relationship involving procedural withdrawal time, adenoma detection, and cancer reduction. A longer withdrawal time, which facilitates more thorough mucosal inspection, has been associated not only with increased adenoma detection but also with a subsequent reduction in colorectal cancer. Withdrawal times in normal colonoscopies in which no biopsies or polypectomies are performed should average ≥6 minutes, but withdrawal time is considered less important than (ADR).Current guidelines recommend that colonoscopists detect one or more conventional adenomas in ≥30% of men and ≥20% of women undergoing screening colonoscopy.

AIM: This audit was designed to evaluate compliance with current guidelines on colonoscopy withdrawal times across Mediclinic Parkview Hospital

METHODS: The single Centre retrospective study of colonoscopic procedures undertaken in Mediclinic Parkview Hospital between the ages of 18-101, Male: Female Ratio was 1:1 over a period from September 1st- December 31st 2018 for group (A) and 1/1/2019- 31/12/2019 for group (B)

Patients undergoing colonoscopy within 3 months immediately before (group A) and after (group B) initiation of CWT recording. Colonoscopies were excluded if procedure times were incomplete, missing, or bad bowel preparation

RESULTS: Average colonoscopy withdrawal time in group A was and the average colonoscopy withdrawal time in group B is 10.13 minutes.

In-group A, We examined 136 (9-13%) average ADR 11% and compared to Group B that were screened 856 patients who underwent colonoscopy. There were 431 patients screened > 6 min and ADR was 20-42% (average 28%) over 12 months compared with in Group A where ADR was 11%.

The average colonoscopy withdrawal time of 10.13 minutes (range, 7.17 – 12.09 minutes) in the screened group. Average withdrawal times were significantly related to the incidence of interval cancers: The risk for ADR was 2.5 times higher at average withdrawal times < 6 minutes than at those ≥6 minutes.

CONCLUSION: In 136 colonoscopy procedures performed, did not adhere to the minimal withdrawal time of 6 min as recommended in the best practice guidelines. If these findings were replicated across the UAE, a significant amount of pathology could be missed, increasing risks to our patients.

CWT recording was associated with a significant increase in polyp detection 28% and this in turn leads subsequent reduction in colorectal cancer by 50% (3 in Group A compared to 6 in group B)

Therefore we recommend that Mediclinic associated hospitals perform Bowel cancer screening programme with recording on CWT > 6 min for performing best quality colonoscopy.

SENSITIVITY AND SPECIFICITY OF MAGNETIC RESONANCE IMAGING COMPARED TO COMPUTERIZED TOMOGRAPHY FOR STROKE IN DUBAI, UNITED ARAB EMIRATES, 2017-2019: A DIAGNOSTIC STUDY

Mr Mohammed Al-Haideri - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE.

Dr Derk Krieger - Department of Neurology, Mediclinic City Hospital, Dubai,UAE.

OBJECTIVE: Evaluate the effectiveness of MRI scans versus CT scans at (i) spotting and assessing acute strokes of varying intensities; and (ii) pinpointing a cut-off limit of stroke intensity at which MRIs should be used as first line rather than CT.

METHODS: An exploratory diagnostic study. Comparing CT and MRI in terms of sensitivity and specificity on different levels of stroke severities in adult patients in Dubai. Participants were admitted between 2017-2019 in two multidisciplinary hospitals. The study was done through visual comparison, breaking down data into categories and carrying out statistical analysis. The images that were compared were taken 6 hours of less apart to ensure the fairest possible comparison.

RESULTS: MRI was proven to be superior at diagnosing and assessing acute strokes and other stroke related events in patients with an NIHSS score lower than 6. MRI also showed a higher sensitivity than CT (78.2% compared to 29.3%). CT scans showed a significant inability of giving a certain diagnosis in numerous cases without an MRI scan for confirmation. CT achieved a specificity of 98% compared to MRI, which was the reference test in this study.

CONCLUSION: The study suggests that if patients have an NIHSS score of lower than 6, then an MRI scan is more suitable as the first line of imaging than CT scan. MRI was also proven to be much better at assessing strokes, ruling out infarction, and diagnosing other pathologies of the brain that may mimic a stroke in symptoms or appearance.

IMPACT OF SINGLE VERSUS BILATERAL INTERNAL THORACIC ARTERY GRAFTING ON THE LONG-TERM SURVIVAL IN ADULTS: A SYSTEMATIC REVIEW

Mr Montaser Al Smady - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Professor Olivier Jegaden - Department of Cardiology, Mediclinic Airport Road Hospital, Abu Dhabi, UAE.

OBJECTIVE: The study aims to compare the survival rates between patients who had undergone bilateral internal thoracic artery grafting versus those with single internal thoracic artery grafting from the available literature. Moreover, to resolve the conflict by providing an update on which procedure seems to be the safest and provides long term survival rates and reduced mortality rates.

METHODS: A literature search of the databases was conducted to retrieve studies that fall under the study design of cohort and randomized controlled clinical trials in English from January 2015 to September 2019. The main focus of the papers retrieved was to compare the mortality rates of patients that received single internal thoracic artery grafts versus bilateral internal thoracic artery grafts.

