Downregulation of thrombomodulin-thrombin-activated protein C pathway as a mechanism for SARS-CoV-2 induced endotheliopathy and microvascular thrombosis

There is emerging evidence of microvascular thrombosis and thrombotic microangiopathy (TMA) induced by COVID-19, presumably from endothelial injury. Thrombomodulin (TM) is an endothelial glycoprotein that plays a dual role in maintaining healthy endothelium-as a natural anticoagulant by binding thrombin to activate protein C (APC) and a negative regulator of the alternate complement pathway (AP). TM is shed into the plasma as soluble TM (sTM) during endothelial injury. We hypothesize that SARS-CoV-2 spike proteins cause direct microvascular endothelial injury, leading to TM shedding, decreased activation of PC, and consequently, microvascular thrombosis in COVID-19. We conducted this study twofold: 1) in vivo, we assessed endothelial injury (by measuring sTM) and AP activation by quantifying Ba (cleavage product of AP component Factor B) in a cohort of critically ill COVID-19 pediatric patients and the implications on clinical outcomes; and 2)in vitro, we investigated endothelial injury (TM shedding) by SARS-COV-2 spike proteins and the subsequent functional consequence in activated PC (APC) levels and Ba levels. sTM and Ba in plasma samples from SARS-CoV-2 positive patients admitted to Texas Children's Hospital Pediatric Intensive Care Unit (n = 33) and from healthy controls (n = 38) were measured by ELISA. In vitro, confluent glomerular microvascular endothelial cells (GMVECs) were incubated for 48 h in the presence or absence (control) of purified SARS-CoV-2 spike proteins, S1 and S2. TM from the cell lysates while Ba and APC from the cell supernatants were measured by ELISA. sTM and Ba levels were significantly higher in the COVID-19 pediatric patients compared to healthy controls (p < 0.01 and p < 0.001, respectively). Among the COVID-19 patients, elevated sTM was associated with increased vasopressor use (p = 0.01) and elevated Ba was associated with increased duration of mechanical ventilation (p = 0.04). In vitro, surface bound TM and soluble APC were significantly lower in GMVECs after addition of spike proteins (p < 0.05), while Ba was undetectable in both control and spike proteins exposed GMVECs. In conclusion, we provide evidence of endothelial injury in COVID-19 pediatric patients and demonstrate a potential pathway of SARS-CoV-2 induced thrombosis. Decreased surface-bound TM results in lower amount of thrombin-TM complex, hence lesser activation of PC, likely leading to a pro-thrombotic state. These findings in GMVECs could explain the vulnerability of kidneys to COVID-19-induced TMA.

Association between Total Dairy and Individual Dairy Foods and Iodine Status in the U.S. Population

Objectives

The objective of this study was to determine the association between the consumption of dairy foods with urinary iodine concentration (UIC) and iodine deficiency risk in a nationally representative sample.

Methods

24-hour dietary recall data and laboratory data for UIC (μg/L) from subjects 2 + years old participating in National Health and Nutrition Examination Surveys (NHANES) 2001–2018 were used (N = 26,838). Data were adjusted for demographic factors for analyses stratified by age/race-ethnicity. Significant associations between iodine status and dairy intake quintile (with non-consumers as the first group) were assessed at P < 0.05. Logistic regression was used to assess the odds ratio (95^th percentile confidence intervals) of being below the iodine insufficient level (UIC < 100 μg/L) and the severely iodine deficient level (UIC < 20 μg/L) for dairy consumption groups with non-consumers as the reference group by age groups.

Results

Mean intakes of total dairy, milk, cheese and yogurt were 2.21, 1.58, 0.78 and 0.46 cup eq respectively for those 2–8 y; 2.17, 1.38, 1.11 and 0.48 cup eq respectively for those 9–18 y; and 1.70, 0.95, 1.09 and 0.57 cup eq respectively for those 19 + y.

Intake of total dairy and milk were positively associated with UIC among those 2- 8 y (β = 27.8 ± 8.8 and 42.4 ± 8.4 μg/L/cup eq, respectively) and 9–18 y (β = 15.9 ± 2.7 and 30.4 ± 5.0 μg/L/cup eq, respectively) but not associated among those 19 + y. Intakes of cheese and yogurt were not associated with UIC among any age group.

