Impact of Plant Protein Intakes on Nutrient Adequacy in the US

There is an increasing interest in plant-based diets and higher levels of plant proteins due to rising concerns around health and environmental sustainability issues. We determined the effects of increasing quartiles of plant protein in the diet on nutrient adequacy using a large nationally representative observational dataset. Twenty-four-hour dietary-recall data from NHANES 2013-2018 from 19,493 participants aged 9+ years were used to assess nutrient intakes. Nutritional adequacy was assessed by estimating the percentage of the population with intakes below the EAR or above the AI. A quartile trend was assessed using regression and the significance was set at Pquartile trend < 0.05. With increasing quartiles of plant protein, the adequacy decreased for calcium, potassium, and vitamin D and increased for copper and magnesium for adolescents. Among the adults aged 19-50 years, the adequacy decreased for protein, choline, selenium, vitamin B12, and zinc and increased for copper, folate, iron, magnesium, thiamin, and vitamin C with increasing quartiles of plant protein. The adequacy for calcium, vitamin A, and zinc decreased and it increased for copper, folate, magnesium, thiamin, and vitamin C with increasing quartiles of plant protein among adults aged 51+ years. The results indicate that diets of mixed protein sources (from both animals and plants) are the most nutritionally adequate.

Contribution of Beef to Key Nutrient Intakes and Nutrient Adequacy in Pregnant and Lactating Women: NHANES 2011-2018 Analysis

Beef is an important source of high-quality protein and several micronutrients, including iron, zinc, and B-vitamins. The objective was to assess the association of beef intake with nutrient intake and adequacy among pregnant and lactating women using 24-h dietary recall data. Usual intakes from foods were determined with the National Cancer Institute (NCI) method and % population below Estimated Average Requirement (EAR) or above Adequate Intake (AI) were estimated. A high proportion of pregnant and lactating women had inadequate intakes for vitamin D (94%), vitamin E (82%), vitamin C (52%), and vitamin A (50%), magnesium (35%), folate (31%), zinc (25%), and vitamin B6 (22%); only 4% and 35% met AI for choline and potassium, respectively. About 67% of pregnant and lactating women were beef consumers, consuming 49 g beef/day. Beef consumers had higher intakes (p < 0.05) of energy, protein, calcium, iron, phosphorus, selenium, sodium, zinc, thiamin, riboflavin, and niacin, and a higher proportion (p < 0.05) met nutrient recommendations for protein, calcium, iron, zinc, thiamin, riboflavin, niacin, vitamin B6, and vitamin B12 compared to non-consumers. In conclusion, pregnant and lactating women generally have inadequate nutrient intakes from their diets. Beef consumers have higher intakes and adequacy for certain nutrients, many of which are inherently available in beef or in foods eaten with beef.

The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were 'uncommon' (10-100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being 'common' (100-1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent.

Peri-operative cardiac arrest: epidemiology and clinical features of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. Here we report the results of the 12-month registry, from 16 June 2021 to 15 June 2022, focusing on epidemiology and clinical features. We reviewed 881 cases of peri-operative cardiac arrest, giving an incidence of 3 in 10,000 anaesthetics (95%CI 3.0-3.5 per 10,000). Incidence varied with patient and surgical factors. Compared with denominator survey activity, patients with cardiac arrest: included more males (56% vs. 42%); were older (median (IQR) age 60.5 (40.5-80.5) vs. 50.5 (30.5-70.5) y), although the age distribution was bimodal, with infants and patients aged > 66 y overrepresented; and were notably more comorbid (73% ASA physical status 3-5 vs. 27% ASA physical status 1-2). The surgical case-mix included more weekend (14% vs. 11%), out-of-hours (19% vs. 10%), non-elective (65% vs. 30%) and major/complex cases (60% vs. 28%). Cardiac arrest was most prevalent in orthopaedic trauma (12%), lower gastrointestinal surgery (10%), cardiac surgery (9%), vascular surgery (8%) and interventional cardiology (6%). Specialities with the highest proportion of cases relative to denominator activity were: cardiac surgery (9% vs. 1%); cardiology (8% vs. 1%); and vascular surgery (8% vs. 2%). The most common causes of cardiac arrest were: major haemorrhage (17%); bradyarrhythmia (9%); and cardiac ischaemia (7%). Patient factors were judged a key cause of cardiac arrest in 82% of cases, anaesthesia in 40% and surgery in 35%.