RESULTS: The two cohort studies show that the bilateral internal thoracic artery grafting is associated with lower mortality rates and better long-term survival outcomes than single internal thoracic artery grafting. While the ART randomized controlled clinical trials showed that there is no significant difference in mortality rates between both the coronary artery bypass grafting techniques. However, both study designs concluded that bilateral internal thoracic artery grafting is associated with a higher frequency of deep sternal wound infections.

CONCLUSION: More randomized controlled clinical trials need to be conducted regarding this topic to resolve the contradiction and conflict that is seen between these two study designs. As the randomized controlled clinical trials can provide updated data that takes into account the confounding factors which cannot be established nor analysed in cohort studies.

PIGMENTED EPITHELIOD MELANOCYTOMA: A RARE MELANOCYTIC NEOPLASM

A. El Sayed, Z. Ahmad, M.A Khan, R. El Bahtimi - Mediclinic Al Noor Hospital, Abu Dhabi, UAE

A 12 year old Pakistani girl presented to the dermatology department with a non-healing dark lesion on the right leg that had slowly been growing over the previous 6 months. Apart from atopic dermatitis her medical history was unremarkable.

Examination revealed a 2.5 cm black keratotic nodule on the right shin. A biopsy was performed and histopathology showed a wedge shaped proliferation of large epithelioid melanocytes in the dermis with abundant coarse melanin, focal pagetoid spread and numerous melanophages. The cells were positive for Melan-A, HMB45, P16 and Wilm's tumour protein and Ki67 showed a low proliferative index. These features were consistent with a diagnosis of pigmented epithelioid melanocytoma. Imaging of the regional lymph nodes did not show any suspicious features. A wide local excision was performed by surgeons and the wound repaired by a rotational flap. A regular follow up at 6 month intervals was decided. Pigmented epithelioid melanocytoma is a very rare melanocytic neoplasm that has features of an atypical epithelioid blue nevus and a low grade animal-type melanoma. It can present at any age and has the potential to spread to regional lymph nodes, less commonly cause distant metastases and rarely death. Overall the malignant potential compared to melanoma is considered favourable. Wide local excision and surveillance of regional lymph nodes is recommended but the role of routine sentinel lymph node biopsy is controversial.

UNIVERSAL ULTRASONOGRAPHY SCREENING PROGRAM OF NEWBORN'S HIPS – SINGLE CENTER PILOT STUDY

Nina Dordevic - Specialist Orthopedic Surgery, Subspecialist Pediatric Orthopedic Surgery, Mediclinic Al Jowhara hospital Al Ain and Mediclinic Airport Road hospital, Abu Dhabi

Abdulgader Bader - Consultant Pediatric, Mediclinic Al Jowhara hospital, Al Ain

Alaa Ahmed A Qasem - Specialist General Pediatrics, Mediclinic Al Jowhara hospital, Al Ain

Marwa Elsayed Farid Manaa Sayed - Specialist General Pediatrics, Mediclinic Al Jowhara hospital, Al Ain Raihanah Mohammed Al Shaibah - Specialist General Pediatrics, Mediclinic Al Jowhara hospital, Al Ain Hany Sabry Abdelmonem Mousa - Specialist General Pediatrics, Mediclinic Al Jowhara hospital, Al Ain Wadah Mohammed Abedalqader Khriesat - Consultant Neonatology, Mediclinic Al Jowhara hospital, Al Ain.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common musculoskeletal deformity in infant age. The outcome of undiagnosed or late diagnosed DDH is disastrous in many ways. In the second half of 20th century the efforts were made to diagnose DDH as early as possible. Method for ultrasonography (US) of infant hips was developing constantly since late 1970s, thanks to the efforts of Prof Reinhard Graf, and became very accurate. Universal US screening of newborns was introduced in many developed countries resulting in a dramatic fall in the rate of operative treatment and complications. But In UAE the universal ultrasonography is not recognized as a mandatory test.

AIMS: To present the obstacles and benefits of universal hips US screening in the Maternity ward of Mediclinic Al Jowhara hospital (MJOW).

To analyze the DDH incidence in all MJOW newborns and with respect to risk factors and clinical presentation

To raise the social awareness of the DDH and importance of US screening

METHODS: Prospective study is ongoing for all newborns in MJOW starting on 12th of December 2019.

The ward is provided with the custom made Informed Consent form and Assessment form that are attached to the file. The forms are approved by the Mediclinic Ethics Committee

Pediatrician are explaining to the mothers the importance of hips US screening and are providing the signature

Pediatricians are making the clinical assessment, fulfilling the Risk factors part in the Assessment form and refer baby for hips US.

Orthopedic surgeon is performing clinical examination and hips US – Graf method, before the discharge in the Maternity ward and inform the parents if any further follow-up or treatment is needed Adequate US documentation is stored:

• Images are labeled with the patient identification, examination date, and side (right or left) of the anatomic site imaged.

• Graf type is defined and recorded

• Final data analysis:

• Incidence of different types of DDH in correlation with the risk factors

• Sensitivity of clinical examination

RESULTS: In last 3 weeks 33 newborns were delivered in MJOW. One baby boy with adduction hips contracture and postural calcaneus deformity of both feet was diagnosed with both hips Type IIC - severely deficient started Pavlik harnesses treatment. One baby boy with unremarkable clinical finding was diagnosed with right hip Type IIc and Pavlik harnesses applied. He had no risk factors for DDH.