Total dairy intake was inversely associated with odds ratio [OR (95^th confidence intervals)] of being iodine deficient or severely deficient among those 2–8 y [0.70 (0.61, 0.82) and 0.53 (0.28, 0.99), respectively], 9–18 y [0.79 (0.73, 0.85) and 0.70 (0.50, 0.98)], respectively], and 19 + y [0.80 (0.77, 0.83) and 0.74 (0.65, 0.84), respectively].

Milk intake was inversely associated with odds ratio of being iodine deficient or severely deficient among those 2–8 y [0.67 (0.59, 0.77) and 0.49 (0.31, 0.79), respectively], 9–18 y [0.76 (0.71, 0.82) and 0.68 (0.50, 0.91)], respectively], and 19 + y [0.84 (0.80, 0.87) and 0.77 (0.66, 0.89), respectively].

Conclusions

The results indicate that dairy foods are beneficially associated with UIC population iodine sufficiency.

Funding Sources

National Dairy Council.

AB0516 IN-HOSPITAL MORTALITY IN YOUNG PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AND ASSOCIATED CLINICAL FEATURES

Background

Patients with systemic lupus erythematosus (SLE) are three times more likely to die from any cause as compared to patients without SLE.1 This is largely driven by cardiovascular disease, malignancy, and an increased risk of infection. Alarmingly, recent studies have shown that younger patients with SLE are particularly vulnerable to all-cause mortality.1 However, there is a paucity in knowledge about patient characteristics and specific etiologies of mortality in this population that needs to be described in order to implement strategies to improve outcomes in younger patients with SLE.

Objectives

To identify disease characteristics and etiologies of mortality in young patients with SLE that died while hospitalized.

Methods

A retrospective chart review of a multi-institutional publicly funded health system in Texas, USA was performed. Deceased patients aged 18-49 with a 2019 EULAR/ACR diagnosis of SLE were identified from 2012 to 2021. Patients with mixed connective tissue disease, missing records, or cardiac arrest in the emergency room that did not have a clear etiology of death were excluded. Data was extracted from the electronic medical records by two independent reviewers to determine the most likely cause of death. If there was any discrepancy between the reviewers, this would be resolved by a third-party reviewer. Baseline demographics, disease activity by the SLE disease activity index (SLEDAI), medications, and reasons for prednisone administration were collected.

Results

Twenty- six patients with SLE (age range 22 to 48) that died in the hospital were identified. The most common cause of death was infection (58%) followed by lupus activity (15%). Of those that died of infection, all but one was on a two-month average dose of prednisone ≥10mg. Furthermore, the majority of patients (71%) that were on prednisone doses of ≥10mg had not undergone a prednisone taper within two months (i.e. were on a consistent dose). This was because of either persistent disease activity or poor follow-up.

Conclusion

To our knowledge, this is the first study to describe characteristics of young patients with SLE that died during hospitalization. Our findings show that young patients with SLE primarily die from infection while on increased doses of corticosteroids that have not been tapered. Further research is warranted to determine association and causality of these findings with mortality. Practitioners should remain vigilant and continue to taper steroids as able as this may be a potential source of mortality in young patients with SLE.

References

[1]Tselios K, Gladman DD, Sheane BJ, Su J, Urowitz M. All-cause, cause-specific and age-specific standardised mortality ratios of patients with systemic lupus erythematosus in Ontario, Canada over 43 years (1971-2013). Ann Rheum Dis 2019;78:802-6.

Table 1.

Baseline characteristics of SLE patients that experienced in-hospital mortality.

SLE Cases(n = 26)Female, n (%)20 (77)Age, range in years22 to 48Race and Ethnicity, n (%)Black6 (23)Hispanic19 (73)Asian1 (4)Disease manifestationsLupus nephritis18 (69)End-stage renal disease3 (12)SLEDAI before admission (median, IQR)7 (4 to 11)SLEDAI on admission (median, IQR)6 (2 to 11)MedicationsPrednisone25 (96)Hydroxychloroquine19 (73)Mycophenolate9 (35)Cyclophosphamide7 (27)Belimumab1 (4)Cause of deathInfection15 (58)Lupus activity4 (15)Cardiogenic shock2 (8)Cancer2 (8)Other3 (12)

IQR = Interquartile range

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

AB0488 THE UTILITY OF ERYTHROCYTE SEDIMENTATION RATE, C-REACTIVE PROTEIN, AND PROCALCITONIN IN DETECTING INFECTIONS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A DIAGNOSTIC TEST ACCURACY REVIEW

Background

Patients with systemic lupus erythematosus (SLE) are at an increased risk of hospitalization for flares or infections. In practice, diagnosing SLE flares versus infection can be challenging as both present with similar signs and symptoms. Strategies are needed to help differentiate between infections and SLE flares in hospitalized patients. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) are commonly used to aid in the diagnosis of infection in hospitalized patients, however, their utility in SLE is unclear.