Peri-operative cardiac arrest: management and outcomes of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12-month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri-operative cardiac arrest, the initial rhythm was non-shockable in 723 (82%) cases, most commonly pulseless electrical activity. There were 665 (75%) patients who survived the initial event and 384 (52%) who survived to hospital discharge. A favourable functional outcome (based on modified Rankin Scale score) was reported for 249 (88%) survivors. Outcomes varied according to arrest rhythm. The highest rates of survival were seen for bradycardic cardiac arrests with 111 (86%) patients surviving the initial event and 77 (60%) patients surviving the hospital episode. The lowest survival rates were seen for patients with pulseless electrical activity, with 312 (68%) surviving the initial episode and 156 (34%) surviving to hospital discharge. Survival to hospital discharge was worse in patients at the extremes of age with 76 (40%) patients aged > 75 y and 9 (45%) neonates surviving. Hospital survival was also associated with surgical priority, with 175 (88%) elective patients and 176 (37%) non-elective patients surviving to discharge. Outcomes varied with the cause of cardiac arrest, with lower initial survival rates for pulmonary embolism (5, 31%) and bone cement implantation syndrome (9, 45%), and hospital survival of < 25% for pulmonary embolism (0), septic shock (13, 24%) and significant hyperkalaemia (1, 20%). Overall care was rated good in 464 (53%) cases, and 18 (2%) cases had overall care rated as poor. Poor care elements were present in a further 245 (28%) cases. Care before cardiac arrest was the phase most frequently rated as poor (92, 11%) with elements of poor care identified in another 186 (21%) cases. These results describe the management and outcomes of peri-operative cardiac arrest in UK practice for the first time.

Organisation of UK hospitals and anaesthetic departments in the treatment of peri-operative cardiac arrest: an analysis from the 7th National Audit Project (NAP7) local co-ordinator baseline survey

We report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri-operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paediatric anaesthetic care was provided by 188 (95%) and 165 (84%) hospitals, respectively. There was no paediatric intensive care unit on-site in 144 (87%) hospitals caring for children, meaning transfer of critically ill children is required. Remote site anaesthesia is provided in 182 (92%) departments. There was a departmental resuscitation lead in 113 (58%) departments, wellbeing lead in 106 (54%) and departmental staff wellbeing policy in 81 (42%). A defibrillator was present in every operating theatre suite and in all paediatric anaesthesia locations in 193 (99%) and 149 (97%) departments, respectively. Advanced airway equipment was not available in: every theatre suite in 13 (7%) departments; all remote locations in 103 (57%) departments; and all paediatric anaesthesia locations in 23 (15%) departments. Anaesthetic rooms were the default location for induction of anaesthesia in adults and children in 148 (79%) and 121 (79%) departments, respectively. Annual updates in chest compressions and in defibrillation were available in 149 (76%) and 130 (67%) departments, respectively. Following a peri-operative cardiac arrest, debriefing and peer support programmes were available in 154 (79%) and 57 (29%) departments, respectively. While it is likely many UK hospitals are very well prepared to treat anaesthetic emergencies including cardiac arrest, the survey suggests this is not universal.

The 7th National Audit Project (NAP7) baseline survey of individual anaesthetists: preparedness for and experiences of peri-operative cardiac arrest

The Royal College of Anaesthetists' 7th National Audit Project baseline survey assessed knowledge, attitudes, practices and experiences of peri-operative cardiac arrests among UK anaesthetists and Anaesthesia Associates. We received 10,746 responses, representing a 71% response rate. In-date training in adult and paediatric advanced life support was reported by 9646 (90%) and 7125 (66%) anaesthetists, respectively. There were 8994 (84%) respondents who were confident in leading a peri-operative cardiac arrest, with males more confident than females, but only 5985 (56%) were confident in leading a debrief and 7340 (68%) communicating with next of kin. In the previous two years, 4806 (46%) respondents had managed at least one peri-operative cardiac arrest, of which 321 (7%) and 189 (4%) of these events involved a child or an obstetric patient, respectively. Respondents estimated the most common causes of peri-operative cardiac arrest to be hypovolaemia, hypoxaemia and cardiac ischaemia, with haemorrhage coming fifth. However, the most common reported causes for the most recently attended peri-operative cardiac arrest were haemorrhage; (927, 20%); anaphylaxis (474, 10%); and cardiac ischaemia (397, 9%). Operating lists or shifts were paused or stopped after 1330 (39%) cardiac arrests and 1693 (38%) respondents attended a debrief, with 'hot' debriefs most common. Informal wellbeing support was relatively common (2458, 56%) and formal support was uncommon (472, 11%). An impact on future care delivery was reported by 196 (4%) anaesthetists, most commonly a negative psychological impact. Management of a peri-operative cardiac arrest during their career was reported by 8654 (85%) respondents. The overall impact on professional life was more often judged positive (2630, 30%) than negative (1961, 23%), but impact on personal life was more often negative.

