The presacral venous system is located under the pelvic fascia covering the anterior of the sacrum and consists of two lateral sacral veins, middle sacral vein, and the veins that communicate them. The presacral venous system can be easily damaged and causes serious bleeding which is difficult to control and may cause intraoperative mortality. Its incidence varies between 3% and 9.4%. Although several methods have been tried to control presacral bleeding, the definitive method of treatment has not yet been identified. We present here our alternative technique in control of massive presacral massive bleeding developed from the presacral plexus secondary to the traction of the specimen during the dissection. The bleeding could not be controlled despite the use of all technical possibilities such as packing, ligation, and hemostatic agents. Bleeding control was provided by GORE-TEX® graft. We conclude that fıxatıon of GORE-TEX® aortic patch should be kept in mind for uncontrolled massive presacral bleeding.

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Background:In the last 20 years, there have been extraordinary improvements and practice-changing developments in the management of rheumatoid arthritis (RA). Exploring the pathogenetic mechanisms first enabled clinicians to use anti-tumor necrosis factor (TNF) alpha agents, then drugs targeting different molecules. Parallel to these developments, treatment guidelines have been changed accordingly. Meanwhile, how these developments have been reflected into the real-word practice is a question of interest.Objectives:In this study, we aimed to explore the first biologic agent trends of our 20-years of single-center experience.Methods:HUR-BIO (Hacettepe University Rheumatology Biologic Registry) is a single center biological disease modifying anti-rheumatic drug (DMARD) registry since 2005. Patients who were started biologics before 2005 were registered retrospectively. In brief; demographic data, treatment-related data (including adverse events) and disease-related data of RA patients have been recorded in HUR-BIO. Until the end of the 2020, 21 different rheumatologists contributed to the development of HUR-BIO. In this study, distribution of the first-line biologic agents was calculated according to 5-year periods starting from the 2001. Also, demographic and serologic data of RA patients were reported.Results:A total of 2080 RA patients was registered in HUR-BIO by the end of 2020. Of these patients, 79.5% was female. Mean age at the starting of bDMARD was 53.3 ± 17.8 years. Rate of rheumatoid factor and anti-cyclic citrullinated peptide positivity was 67.6% and 61.0%, respectively. 65 (3.2%), 335 (16.1%), 858 (41.2%) and 822 (39.5%) patients were prescribed with their first bDMARD in 2001-2005, 2006-2010, 2011-2015 and 2016-2020, respectively. There was a trend towards the increasing prescription of non-Anti-TNF bDMARDs over time.Table 1.Distribution of first biologic DMARDs in RA patients according to 5-years periods2001-20052006-20102011-20152016-2020TotalAdalimumab15 (23.1)111 (33.0)187 (21.8)153 (18.6)466 (22.4)Etanercept30 (46.2)154 (45.8)229 (26.7)54 (6.6)467 (22.4)İnfliximab20 (30.8)58 (17.3)64 (7.5)7 (0.9)149 (7.1)Golimumab0037 (4.3)43 (5.2)80 (3.8)Certolizumab0037 (4.3)68 (8.3)105 (5.0)Anti-TNF65 (100)323 (96.4)554 (64.5)325 (39.5)1267 (60.9)Tofacitinib006 (0.7)212 (25.8)218 (10.5)Tocilizumab009 (1.0)102 (12.4)111 (5.3)Rituximab012 (3.6)136 (15.8)84 (10.2)232 (11.1)Abatacept00153 (17.8)99 (12.0)252 (12.1)Non-Anti-TNF012 (3.6)304 (35.5)497 (60.5)813 (39.1)Total65 (100)335 (100)858 (100)822 (100)2080 (100)Approval years of drugs in Turkey; Infliximab: 2003, etanercept:2004, adalimumab: 2005, golimumab: 2013, certolizumab: 2014, abatacept: 2010, tocilizumab: 2013, rituximab:2009, tofacitinib: 2015,Conclusion:Real-life practice in RA seems consistent with treatment guidelines. Use of non-Anti-TNF bDMARDs becoming more frequent year-by-year. Jak kinase inhibitor has rised through the last 5 years. Next decade may be the years of Jak kinases inhibitors.Disclosure of Interests:None declared