Objectives

To summarize the evidence about accuracy of ESR, CRP, and PCT in diagnosing infection in hospitalized patients with SLE.

Methods

We searched five databases until April 2021. We included studies published in English investigating levels of ESR, CRP, or PCT on adults hospitalized with a diagnosis of SLE comparing infection versus non-infection. We excluded studies with no clinical data, inadequate data to perform analysis, different conditions, and not relevant study types (such as case reports, other reviews). We also excluded studies with overlapping data (e.g., abstracts that are later published as full-text articles). We used the Quality Assessment of Diagnostic Studies to assess for bias and applicability. We obtained pooled sensitivities and specificities from studies that used similar cut-offs. We also generated mean differences for ESR, CRP, and PCT in infection versus non-infection hospitalized SLE patients.

Results

We included 26 studies in our analysis. Most studies had an unclear or high risk of bias. Most patients from both infection and non-infection groups were women aged from 27-40 years. The definitions for infection were heterogenous but mainly included positive culture or biochemical testing, suggestive imaging, response to antibiotics, or obvious signs/symptoms (such as purulence). The CRP had a pooled sensitivity of 0.75 (95%CI 0.57-0.94) and specificity of 0.72 (0.59-0.85), PCT had a pooled sensitivity of 0.68 (95% CI 0.0.59-0.77) and specificity of 0.75 (0.59-0.90), and for ESR pooled estimates were not calculated due to insufficient data but sensitivity ranged from 50 to 69.8 and specificity from 38.5 to 55.6. Modifying cut-offs improved sensitivities and specificities (see Table 1). The ESR, CRP, and PCT mean differences were all greater in infection groups versus non-infection (10.1, 95% CI 3.2-17.0; 46.8, 95% CI 36.5-57.0; 0.53, 95% CI 0.26-0.80; respectively).

Table 1.

Pooled sensitivity and specificities of CRP and PCT

Studies(n)Sensitivity(95% CI)Specificity(95% CI)CRPCRP < 1030.68 (0.48-0.89)0.70 (0.62-0.77)CRP > 1020.91 (0.86-0.97)0.87 (0.81-0.93)Overall50.75 (0.57-0.94)0.72 (0.59-0.85)ProcalcitoninPCT > 0.230.66 (0.50-0.81)0.84 (0.76-0.92)PCT < 0.230.70 (0.61-0.80)0.61 (0.53-0.69)Overall60.68 (0.59-0.77)0.75 (0.59-0.90)

Conclusion

Our study showed that although ESR, CRP, and PCT mean values are increased in hospitalized infected SLE patients compared to patients with no infection, the included studies used varying cut-offs for sensitivities and specificities and definitions for infection decreasing the uncertainty on the results and making the clinical usefulness of these biomarkers unclear. Our findings at this time do not support the widespread use of these biochemical markers in SLE patients and highlight the need that more research is needed to investigate the use of these markers in this patient population.

Disclosure of Interests

None declared

Association of Dietary Protein Intake and Grip Strength Among Adults Aged 19+ Years: NHANES 2011–2014 Analysis

Background

Research on the role of protein in the diet has evolved beyond a focus on quantity to include the impact of its quality and distribution across meal times in an effort to optimize dietary protein recommendations.

Objective

To determine the association of dietary protein amount, type, and intake pattern with grip strength in adults.

Design

Data from the National Health and Nutrition Examination Survey (NHANES) 2011–2014 for adults 19 + years (N = 9,214) were used with exclusions for pregnant and lactating women. Intakes of dietary total protein (TP), animal protein (AP, including dairy), plant protein (PP), and leucine (Leu) were determined using day 1 24 h dietary recall data after adjusting for the complex sample design of NHANES. Regression analyses were used to assess the association of dietary protein and leucine intake quartiles, and whether consuming &gt; 20 g of dietary protein at one or more meals was related to grip strength with adjustment for age, gender, and ethnicity.