Assessment of Beverage Trends and Replacing Nondairy Caloric Beverages with Milk at Meals across Childhood Improves Intake of Key Nutrients at Risk of Inadequate Consumption: An NHANES Modeling Study

Background

Milk is a key source of important nutrients including the nutrients of public health concern. However, most Americans do not meet current (dairy) United States Department of Agriculture (USDA) dietary guideline recommendations, and the intake has been declining.

Objective

The aim of this study was to investigate milk and beverage intake trends and nutrient intakes from these products in United States children aged 6-18 y and to model the effect of isocaloric substitution of nondairy beverages with milk.

Methods

Data from National Health and Nutrition Examination Survey (NHANES) 2001-2018 for children age 6-8 (N = 4696), 9-13 (N = 8117) and 14-18 y (N = 8514) were used with milk and other beverage intakes determined from the first 24-h in-person dietary recall. Nutrient intake was determined using the NHANES cycle-specific total nutrient intake files. Nutrient modeling was performed by isocaloric substitution with milk of all nondairy beverages consumed during lunch and dinner meals combined. Sample-weighted analyses were performed using SAS 9.4.

Results

Between ages 6-8 and 14-18 y, daily intake of milk and flavored milk decreased by 10% and 62%, respectively, while daily intake of caloric beverages excluding milk increased by 96%. Daily intake from caloric beverages and milk combined decreased for fiber, protein, fat, saturated fat, calcium, magnesium, potassium, vitamin A, and vitamin D and increased for energy, carbohydrates, added sugars, and folate between ages 6-8 y and 14-18 y. Isocaloric substitution of all caloric nondairy beverages at meals with milk (using nutrient contribution of USDA milk, not further specified (NFS)) resulted in increases in protein, fat, saturated fat, calcium, magnesium, potassium, sodium, vitamin A, folate, vitamin B12, and vitamin D and decreases in carbohydrate, fiber, and added sugar.

Conclusion

These findings provide additional evidence to support dietary recommendations for milk, and efforts should be made on behalf of leading health professionals and childhood meal programs to highlight milk as a beverage of choice in children and adolescents.

Effect of Adding Pulses to Replace Protein Foods and Refined Grains in Healthy Dietary Patterns

Pulses are dry seeds of legumes which are high in fiber and contain plant protein and several important macronutrients. Our aim was to model the nutritional effects of substituting servings of protein foods and/or refined grains with servings of beans and peas in the Healthy U.S.-Style Pattern identified in the Dietary Guidelines for Americans, 2020-2025. Dietary modeling was accomplished by substituting nutrients of protein foods and/or refined grains with nutrients of the USDA's beans and peas (pulses) composite in the 2000 kcal Healthy U.S.-Style Pattern. A 10% or more change was used as an indicator of meaningful differences. Cost implications were computed by adding the cost of pulses and subtracting the cost of protein foods/refined grains according to the modeling scenario. The substitution of 6-8 oz/week protein foods with 1.5-2.0 cups/week pulses increased fiber and decreased cholesterol. Higher amounts of pulses replacing refined grains or combinations of protein foods and refined grains generally increase fiber, iron, magnesium, potassium, and copper depending on the modeling scenarios. All modeling scenarios of substituting the servings of protein foods alone or in combination with refined grains with the servings of pulses were associated with cost savings. Our results suggest that encouraging increased pulse consumption may be an effective strategy for improving diet.