Background:In the last 20 years, anti-tumor necrosis factor (TNF) alpha agents re-designed the management of rheumatoid arthritis (RA). Despite this, unmet needs in the management of RA brought several drugs targeting different molecules and cytokines. It is still a research question that how did these developments changed daily-practice in RA patients who are intolerant/unresponsive to the first biological disease modifying anti-rheumatic drugs (bDMARD).Objectives:In this study, we aimed to explore the second biologic agent trends of our 20-years of single-center experience.Methods:HUR-BIO (Hacettepe University Rheumatology Biologic Registry) is a single center biological disease modifying anti-rheumatic drug (DMARD) registry since 2005. Patients who were started biologics before 2005 were registered retrospectively. Until the end of the 2020, 21 different rheumatologists contributed to the development of HUR-BIO. Distribution of the second-line biological agents (switch from first-line biological agent because of either adverse events or unresponsiveness) was calculated according to 5-year periods starting from the 2001. Also, demographic and serologic data of RA patients were reported.Results:A total of 776 (776/2080, 37.3%) RA patients, who was prescribed a second biological agent, was registered in HUR-BIO by the end of 2020. Of these patients, 83.7% was female. Mean age at the starting of bDMARD was 53.1 ± 13.3 years. Rate of rheumatoid factor and anti-cyclic citrullinated peptid positivity was 69.1% and 60.5%, respectively. Distribution of first-line bDMARDs was as follows: adalimumab 194 (24.9%), etanercept 209 (26.9%), infliximab 105 (13.5%), golimumab 39 (5.0%), certolizumab 35 (4.5%), abatacept 78 (10.0%), rituximab 46 (5.9%), tofacitinib 37 (4.7%), tocilizumab 33 (4.2%). 11 (1.4%), 85 (11.0%), 282 (36.3%) and 398 (51.3%) patients were prescribed with their second bDMARD in 2001-2005, 2006-2010, 2011-2015 and 2016-2020, respectively. There was a trend towards the increasing prescription of non-Anti-TNF bDMARDs as second-line over time.Table 1.Distribution of second biologic DMARDs in RA patients according to 5-years periods2001-20052006-20102011-20152016-2020TotalAdalimumab3 (27.3)15 (17.6)69 (23.9)77 (18.9)164 (20.8)Etanercept8 (72.7)35 (41.2)49 (17.0)41 (10.1)133 (16.8)İnfliximab012 (14.1)13 (4.5)25 (6.2)50 (5.4)Golimumab0019 (6.6)8 (2.0)27 (3.4)Certolizumab002 (0.7)26 (6.4)28 (3.5)Anti-TNF11 (100)62 (72.9)152 (53.9)177 (44.5)402 (51.8)Tofacitinib004 (1.4)73 (17.9)77 (9.7)Tocilizumab0012 (4.2)81(19.9)93 (11.7)Rituximab022 (25.9)53 (18.3)32 (7.8)107 (13.5)Abatacept01 (1.2)61 (21.1)35 (8.6)97 (12.2)Non-Anti-TNF023 (27.1)130 (46.1)221 (55.5)374 (48.2)Total11 (100)85 (100)282 (100)398 (100)776 (100)Approval years of drugs in Turkey; Infliximab: 2003, etanercept:2004, adalimumab: 2005, golimumab: 2013, certolizumab: 2014, abatacept: 2010, tocilizumab: 2013, rituximab:2009, tofacitinib: 2015Conclusion:As the choice of second-line biologic and targeted synthetic DMARD, non-Anti-TNF bDMARDs, especially tofacitinib and tocilizumab becoming more frequent year-by-year. Despite that, anti-TNF agents as a group are still highly-prescribed options as second-line bDMARD.Disclosure of Interests:None declared