Results

Mean intake of TP among adults aged 19 + years was 83.6 ± 0.5 g/day, and 2/3rd of this was from animal sources (including dairy). Grip strength increased (p &lt; 0.05) with increasing quartiles of TP, AP, PP, and leucine among all adults 19 + years (β = 1.340.19, 1.27 ± 0.19, 0.76 ± 0.20, and 1.33 ± 0.23, respectively), 19–50 years (β = 1.14 ± 0.27, 1.06 ± 0.25, 0.77 ± 0.30, and 1.18 ± 0.27, respectively), and 51 + years (β = 0.95 ± 0.26, 1.08 ± 0.27, and 1.05 ± 0.27, respectively, for TP, AP, and Leu); however, the increase was more pronounced for AP than PP. Grip strength also increased (p &lt; 0.05) with increasing the number of meal occasions containing &gt; 20 g of dietary protein (β = 1.50 ± 0.20, 1.41 ± 0.25, and 0.91 ± 0.37 for 19+, 19–50, and 51 + years, respectively), and significant increases were detected for two meals compared to zero meals.

Conclusion

Dietary protein quantity, quality, and distribution should be considered collectively when looking to optimize protein intake to support muscle strength and function.

Gap Statistics for Confined Particles with Power-Law Interactions

We consider the N particle classical Riesz gas confined in a one-dimensional external harmonic potential with power-law interaction of the form 1/r^{k}, where r is the separation between particles. As special limits it contains several systems such as Dyson's log-gas (k→0^{+}), the Calogero-Moser model (k=2), the 1D one-component plasma (k=-1), and the hard-rod gas (k→∞). Despite its growing importance, only large-N field theory and average density profile are known for general k. In this Letter, we study the fluctuations in the system by looking at the statistics of the gap between successive particles. This quantity is analogous to the well-known level-spacing statistics which is ubiquitous in several branches of physics. We show that the variance goes as N^{-b_{k}} and we find the k dependence of b_{k} via direct Monte Carlo simulations. We provide supporting arguments based on microscopic Hessian calculation and a quadratic field theory approach. We compute the gap distribution and study its system size scaling. Except in the range -1<k<0, we find scaling for all k>-2 with both Gaussian and non-Gaussian scaling forms.

Life-saving transfusion in autoimmune hemolytic anemia: a case report and procedure review of the dilution method

A woman with autoimmune hemolytic anemia (AIHA) presented in the emergency department with life-threatening anemia (hemoglobin 3 g/dL). Exaggeration of preexisting chronic anemia to severe anemia after a recent red blood cell (RBC) transfusion led to suspicion of delayed hemolytic transfusion reaction. Given the urgency for transfusion along with a stronger suspicion for coexistence of an alloantibody, the dilution method proposed by Lawrence Petz and George Garratty was used to find an RBC unit for transfusion. An alloantibody with Fy^b specificity was identified, which was masked by the coexistent autoantibody. This method is based on the assumption that the titers of an alloantibody are higher than that of autoantibody. Diluting the autoantibody would reveal the alloantibody and, for this purpose, a serial doubling dilution of serum is performed. This method has an important limitation of missing any alloantibodies with titers less than that of the autoantibody. In spite of this, this method may be of use at a resource-poor setting, where trained personnel and other reagents intended for advanced immunohematology methods are unavailable.

Clinicopathologic spectrum of newly diagnosed multiple myeloma presenting with renal impairment: A tertiary care center experience from north India

Multiple myeloma (MM) is a hematologic malignancy, characterized by the neoplastic proliferation of plasma cells producing a monoclonal immunoglobulin. Patients presents with signs and symptoms related to the infiltration of plasma cells into the bone or other organs or to kidney damage from excess light chains. Renal involvement with various presentations may be the first manifestation of the disease.

MATERIAL

All patients of MM presenting with renal dysfunction between July 2019 to June 2021 were included. Diagnosis of MM was made according to the 2014 guidelines of international myeloma working group.