Two baby girls have Type IIa + on both sides, and for them double nappies and US after one moth are advised.

The study is still ongoing and until the Medical research day the number of babies is assumed to triple. Then there will be more accurate data topics for discussion.

There are several technical obstacles for the smooth process in the Maternity ward, before the discharge:

• Shifting the US machine from the OPD to the Maternity ward is time consuming and in conflict with other doctors needs.

• The Informed Consent forms are not signed and mothers are not fully informed on time

• There is no sufficient nurses’ support for the preparation of babies

• Orthopedic surgeon is off duty or busy and parents are anxious to leave earlier

CONCLUSION: The US is harmless and very efficient method for early diagnosis of DDH, only when done by skilled professionals.

Universal US is not increasing the costs of DDH diagnosis in infant age, but reduces dramatically the costs of late diagnostics and treatment. The motto “Prevention is better than operation” holds true.

Bigger sample is needed for proper assessment of the DDH incidence and role of risk factors, but this pilot study is just a first step in the right direction.

After this pilot study and proper orientation of the relevant professionals in other Mediclinic hospitals, next step could be to do neonatal universal hips US throughout the UAE facilities and come out with much bigger number of data to help our patients better.

The US screening program performed in the Maternity ward is a step forward to the newborns. To bring the US machine in the ward is a good idea for the following reasons: mothers find it baby friendly, all newborns are examined and the message is sent that MJOW cares about the babies hips. But, with the present taskforces it doesn’t go very smoothly and fine adjustments are needed.

Universal US is not increasing the costs of DDH diagnosis in infant age, but reduces dramatically the costs of late diagnostics and treatment. The motto “Prevention is better than operation” holds true.

HEPATIC SUPER SCAN – ON FDG PET-CT SCAN

Dr. Raghuveer Reddy Venkannagari, Sujith Kumar, Bervelyn Engada, Dr. Mazin Al Janabi – Department of Nuclear Medicine, Mediclinic City hospital

Hepatic super scan in an uncommon finding on FDG PET-CT scan. Liver is a common site for metastasis from multiple primary malignancies. Here we present two FDG PET-CT scans demonstrating appearances of hepatic ‘super scan’. Both patients presented with Rectal malignancy and metastases in the Liver at the time of diagnosis. They underwent FDG PET-CT scans for distant staging. Imaging was performed 60 minutes after intravenous administration of FDG according to the protocol. Both scans demonstrated intense FDG avidity at the known primary rectal malignancy as well as extensive and intense FDG avidity in the Liver, significantly more than the background as well as uptake in the brain. Hepatic super scan may be seen with very high metabolic state of the tumour cells as well as extensive metastasis.

SURGICAL CHALLENGES WITH MANAGEMENT OF GIANT CERVICAL FIBROID-A CASE REPORT

Dr. Rimpi Datta - OBS/GYN, Mediclinic Al Noor Hospital, Abu Dhabi, UAE.

OBJECTIVE: Reporting a case of huge cervical fibroid which is unique due to its rarity, location, size and rapid growth. The purpose is to discuss the challenges during the surgery with an optimum management and minimal morbidity.

METHODS: Case Report with literature review

A 35 year old single, nulliparous female presented with recent worsening of her dysmenorrhea since the last 3 months and felt bloating with some hard swelling in her abdomen since 2 months. A large abdominal mass of around 30 weeks gravid uterus size, arising from the pelvis was noted. It was firm in consistency with restricted mobility. MRI pelvis confirmed the diagnosis of huge cervical fibroid of 19 x 14 x 15 cm. Decision of abdominal hysterectomy with sparing of the bilateral ovaries was taken owing to the size and location of the fibroid and patient's lack of desire for future fertility.

A low transverse incision was done considering the better healing and reduced post-operative morbidity. This posed a challenge during the surgery due to the fibroid's irregular shape, lateral extension, large size and reduced accessibility.

A stepwise approach was taken and the uterus was first removed supracervically above the mass. The cervical fibroid was of 20x19x15 cm which was enucleated and removed and weighed 1295gm. Intraoperative cystogram and cystoscopy was performed to rule out bladder and ureteric injuries. Patient recovered well postoperatively.

DISCUSSION: Uterine fibroids, also known as leiomyomas are benign smooth muscle tumors of the uterus. The incidence of these tumors are around 20-25%. Most of the fibroids are limited to the body of the uterus but only 1-2% arises from the cervix.

Cervical fibroids can present with urinary retention, dysmenorrhea, menorrhagia, mass coming out from vagina, foul smelling vaginal discharge or lump in abdomen with pressure symptoms. Cervical fibroids pose enormous surgical difficulty by virtue of their relative inaccessibility and proximity to bladder anteriorly, rectum posteriorly and ureters laterally. The larger ones also leads to distortion of the normal anatomical relationships of ureter, bladder and uterine vessels thus increasing the risk of injury to these structures. Proper preoperative imaging and planning is the key to success.

CONCLUSION: Cervical fibroids are a rarity compared to fibroids located in other parts of the uterus and poses many challenges during surgical management. Preoperative detailed imaging, knowledge of distorted pelvic anatomy and multidisciplinary approach is the key to successful outcome and reducing patient morbidity.