Dairy food consumption is beneficially linked with iodine status in US children and adults: National Health and Nutrition Examination Surveys 2001-2018

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 of the US population.

DESIGN, SETTING AND PARTICIPANTS

24-hour dietary recall data and laboratory data for UIC (μg/l) from subjects 2+ years old US population participating in National Health and Nutrition Examination Surveys 2001-2018 were used (n 26 838) for analyses after adjusting for demographic covariates. Significant associations were assessed at P < 0·05.

RESULTS

Mean intakes of total dairy were 2·21, 2·17 and 1·70 cup equivalents (cup eq) among those 2-8, 9-18 and 19+ years, respectively. Of the dairy components, intake of milk was highest followed by cheese and yogurt for all age groups. Total dairy intakes were positively associated with UIC among those 2-8 years (β = 29·9 ± 9·9 μg/l urine/cup eq dairy) and 9-18 years (β = 26·0 ± 4·8 μg/l urine/cup eq dairy) but not associated among those 19+ years. Total dairy intakes were associated with lowered risks (30 %, 21 % and 20 % for among 2-8, 9-18 and 19+ years, respectively) of being classified as iodine insufficient (UIC < 100 μg/l) or lowered risk (47 %, 30 % and 26 % among 2-8, 9-18 and 19+ years, respectively) of being classified as iodine severely deficient (UIC < 20 μg/l).

CONCLUSIONS

The results indicate that dairy foods are beneficially associated with UIC and lowered iodine deficiency risk.

Association of Pork (All Pork, Fresh Pork and Processed Pork) Consumption with Nutrient Intakes and Adequacy in US Children (Age 2-18 Years) and Adults (Age 19+ Years): NHANES 2011-2018 Analysis

Pork is a rich source of high-quality protein and select nutrients. The objective of this work was to assess the intakes of all pork (AP), fresh pork (FP) and processed pork (PP) and their association with nutrient intake and meeting nutrient recommendations using 24 h dietary recall data. Usual intake was determined using the NCI method and the percentage of the population with intakes below the Estimated Average Requirement, or above the Adequate Intake for pork consumers and non-consumers, was estimated. About 52, 15 and 45% of children and 59, 20 and 49% of adults were consumers of AP, FP and PP, respectively, with mean intakes in consumers of 47, 60 and 38 g/day for children and 61, 77 and 48 g/day for adults, respectively. Among consumers of AP, FP and PP, the intakes of copper, potassium, selenium, sodium, zinc, thiamine, niacin, vitamin B₆ and choline were higher (p < 0.05) and a higher (p < 0.05) proportion met nutrient recommendations for copper, potassium, zinc, thiamin and choline compared to non-consumers. There were additional differences (p < 0.05) in intakes and adequacies for other nutrients between consumers and non-consumers depending upon the age group and pork type. In conclusion, pork intake was associated with higher intakes and adequacies in children and adults for certain key nutrients.

Nutritional Effects of Removing a Serving of Meat or Poultry from Healthy Dietary Patterns—A Dietary Modeling Study

Meat and poultry are nutrient-dense sources of protein and typically are recommended as part of an overall healthy diet. The objective was to assess the nutritional impact of removing a serving of meat/poultry in Healthy Dietary Patterns (HDPs) using a similar approach to that used by the USDA for Dietary Guidelines for Americans. Composites of minimally processed and further processed meat and poultry were developed and their nutrient profiles were used to accomplish modeling by removing nutrients of each meat and poultry composite from the HDPs. The removal of a 3 oz (85 g) serving of meat or poultry resulted in decreases (10% or more from baseline) in protein and several key micronutrients including iron, phosphorus, potassium, zinc, selenium, thiamine, riboflavin, niacin, vitamin B6, vitamin B12, and choline as well as cholesterol and sodium in the HDPs, and the decreases were consistent for most nutrients with the removal of either minimally processed (fresh) or further processed meat or poultry and even after adjusting for changes in calories. In conclusion, the results of this dietary modeling study show that the removal of a meat and poultry serving from HDPs resulted in decreases in protein and several key nutrients.

Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4-69.1) to 52.8 (32.1-69.2) years. The median (IQR) BMI increased from 24.9 (21.5-29.5) to 26.7 (22.3-31.7) kg.m^-2 . The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.