OBSERVATION

Out of total 144 cases of multiple myeloma renal involvement was present in 43 (29.8%). Mean age of study population was 55.49 years with 72% males. Most common clinical features were fatigue (59%), anorexia (47%) &amp; edema (42%). Anemia was present in 79%, hypercalcemia in 16.2% and hyperuricemia in 20.9% patients. Renal failure was present in 72.1% with a mean eGFR 35.8 ml/min/1.73m2. Serum protein electrophoresis revealed M band in 81.4% and all except one patient had increased light chains in serum. Most common histological lesion were myeloma cast nephropathy (39.5%), primary amyloidosis (30.2%) &amp; monoclonal immunoglobulin deposition disease (14%). Primary amyloidosis group had maximum 24-hour proteinuria and highest eGFR.

CONCLUSION

The spectrum of renal involvement in multiple myeloma is heterogenous. It mainly affects middle and elderly age group. Typical clinical features might not be seen in all the cases and therefore a high index of suspicion in unexplained renal failure cases might help in early diagnosis and timely management.

CaSR expression in normal parathyroid and PHPT: new insights into pathogenesis from an autopsy-based study

PURPOSE

Calcium sensing receptor (CaSR), on the surface of normal parathyroid cells, is essential for maintaining serum calcium levels. The normal pattern of CaSR immunostaining remains undefined and is presumptively circumferential. Given the physiological variation in serum calcium, we postulated that CaSR expression could not be uniformly circumferential. Also, cytoplasmic expression has not been evaluated either in normal or pathological tissues. We studied normal parathyroid tissues derived from forensic autopsies and those rimming parathyroid adenomas for membranous and cytoplasmic CaSR immunoexpression. Results were compared with primary hyperparathyroidism (PHPT) to look for any pathogenetic implications.

MATERIALS AND METHODS

We evaluated 34 normal parathyroid tissues from 11 autopsies, 30 normal rims, 45 parathyroid adenoma, 10 hyperplasia, and 7 carcinoma cases. Membranous expression was categorized complete/incomplete and weak/moderate/strong; scored using Her2/Neu and Histo-scores; predominant pattern noted. Cytoplasmic expression was categorized negative/weak/moderate/strong; predominant intensity noted.

RESULTS

Normal autopsy-derived parathyroid tissues were Her2/Neu 3 + , but incomplete membranous staining predominated in 85%. Their immune-scores were significantly more than the cases (p <  < 0.05). The mean histo-score of normal rims was intermediate between the two (p <  < 0.05). Cytoplasmic expression was strong in all autopsy-derived tissues, weak/negative in hyperplasia (100%), moderate in 16% adenomas, and 43% carcinomas.

CONCLUSIONS

Normal autopsy-derived parathyroid tissues showed strong but predominantly incomplete membranous expression. Surface CaSR expression decreased in PHPT and is probably an early event in parathyroid adenoma, seen even in normal rims. Whether there is a defect in CaSR trafficking from the cytoplasm to the cell surface in adenoma and carcinoma needs further evaluation.

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers

BACKGROUND

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications.

METHODS

Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy.

RESULTS

One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m². Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks.

CONCLUSION

ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

Effects of COVID-19 on maternal, child healthcare (MCH) services in slums: lessons from India

Background

The study aims to understand the effect of COVID lockdown on MCH for slum dwellers and coping mechanisms adopted in Indore and Agra, India. Slum women's perspectives on seeking, delaying, avoiding healthcare in COVID-19, barriers and facilitators were explored.

Methods

In-person qualitative interviews were conducted in slums in Sept-Oct 2020 with mothers who had deliveries; pregnant women needing ante-natal care; mothers with children <2 yrs needing immunization during COVID lockdown. 30 mothers requiring these MCH services during April -June 2020 (lockdown phase) were interviewed. We chose qualitative study over quantitative as a shorter and useful precedent to replicate in similar situations.

Results

Govt. and most private hospitals refused non-COVID services during lockdown.; Police restricted movement on roads. Being on COVID duty, frontline health functionaries were not doing outreach health sessions. Women missed ante-natal check-up, Iron Folate, Tetanus toxoid; Demand side challenges included fear of COVID infection, lack of money due to livelihood loss; Home deliveries by self, neighbors were resorted to; Maternal, neonatal deaths ensued; Children missed immunization e.g., Measles, DPT. Few peri-urban slum families visited nearby rural health facility for delivery. Some families borrowed money from community saving's groups for delivery in private hospitals. Few families visited low-cost private doctor/nurse for immunization of pregnant mother, children.