PREVENTION OF PERIPHERAL INTRAVENOUS COMPLICATIONS: A DIAMOND RULE OF VASCULAR HEALTH PROMOTION PROGRAM (VHPP)

Saira Khimani - Unit Manager, Mediclinic Al Noor Hospital, Abu Dhabi, UAE.

BACKGROUND: Placement of an intravenous(IV) catheter for administration of parenteral therapy is one of the most common invasive procedures performed in hospitals. In US it is believed to account for one third of all nosocomial bacteremia. As per center of disease control infusion therapy is a major cause of morbidity. In patients with peripheral intravenous catheters, 3 types of complications occur frequently: (1) phlebitis, (2) catheter-related infection, and (3) obstruction of the catheter. In this study, one of the hospital initiative related to vascular health promotion program is presented.

OBJECTIVE: To determine the role of vascular health promotion program “a diamond rule” in prevention of peripheral IV complications in adult medical patients.

METHOD: Research method used in this study was a retrospective, interventional design using an interrupted time series to compare catheter related complications for all patients with peripheral IV lines admitted in our adult medical ward from Jan 2019 till October 2019.

Total of 240 cannula sites were observed before application of VHPP. The findings were shared with the unit heads in a quarterly meeting.” Diamond Rule” (5) Strategies were discussed. First, development of “Right Line Decision Tool” which helped the nurses and physician to prescribe appropriate selection of catheter according to the therapy required. Second, formulating a vascular access team, consist of senior RNs from each unit, anesthesia technicians and physicians. Third, a unit based staff training done for the new protocol. Fourth, routine site assessment.

OUTCOME: Pre intervention (Jan 2019-Apr 2019), IV sites were observed by the team leaders as their daily patient rounds. Out of 240 sites observed, 10 sites were found to have different types of complications 1 patient had severe thrombophlebitis, 2 patients had infiltration and 7 patient had erythema and tenderness. These patients were mostly with IV cannula for more than 2 days, patients on IV infusion of irritant fluids and antibiotics.

Post intervention, (May 2019-Oct 2019) In a period of six months 300 random cannula sites were observed and it was observed that, 1patient was reported to get stage1 phlebitis and 13 episodes of erythema around the cannula site.

CONCLUSION: Vascular health promotion program, a diamond rule of strategies contributed a vital role in prevention of catheter related complications. In order to further improve the outcome and patient satisfaction, it is mandatory to extend the scope of peripheral catheters to ultrasound guided catheterization for long and complicated therapies.

References

• Boyd, S et al (2011) Peripheral intravenous catheters: the road to quality improvement and safer patient care, Journal of Hospital Infection (77) 37-41

• Bregenzer T, Conen D, Sakmann P, Widmer AF.(1998) Is Routine Replacement of Peripheral Intravenous Catheters Necessary? Arch Intern Med.158(2):151–156.

IMPACT OF MODIFIED EARLY WARNING SCORE (MEWS) AND EARLY MEDICAL INTERVENTION BY RAPID RESPONSE TEAM (RRT) ON PRE ICU CARDIAC ARREST.

Saira Khimani - Unit Manager, Mediclinic Al Noor Hospital, Abu Dhabi, UAE.

BACKGROUND: The mearly warning score (EWS) is a simple physiological scoring system suitable for bedside application. A modified EWS has the ability to identify medical patients who are at risk for catastrophic deterioration. (Kruger, 2001) Rapid response teams (RRTs), also known as a medical emergency teams or medical response teams, were developed to promote rapid assessment and treatment of patients whose clinical condition was deteriorating but who were not yet in shock or cardiac arrest. (Lee, 1995). In 2008, RRTs became part of hospital accreditation by The Joint Commission. (JCIA,2008) Hospital introduced concept of rapid response team in December 2018. This response team was activated by the bedside nurse or doctor according to predefined criteria using early warning scoring system.

OBJECTIVE: Our goal was to determine the impact of early warning score (EWS) and rapid response team (RRT) in reducing the incidence of cardiac arrest prior to ICU transfer.

METHODS: A nonrandomized, population-based study included inpatient admissions in 2018 and 2019 (Jan till Nov).

Inclusion criteria was to include cases in which medical intervention was done by rapid response team, cardiac arrest cases outside the critical care areas and number of patients transferred to ICU.

Main outcome measures were incidence of cardiac arrest outside ICU. During the period of this study, the team covered 6 patient-care-units. If a patient meets one of the criteria, the primary responsible nurse is expected to perform interventions as per the EWS policy and call the RRT simultaneously with the resident on duty so that the care decisions are made safe and informed and with the help of multidisciplinary team.

OUTCOME: Our measure of study, the incidence of cardiac arrest in non ICU/critical care area.

In year 2018 (Jan till Nov), there were 6 cases out of 25 cardiac arrests cases happened outside ICU (24%).

However in year 2019 (Jan till Nov), there were 4 cases out of 34 cardiac arrests cases in the hospital announced in non ICU setting (11%).

After adjustment for case mix the intervention was associated with a 13% reduction in the incidence of unexpected cardiac arrest.