Identification of the Language Network from Resting-State fMRI in Patients with Brain Tumors: How Accurate Are Experts?

BACKGROUND AND PURPOSE

Resting-state fMRI helps identify neural networks in presurgical patients who may be limited in their ability to undergo task-fMRI. The purpose of this study was to determine the accuracy of identifying the language network from resting-state-fMRI independent component analysis (ICA) maps.

MATERIALS AND METHODS

Through retrospective analysis, patients who underwent both resting-state-fMRI and task-fMRI were compared by identifying the language network from the resting-state-fMRI data by 3 reviewers. Blinded to task-fMRI maps, these investigators independently reviewed resting-state-fMRI ICA maps to potentially identify the language network. Reviewers ranked up to 3 top choices for the candidate resting-state-fMRI language map. We evaluated associations between the probability of correct identification of the language network and some potential factors.

RESULTS

Patients included 29 men and 14 women with a mean age of 41 years. Reviewer 1 (with 17 years' experience) demonstrated the highest overall accuracy with 72%; reviewers 2 and 3 (with 2 and 7 years' experience, respectively) had a similar percentage of correct responses (50% and 55%). The highest accuracy used ICA50 and the top 3 choices (81%, 65%, and 60% for reviewers 1, 2, and 3, respectively). The lowest accuracy used ICA50, limiting each reviewer to the top choice (58%, 35%, and 42%).

CONCLUSIONS

We demonstrate variability in the accuracy of blinded identification of resting-state-fMRI language networks across reviewers with different years of experience.

Major haemorrhage: past, present and future

Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained > 2 g.l^-1 in postpartum haemorrhage and > 1.5 g.l^-1 in other haemorrhage. Improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care.

Methods of the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists: peri-operative cardiac arrest

Cardiac arrest in the peri-operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri-operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, and anaesthetists may not be involved in such cases for years. Therefore, a large-scale prospective cohort is needed to gain a deep understanding of events leading up to cardiac arrest, management of the arrest itself and patient outcomes. Consequently, the Royal College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents' prior peri-operative cardiac arrest experience, resuscitation training and local departmental preparedness. Second, an activity survey to record anonymised details of all anaesthetic activity in each site over 4 days, enabling national estimates of annual anaesthetic activity, complexity and complication rates. Third, a case registry of all instances of peri-operative cardiac arrest in the UK, reported confidentially and anonymously, over 1 year starting 16 June 2021, followed by expert review using a structured process to minimise bias. The definition of peri-operative cardiac arrest was the delivery of five or more chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist. The peri-operative period began with the World Health Organization 'sign-in' checklist or first hands-on contact with the patient and ended either 24 h after the patient handover (e.g. to the recovery room or intensive care unit) or at discharge if this occured earlier than 24 h. These components described the epidemiology of peri-operative cardiac arrest in the UK and provide a basis for developing guidelines and interventional studies.

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.

Association between Psychological Status and Functional Outcome in Surgically Managed Fractures around Hip in Geriatric Patients - A Prospective Study

Introduction:

Fractures around the hip in the geriatric population not only lead to functional but also psychological impairment. Psychiatric disturbances can be associated with poor participation in rehabilitation, increased risk of falling again, and higher rates of mortality. The present study was undertaken to assess the association between the psychological status and functional outcome of surgically managed elderly Indian patients who had sustained fractures around the hip.

Material and Methods:

The present study was a hospital based prospective, single centre study. One hundred and two geriatric patients who had sustained hip fracture and had been managed surgically, having no cognitive dysfunction, living independently, having unhindered walking capability before the fracture, were included in the study. They were called for follow-up at 3rd, 6th, and 12th month after the hip surgery. Psychological assessment was done by the Hospital Anxiety and Depression Scale (HADS) and functional outcome by using the Harris hip score (HHS).

Results:

Our study did not show association between psychological status and functional outcome except in one sub-group. Significant correlation was observed between the psychological status and functional outcome in most of the patients in the extra-capsular group. We have identified improvement in the depression, anxiety and functional scores during the follow-up.

Conclusion:

We conclude that psychiatric disturbances in a geriatric patient after undergoing a surgery for hip fracture may lead to poor recovery. We recommend that all such geriatric patients should undergo a psychological assessment and proper therapy should be instituted to achieve good functional recovery.