Conclusions

Demand and supply side factors led to pregnant women and children not receiving care during lockdown. Peri-urban slum families should be encouraged to link with nearby rural health facility for MCH services during COVID-19 or similar situations. Govt. partnering with private providers near slums will help access during challenging times. Promoting community savings groups as mandated under National Urban Health Mission can enable slum families borrow with ease when in need.

Key messages

Government health system should set up emergency (e.g., mobile clinic) MCH services for future epidemic, disaster, should partner with private doctors/nurses near slums.

Rural health infrastructure serving nearby peri-urban slums formally recognized by Govt. despite separate jurisdictions is an approach adaptable in LMIC cities.

Vegetable gardening in slum homes for food security especially in COVID-19 and well-being in India

Issue

With livelihood loss, uncertain earning, slum families are often food insecure, at risk of undernutrition particularly during COVID-19 in Indian and other LMIC cities. While wheat flour was provided free during lockdown, later at subsidized costs and during non-COVID times, vegetables need to be bought at market price.

Methods

UHRC provided seeds, encouraged families to grow vegetables in slums of Indore, India for five years. In 2019-20 and 20-21, data was gathered through interviews, observations in 20 slums (where &gt;15 families grew vegetables).

Results

Uptake of seeds increased from 900 families in 2019-20 to 1200 in 20-21. With sharing of surplus harvest, 70,000 persons benefited in 2020-21. Families overcame food insecurity by arranging just wheat flour and cooked a vegetable for a meal. Used paint tubs, broken buckets and small spaces were used. Creepers were made to climb on roofs, walls, trees. Green cover increased to &gt; 8 acres in 2021. The practice saves valuable family resources particularly in COVID-19 distress through provision of vegetables for family consumption.

Lessons

Perseverant efforts are key and help build a ‘fairer, healthier world'. Yield per family increased as they grow with incremental confidence. Despite small spaces slum families creatively grew vegetables. Children and youth help overcome constraints and are key actors. Early adopters serve as motivators and champions for subsequent adopters who begin growing vegetables on observing neighbours, friends grow vegetables and share with them. Nurturing plants, seeing vegetables grow fostered positivity, hope, motivation to grow every year, enhanced self-worth, and a positive feeling about their abode. People particularly children and youth learn how eating home-grown vegetables reduces carbon footprint of purchased vegetables transported to urban markets, save cost and overcome food insecurity. They reduce ambient air temperature to cool urban spaces.

Key messages

Despite small spaces, slum families grow, share vegetables, feel accomplished, enable food security, social cooperation, all crucial to well-being of slum populations. Methods used and lessons learnt of perseveringly motivating slum families have the potential of replication/adaptation in cities of India and other LMICs.

Birth Preparedness and Complication Readiness (BPACR) among brick kiln workers in Indore, India

Background

Birth preparedness and complication readiness (BPACR), promotes utilization of skilled maternal and neonatal care. Preparing for childbirth reduces delays in seeking care. Brick-kiln workers constitute a vulnerable social group who contribute to city infrastructure by laboring at low wages. 37% of the sample were Scheduled Castes, 49% Scheduled Tribes.

Methods

139 mothers of children &lt; 2 years, residing temporarily in brick kilns of Indore were asked about preparedness for birth of youngest child. Birth preparedness was assessed by enquiring about saving money, arranging transport, identifying health facility for delivery, identified family member to accompany for labor/emergency.

Findings

10% did &gt;3 BPACR practices implying good level of preparedness; 50% did 1-2 BPACR practices; 40% did no birth preparedness. Access to maternity benefit scheme was twice as likely to result in reasonable birth preparedness as compared to no access. Those with primary to class XII were twice as likely to practice birth preparedness as compared to those with no formal education. &gt;3 ANC was associated with 8 percentage points greater practice of reasonable BPACR as compared to &lt; 2 or no ANC. Mothers with knowledge of one danger sign each of pregnancy and delivery were 3 times more likely to practice BPACR than those without this knowledge. FGDs revealed challenges in access to bank account, obtaining required documents to apply for and access state maternity benefit. Lack of family support led to low BPCAR and low institutional delivery.

Conclusions

Brick-kiln women face risk of low utilization of government healthcare services. The health systems should conduct outreach antenatal care sessions in brick-kilns on knowledge of key danger signs and BPACR during health education and ANC counselling can help promote BPACR and hospital delivery. Information on requisite steps to apply for maternity benefit schemes should be shared among brick-kiln workers.