CONCLUSION: Training and educating the primary care nurses about the role of RRT in patients with reportable early warning scores, facilitated decrease in code blues/ cardiac arrests outside critical care areas. The introduction of RRT as best practice in this hospital benefited the population at large which evidently led in a reduction in mortality and morbidity rates. They may even pave the way for a modest lessening of the overall cost of care.

References:

The Medical Emergency Team.Lee A, Bishop G, Hillman KM, Daffurn K Anaesth Intensive Care. 1995 Apr; 23(2):183-6.

C.P. Subbe, M. Kruger, P. Rutherford, L. Gemmel, Validation of a modified Early Warning Score in medical admissions, QJM: An International Journal of Medicine, Volume 94, Issue 10, October 2001, Pages 521–526, https://doi.org/10.1093/qjmed/94.10.521

IMAGE GUIDED BRACHYTHERAPY (IGBT) IN LOCALLY ADVANCED CERVICAL CANCER: NEW SCOPE OF SERVICE AT MCCH

Salim Chaib - Oncology, Mediclinic City Hospital, Dubai, UAE.

The standard of care for locally advanced cervical cancer is external beam radiotherapy (EBRT) with concurrent chemotherapy followed by brachytherapy (BT) [1]. BT is a crucial component and has been shown to be an essential independent treatment factor associated with improved pelvic control [2] and overall survival [2,3]. In most institutions worldwide, BT is based on orthogonal X-rays for treatment planning with standard treatment plans irrespective of tumor stage, size, response to EBRT, or the topographic position of organs at risk (OAR).

Over the past 15 years, image guided brachytherapy (IGBT) with magnetic resonance imaging (MRI) or computed tomography (CT) guidance has been an emerging subject. IGBT allows for individualization of treatment with dose adaptation, and dose escalation when appropriate, to take into account tumor size at diagnosis, and at the time of BT, while simultaneously sparing OAR [4,5].

Mono-institutional reports from some pioneering institutions have shown 3-year local control rates ranging from 85%- to 97%, with limited or reduced toxicity [6–15]. These figures compare favorably with historical series using conventional BT [16–21], but the patient numbers were relatively small (40–225 patients).

We at Mediclinic City Hospital started this new scope of service on March 2018 and so far 15 patients were treated or in process. We were the first center in the UAE to introduce this new scope of service following the GEC ESTRO Brachytherapy group recommendations.

So far we have treated 15 patients over the last 20 months

Regarding the results it is too early to report survival rates. Local control will assessed just before the poster is due to be presented.

CONCLUSION: The management of locally advanced cervical cancer (LACC) is definitive EBRT ± concurrent chemotherapy followed by Image guided brachytherapy (IGBT)

IGBT for (LACC) allows dose escalation to the high-risk clinical target volume (HRCTV) while sparing organs at risk (OAR) This has been demonstrated in RetroEMBRACE, a multicenter cohort study from twelve centers and 731 patients treated. IGBT combined with radio-chemotherapy leads to excellent LC (91%), PC (87%), OS (74%), CSS (79%) with limited severe morbidity. These results provide a benchmark for advanced clinical practice and future clinical trials in locally advanced cervical cancer

This is the first publication of a large multi-institutional patient cohort treated with EBRT ± concomitant chemotherapy and MRI or CT-based IGBT. The excellent LC of 91% at 3 years and 89% at 5years confirms the results from mono-institutional reports [6–15].

References

• [1]Thomas G. Improved treatment for cervical cancer – concurrent chemotherapy and radiotherapy. N Engl J Med 1999;340:1198–2000.
• [2]Lanciano RM, Martz K, Coia LR, Hanks GE. Tumor and treatment factors improving outcome in stage III-B cervix cancer. Int J Radiat Oncol Biol Phys 1991;20:95–100.
• [3]Han K, Milosevic M, Fyles A, Pintilie M, Viswanathan AN. Trends in the utilization of brachytherapy in cervical cancer in the United States. Int J Radiat Oncol Biol Phys 2013;87:111–9.
• [4]Haie-Meder C, Potter R, Van Limbergen E, et al. Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV. Radiother Oncol 2005;74:235–45.
• [5]Pötter R, Haie-Meder C, Van Limbergen E, et al. Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology. Radiother Oncol 2006;78:67–77.
• [6]Lindegaard JC, Fokdal LU, Nielsen SK, Juul-Christensen J, Tanderup K. MRI- guided adaptive radiotherapy in locally advanced cervical cancer from a Nordic perspective. Acta Oncol 2013;52:1510–9.
• [7]Tinkle CL, Weinberg V, Chen LM, et al. Inverse planned high-dose-rate brachytherapy for locoregionally advanced cervical cancer: 4-year outcome. Int J Radiat Oncol Biol Phys 2015;92:1093–100.
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• [9]Nomden CN, de Leeuw AA, Roesink JM, et al. Clinical outcome and dosimetric parameters of chemo-radiation including MRI guided adaptive brachytherapy with tandem-ovoid applicators for cervical cancer patients: a single institution experience. Radiother Oncol 2013;107:69–74.
• [10]Pötter R, Georg P, Dimopoulos JA, et al. Clinical outcome of protocol based image (MRI) guided adaptive brachytherapy combined with 3D conformal radiotherapy with or without chemotherapy in patients with locally advanced cervical cancer. Radiother Oncol 2011;100:116–23.
• [11]Tan LT, Whitney D, Coles CE. Long term outcome of CT-based Image-Guided Brachytherapy for cervix cancer using the tandem-ring applicator. OMICS J Radiol 2014;S1:003.
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• [13]Rijkmans EC, Nout RA, Rutten IH, et al. Improved survival of patients with cervical cancer treated with image-guided brachytherapy compared with conventional brachytherapy. Gynecol Oncol 2014;135:231–8.
• [14]Gill BS, Kim H, Houser CJ, et al. MRI-guided high-dose-rate intracavitary brachytherapy for treatment of cervical cancer: the University of Pittsburgh experience. Int J Radiat Oncol Biol Phys 2015;91:540–7.
• [15]Refaat T, Castelain B, Small Jr W, et al. Concomitant Chemotherapy with Image-guided Pulsed Dose Rate Brachytherapy as a Definitive treatment modality for Early-stage Cervical Cancer. Am J Clin Oncol 2015;38:289–93.
• [16]Perez CA, Grigsby PW, Chao KS, Mutch DG, Lockett MA. Tumor size, irradiation dose, and long-term outcome of carcinoma of uterine cervix. Int J Radiat Oncol Biol Phys 1998;41:307–17.
• [17]Landoni F, Maneo A, Colombo A, et al. Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer. Lancet 1997;350:535–40. [18] Barillot I, Horiot JC, Pigneux J, et al. Carcinoma of the intact uterine cervix treated with radiotherapy alone: a French cooperative study: update and multivariate analysis of prognostic factors. Int J Radiat Oncol Biol Phys 1997;38:969–78.
• [18]Jampolis S, Andras EJ, Fletcher GH. Analysis of sites and causes of failures of irradiation in invasive squamous cell carcinoma of the intact uterine cervix. Radiology 1975;115:681–5.
• [19]Eifel PJ, Jhingran A, Brown J, et al. Time course and outcome of central recurrence after radiation therapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2006;16:1106–11.
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THE SEVERITY, PREVALENCE, AND ASSOCIATED FACTORS WITH DRY EYE DISEASE IN DUBAI, UNITED ARAB EMIRATES, 2019: A CROSS-SECTIONAL STUDY

Ms Sarah Alkabbani - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Pramod Warhekar - Department of Ophthalmology, Mediclinic City Hospital, Dubai, UAE.

OBJECTIVE: To describe the epidemiology, prevalence, and severity of dry eyes in Dubai, United Arab Emirates in 2019. Association of dry eyes with possible factors such as gender, contact lenses, screen time, exposure to smoking, history of eye surgery/injury, and age will be tested.

METHODS: This is an analytical cross-sectional survey-based study. An online survey was emailed to Mohammed Bin Rashid University students, staff, and faculty, and Mediclinic City and Parkview hospitals’ staff in Dubai, United Arab Emirates between April and June 2019. The survey includes the Ocular Surface Disease Index (OSDI) which is a standardized questionnaire, and demographic questions which allow finding the prevalence of dry eyes, severity, and testing associated factors.

RESULTS: A total of 452 participants completed the survey with approximately two thirds being females (288/452) (63.7%). The prevalence of dry eyes in Dubai is estimated to be (62.6%) (283/452) with severe dry eyes being the most prevalent among affected individuals (119/283) (42.0%). Females, high screen time (>6 hours), and use of contact lenses were found to be associated with dry eyes (P-value < 0.05). Exposure to smoking/shisha, history of eye injury/surgery, and age were not associated with dry eyes.

CONCLUSION: This is the first cross-sectional study to assess the prevalence of dry eyes in Dubai (62.6%). The severity of dry eyes from most common to least common was severe, mild, and moderate dry eyes. Severe dry eyes are more common in females and those who wear contact lenses.

BEDSIDE HANDOVER: IMPROVING PATIENT SATISFACTION AND SAFETY

Shazia Naz RN RM BSN MSN, Mediclinic Al Ain Hospital UAE

BACKGROUND: Nurse-to-nurse beside handover is very useful to maintain the communicate chain between incoming and outgoing nurses. It allows both shift nurses to visualize the patient and ask questions if needed. It encourages patient to involve in their daily care plans and actively participate in hospital protocols about patient safety and rehabilitation (Baker, 2010).

OBJECTIVE: The goal of this project was to implement bedside handover in all in-patient departments to improve patient satisfaction and decrease incident reports.

METHODS: To identify the strengths, weaknesses, opportunities, and threats of bedside handover, a SWOT analysis of the inpatient units in the Mediclinic Al Ain Hospital was completed. A Quality Improvement (QI) method further used to attain the project's goal and objectives. This methodology included effective communication; the development of change competence, and creation of an environment supporting patient-family centred care. The project was started with the identification of the QI team.

Thereafter the project was introduced and the significance of the problem and literature review was discussed with the nursing management and other stakeholders. In-service sessions were conducted, which consisted of a video, role play and interactive sessions, (Manchester et al., 2014)

Lewin's (1947) change theory served as framework to implement bedside handover. A pilot was started in medical unit to identify potential barriers and driving forces to facilitate the implementation process. In redesigned process incoming and outgoing nurses were required to go in patients’ room for handover using SBAR communication tool and ask patient for any question or query.