Key messages

It is crucial to promote BPACR among urban vulnerable sections, through NUHM’s outreach sessions by ANMs/ASHAs in brick-kiln, construction workers and similar groups. Access to maternity benefit cash transfer scheme should be enhanced particularly among excluded temporary urban groups such as brick-kiln workers as it is a motivation to avail hospital care.

A facile method for high-throughput screening of drug-eluting coatings in droplet microarrays based on ultrasonic spray deposition

Coating modification such as drug-eluting coating is one of the most important approaches for the functionalization of biomedical devices. However, the throughputs are limited in conventional coating methods and the concept of miniaturization is rarely fulfilled. A droplet microarray (DMA), as a unique high-throughput platform, can avoid cross-contamination and reduce the consumption of materials which is inherently suitable for coating research yet is difficult to apply with coating materials via traditional methods. Here, we bring up a facile method based on ultrasonic spray deposition to integrate coating materials into a DMA. Several common polymer materials were selected to fabricate a DMA, and the obtained DMA showed the ability to anchor water droplets and form specific patterns. Coating arrays with a typical sandwich structure were also prepared for the high-throughput screening of drug-eluting coatings to demonstrate the potential of the platform in coating research. This developed method is efficient and compatible and enriches the choices of materials that can be applied in DMAs.

224 A 5-Year Observational Study on Distal Femoral Periprosthetic Fractures in Elderly Patients in a Single Institution: Distal Femoral Replacement vs. Internal Fixation

Aim

To evaluate the outcome of distal femoral replacements versus internal fixation for elderly patients with distal femoral periprosthetic fracture in a single institution.

Method

A five-year retrospective observational study was conducted of a consecutive series of patients with distal femoral periprosthetic fracture who underwent either distal femoral replacement (DFR) or internal fixation (IF) in a tertiary referral centre. Clinical information analysed included patient demographics, co-morbidities, interval between primary total knee arthroplasty (TKA) to distal femoral periprosthetic fracture, type of fracture, operative technique, preoperative ASA grade, post-operative complications, intensive therapy unit (ITU) stay, length of hospital stay (LOS), re-fixation and mortality.

Results

Study included 27 patients of which fourteen patients underwent a DFR while 13 underwent an IF. 89% of the patients were females. Mean age of the patients at the time of fracture was 85 versus 80 (DFR vs IF). The mean interval from the primary TKA to the fracture were 80 months (range 0-181). There were no intraoperative complications in either group. Three patients required ITU stay from the DFR group while one patient from the IF group required re-fixation. Median LOS was 56 days (range 9-144) after DFR and 55 days (range 4-83) after IF. There was one 30-day mortality in the DFR group. One-year mortality for the DFR group was 7% vs 15% for the IF group.

Conclusions

In our study, DFR and IF were observed to have similar LOS with a higher mortality in the IF group at one year. There was one re-fixation in the IF group.

1064 Extra-Articular Tibial Deformity Management in Total Knee Replacement

Aim

In knee replacements, restoration of mechanical alignment is essential. Patients with extra-articular deformities (EAD) pose challenges in planning knee replacements. We present a method, based on our experience and review of literature on planning knee replacement surgery, in the presence of extra-articular coronal plane deformity of the tibia.

Method

Retrospective analysis was made of six patients with EAD of the tibia who underwent knee replacement at our centre. Mechanical axis of the tibia is considered and positioning of the tibia component is planned perpendicular to the mechanical axis of the tibia. The integrity of the collaterals determines the need for correction. Tibial resection &gt;15mm from medial or lateral aspect of the tibia is an indication for corrective osteotomy prior to replacement surgery. The hip knee ankle angle (HKA) was noted. Pre-operative, post-operative clinical score, degree of constraints and post-operative complications were recorded. A post-operative long leg alignment radiograph was obtained.

Result

All patients had total knee replacement without correction of deformity. Adequate alignment of the limb and restoration of mechanical axis was achieved in all six patients without the need for correction of tibial deformity. All patients had improvement in their HKA angle and Oxford knee score. No re-operations were required, and no complications recorded.

Conclusions

Our study will help provide guidance on operative planning and decisions making for patients with extra-articular coronal plane tibial deformities.