RESULTS: The audit tool contained five main areas and 25 criteria (Addendum A). Targets were not reached over one month, for seven, of the criteria and further improvement was needed. These criteria included: patients and relatives encouraged to participate in the handover process; asked the patient to verbalize full name; discharge planning; were patients asked if they had any questions, was the patient or family asked to clarify information, was conversation about hourly rounds initiated, did any nursing staff stay in the station during the handover process. An action plan still needs to be initiated to address the gaps. No physicians or patients mentioned that there was no nurse available during handover time.

CONCLUSION: Incorporating bedside handover in our daily routine improved communication between incoming and outgoing shifts and helped to better serve the patients. Bedside handover is one of the best activities to promote a patient-centred approach to nursing care and many benefits for both staff and patients were uncovered during implementation of this initiative. Patients are encouraged to participate in their own care and nurses are helped to prioritise their work and gain a better understanding of their patients.

References

Baker, S. J. (2010). Bedside shiftreport improves patient safety and nurse accountability. Journal of Emergency Nursing, 36(4), 355-358. doi:10.1016/j. jen.2010.03.009

Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., & Owens, M. G. (2014). Facilitating Lewin's change model with collaborative evaluation in promoting evidence based practices of health professionals. Evaluation and Program Planning, 47, 82-90. doi: 10.1016/j.evalprogplan.2014.08.007

PRIMARY CESAREAN SECTION AUDIT AS PART OF QUALITY IMPROVEMENT PROJECT

Dr.Siddiqua Banu Sayeeda, Specialist, Obstetrician and Gynaecologist, DGO, DNB, MRCOG.

Mediclinic Middle East, MMUS Abudhabi. Dr. Raoya Farah Consultant, Obstetrician and Gynaecologist, MRCOG, CCT. Mediclinic Middle East, MNOO Abudhabi

BACKGROUND: Cesarean delivery has become a commonly used measure for delivery of the fetus(1). In the recent years incidence of Cesarean section (CS) has increased dramatically .It is called Primary Cesarean section when it is performed for the first time on a pregnant woman.(2) Primary caesarean section (PCS) rate is one of the main indicators of quality of care, therefore lower rates reflect more appropriate clinical practice.(3)

The World Health Organization suggests it lies between 10 and 15 percent, while a more recent study found it is a little higher, around 19 percent. North America and Western Europe are well above this optimal rate, with 32 percent(4) and 27 percent of babies delivered by cesarean section respectively. In the UK one in 4 pregnant women has a chance of section a Cesarean averaging a rate of 25%.(5) The prevalence of the overall Cesarean section in UAE is 33%.(6)

AIM:

• 1.To Reduce Primary Cesarean section rate and this can lead to a reduction in overall caserean rate.
• 2.To reach Full ward KPI as per international standards.
• 3.To Encourage Vaginal birth after cesarean section (VBAC) and monitor outcomes and percentages.
• 4.To Disseminate learning and feedback to improve practice.
• 5.To ascertain Cesarean section Indication Validity

METHODS

• Data are collected weekly retrospectively from maternity log book

• Primary audit - 05th of July-26th of September 2019 all primary caserean section

• Comparative audit-27th September to 20th December 2019 after feedback to look at the change

RESULTS

Primary Audit: 05th of July-26th of September 2019

• Total Delivery rate 142 in the above period

• 75 cesarean sections rate 52.8%

• 26 primary cesarean section 18.3%

Comparative audit: 27th September to 20th December 2019

• Total Delivery rate 153 in the above period

• 74 cesarean sections rate 48.3%

• 32 primary cesarean section 20.9%

RECOMMENDATION AND DISCUSSION

The most common indications for primary cesarean delivery include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia, IUGR with Doppler changes.

• Primary Cesarean sections rate is variable, majority of indications appropriate and Mediclinic Khalifa branch (MNOO) is nearly in par with the international standard.

• Continue to collect data and present for learning to clinicians audit findings quarterly in perinatal meetings

• To review every three month 10-12 notes for primary caesarean section and discuss with involved clinicians to give feedback if caesarean section is inappropriate.

• Encourage VBAC in 1 previous caesarean section to reduce overall cesarean section rate

References

• 1.Triunfo S, Ferrazzani S, Lanzone A, Scambia G. Identification of obstetric targets for reducing cesarean section rate using the Robson ten Group classification in a tertiary level hospital. Eur J Obstet Gynecol Reprod Biol.2015 Jun;189:91–5.
• 2.World Health Organization Human Reproduction Programme. WHO statement on caesarean section rates. Reprod Health Matters. 2015 May; 23(45):149–50.
• 3.National Institute of Health. Ministry of Health. National system for the Guidelines. Cesarean www.salute.gov.it/imgs/C_17_ pubblicazioni_1330_allegato.pdf. Accessed 25 May 2018. Section: an appropriate choice and consciously. 2010.
• 4.Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Kirmeyer S, Mathews TJ, et al. Births: Final Data for 2009. Natl Vital Stat Report. 2011;60(1):1–35. [PubMed] [Google Scholar].
• 5.Maternity Services Monthly Statistics, England, March 2018, Experimental Statistics
• 6.Exploring Obstetrical Interventions and Stratified Cesarean Section Rates Using the Robson Classificationi n Tertiary Care Hospitals in the United Arab Emirates. Rev Bras Ginecol Obstet 2019;41:147–154.

WHICH CORONARY FLOW ASSESSMENT METHODS PROVIDE THE MOST PRACTICAL AND RELIABLE ASSESSMENT OF CORONARY ARTERY STENOSIS SEVERITY? A LITERATURE REVIEW

Mr Umberto Battistin - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Ahmed Mustafa Al-Masaeed - Department of Cardiology, Mediclinic Parkview Hospital, Dubai, UAE.

OBJECTIVE: The objective of this study is to review recent literature regarding coronary flow assessment methods, providing a focus on how newer methods compare to Fractional Flow Reserve (FFR).

METHODS: A literature search (PubMed) of studies comparing different coronary flow assessment methods was produced in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and limited to clinical trials or prospective studies published between 2016 and 2019 (August).

RESULTS: Eight studies satisfied the eligibility criteria and were included in the review. These demonstrated good diagnostic accuracy of all coronary flow assessment methods (83.2%; 84.3%; and 92.7% for iFR, Pd/Pa and QFR, respectively), and good correlation with FFR (0.77; 0.84; and 0.86 for iFR, Pd/Pa and QFR, respectively). Hybrid approaches (iFR-FFR) also had a good diagnostic accuracy; 95%).

CONCLUSION: This study shows a strong correlation between adenosine-free coronary flow assessment methods and FFR; and these indices also have good diagnostic performance. Therefore, these methods can be safely and effectively used to guide percutaneous coronary intervention. Hybrid methods are also effective and are a suitable alternative for those who wish to rely on FFR. Adding QFR to simple angiography can also increase diagnostic accuracy, and reliably estimate FFR, whilst being a rapid assessment method.

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: NOT SO UNCOMMON IN ICU

Vinod Jaiswal

AIM: To bring awareness and highlight importance of early diagnosis and prompt treatment of Hemophagocytic lymphohistiocytosis (HLH) in the ICU.

BACKGROUND: HLH is an uncommon, often unrecognized, aggressive life threatening syndrome of excessive immune activation that presents with nonspecific findings. The mortality rate is as high as 50% even after appropriate treatment. It affects all age groups, predominantly infants. The common etiologies are malignancy, autoimmune disorders or viral infections.

CASE DESCRIPTION: A 43-year old female with diabetes mellitus and hypertension, was admitted with severe DKA and sepsis. She developed high grade fever, sudden, unexplained pancytopenia, massive hepatospleenomegaly, hemodynamic instability, multiorgan failure including fulminant hepatic failure. Her workup revealed high ferritin, hypertriglyceridemia, hypofibrinogenemia and scattered histiocytes with phagocytosed lymphocytes on bone marrow biopsy. Diagnosed with HLH, patient received pulse Methylprednisolone, broad spectrum antibiotics and responded dramatically. She later received Etoposide to achieve better suppression of hyper-immune response. Patient made full recovery and was discharged after one and a half month of hospital stay. Our patient met six of eight diagnostic criteria for HLH. Moreover, the resolution of symptoms and normalization of labs with the steroids, antibiotic therapy supported our diagnosis.

CONCLUSION: Early recognition and appropriate timely treatment with rapid recovery was the hallmark of our case. It also highlights the unusual presentation of HLH secondary to sepsis. Given the high mortality rate and non specific presentation, high index of suspicion is required to diagnose HLH in the ICU setting.

CARDIAC SCREENING TO MITIGATE THE RISK OF SUDDEN CARDIAC DEATH IN MIDDLE EASTERN AND AFRICAN COMPETITIVE ATHLETES. A LITERATURE REVIEW

Mr Yusuf Hallak - College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE. Dr Ahmed Mustafa Al-Masaeed - Department of Cardiology, Mediclinic Parkview Hospital, Dubai, UAE.

OBJECTIVE: The study aims to review the literature regarding abnormalities predisposing to Sudden Cardiac Death (SCD) in young Middle Eastern and African competitive athletes between the years 2009-2019 and aims to assess cardiac pre-participation screening methods.

METHODS: A PubMed search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search targeted articles that reported the prevalence of cardiac abnormalities found in Middle Eastern and African athletes, and it also focused on comparing cardiac screening methods for assessment of athletes.

RESULTS: Four studies fell within the inclusion criteria and were included in the study. Results identified a shortage in the literature regarding prevalence rates of SCD in the Middle East and Africa. Additionally, there seems to be a lack of ethnicity-specific cardiac pre-participation screening programs in the region. Nevertheless, the prevalence of SCD-related abnormalities (HCM, ARVC, etc.) ranged from 0.47-4.29%. Included studies conveyed only male athletes with no reports on the female athletic population.

CONCLUSION: The present study highlights a need to develop an efficient cardiac pre-participation screening program specific to Arab and African athletes due to their high false-positive rates in contrast to Caucasian athletes. Significant evidence proves that an adequate cardiac screening program can prevent SCD in young competitive athletes. Therefore, it is imperative that future studies highlight the prevalence of abnormalities directly related to SCD in order to create a valid screening program that can be implemented in the region to mitigate the risk of shocking events.