Changes in Adults' Eating Behaviors During the Initial Months of the COVID-19 Pandemic: A Narrative Review

Factors such as regulations and health concerns shifted daily habits, including eating behaviors, during the early months of the coronavirus disease 2019 (COVID-19) pandemic. This comprehensive narrative review synthesizes research on eating behavior changes during the early months of the pandemic (February to June 2020), including changes in amount, rate, and timing of food consumption, types and healthfulness of foods consumed, the occurrence of other specified eating behaviors (eg, restrained eating or binging), and reasons for eating (eg, stress or cravings), among adults. A literature search using three EBSCOhost databases and Google Scholar was conducted to identify relevant articles made available in 2020. A total of 71 articles representing 250,715 individuals from more than 30 countries were reviewed. Findings show eating behaviors changed little during the early COVID-19 pandemic for most participants. Among those whose eating behaviors changed, increases in both intake and frequency of eating meals and snacks were more common than decreases. Findings on timing of eating and healthfulness of food consumed showed mixed results. How-ever, when changes occurred in the type of food consumed, increases were more common for snacks, homemade pastries, white bread/pasta, legumes, and fruits/vege-tables;decreases were more common for meats, seafood/fish, frozen foods, fast food, dark breads/grains, and dark leafy green vegetables. During the pandemic, binging, uncontrolled eating, and overeating increased, meal skipping decreased, and restrictive eating had mixed findings. Changes in factors such as emotions and mood (eg, depression), cravings, and environmental factors (eg, food insecurity) were related to changes in eating behaviors. Findings can inform clinical practitioners in efforts to mitigate disruptions to normal, healthy eating patterns among adults both in and outside of global health catastrophes. J Acad Nutr Diet. 2023;123(1):144-194.

Gamification: Teaching a practice-based subject virtually for transformative impact

University teaching involves delivering resource intensive subjects that have practical components, such as a science laboratory, hospitality practical, computer laboratory, or simulated clinical setting. Teaching practical subjects in the non-traditional, virtual classroom requires careful decisions about the methods of teaching that kind of knowledge. The outbreak of the COVID-19 virus and the subsequent hurried closure of the traditional campus that disrupted in-person teaching, led many higher education lecturers and professors who teach practical subjects to reflect deeply on their practice by thinking how to replicate the teaching of virtual culinary classes when students are not on campus. In an outcome-based learning dispensation, students' learning outcomes precede consideration of the mode of delivery or the structure of teaching content. This chapter reflects on a case study involving the teaching of subjects in hospitality and culinary arts through gamification, both of which having learning outcomes grounded in practice. The chapter explores the seemingly impossible world of taking practical based subjects and making them work in an online space. It describes and offers a measure by which to justify a pedagogy for teaching the practical in a virtual context. The chapter offers important initial conceptualisations that challenge assumptions of virtual meaningful learning design for practical module delivery. © 2022 by David Graham, James Ellerby and Norman Dinsdale.

Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study.

OBJECTIVES: Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality. DESIGN: Prospective, observational cohort study. SETTING: Four tertiary hospitals in Edmonton, Alberta, Canada. PATIENTS: Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021). INTERVENTIONS: Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression. CONCLUSIONS: There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.

UTILISATION OF THE CYTOSPONGE DEVICE AS A TOOL FOR RISK STRATIFICATION IN PATIENTS WITH BARRETT'S OESOPHAGUS WHO ARE OVERDUE ENDOSCOPIC SURVEILLANCE DUE TO THE COVID-19 PANDEMIC

Introduction: At the onset of the COVID-19 pandemic, all patients undergoing endoscopic surveillance for Barrett's Oesophagus (BE) in the UK were indefinitely postponed. As well as the potential for missed progression to dysplasia, the negative impact on patients' quality of life is immeasurable. The Cytosponge® is a minimally invasive cell sampling device which has been researched in screening for BE. We describe the first worldwide use of the Cytosponge® outside of a clinical trial to support the triage of BE patients unable to undergo endoscopic surveillance due to COVID-19. Aims and Methods: Consecutive patients with non-dysplastic BE (NDBE) or those deemed to be low risk after previous treatment for BErelated dysplasia, DBE (more than 18 months after completion of therapy with no visible BE and no intestinal metaplasia/dysplasia at last endoscopy) with no prior history of stenosis who were overdue endoscopy (OGD) were invited to have the Cytosponge®. The sample was analysed for TFF3 (a marker of intestinal metaplasia), cellular atypia and p53. Fisher's test was used to examine the association between the overall cytosponge result and its individual components with follow-up OGD outcomes. Results: To date, 153 patients (mean age 66 years, 126 male) have undergone the Cytosponge® procedure. The median maximal length of BE was 3cm (1-15cm). Three patients were unable to swallow the device and 19 (12%) needed a repeat procedure as no columnar cells were present suggesting that the sponge had not entered the stomach. 87 patients (80%) with NDBE had a either a low-risk result (TFF3 positive only – 62) or required a repeat Cytosponge® routinely (TFF3/atypia/ p53 negative – 25). The remaining 21 patients (20%) needed an OGD within 3 months, 17 of which have since had an OGD. Of these 17 patients, 4 had a new diagnosis of dysplasia (indefinite - 2, low grade dysplasia – 1, intramucosal cancer - 1) and 2 a new diagnosis of cancer. 18/87 patients in the low-risk NDBE cohort have undergone follow-up OGD (NDBE 17/18, high grade dysplasia 1/18). Of the 23 patients in the post-treatment BE cohort, 1 patient had a high-risk result and subsequent OGD confirmed HGD (Table 1). A high-risk cytosponge result and the presence of both p53 and typia were all associated with a positive OGD result. Over-expression of p53 appeared to be the most sensitive marker (Table 2). In treatment naive patients, a low-risk cytosponge result was closely associated with no dysplasia detected at follow-up OGD with a negative predictive value of 94%. Conclusions: Cytosponge® has proved to be a useful non-endoscopic tool for patients with BE under surveillance where OGD is not possible. Preliminary data are promising to help triage patients and may in turn offer a less invasive approach to monitoring patients compared to endoscopy, particuarly for low risk patients. (Table Presented) (Table Presented)

Local Experience of Breakthrough SARS-CoV-2 Infections after Full Vaccination

Background. SARS-CoV-2 the etiology of COVID-19 has caused more than 33 million cases and almost 600,000 deaths in the United States alone. Vaccination is a vital tool in controlling the pandemic. With accelerated infection rates in various parts of the world, the incidence of variants has risen and threatens to set back the long sought after immunity, provided by available vaccines. The objective of this study was to evaluate the breakthrough infection rate after complete vaccination, in Sangamon County, with a rural and urban population of 195,000 in Central Illinois. Methods. Data regarding breakthrough infections collected from the Sangamon County Department of Public Health, included the total number of infections, time after vaccination, age range of those infected and the type of vaccine used. Complete vaccination was defined as 14 days after the single dose of Johnson & Johnson/Janssen or the second dose of Pfizer-BioNTech or Moderna Inc. vaccine. Results. (Table Presented) The number of fully vaccinated individuals at the time of writing of this study was 87,086 which corresponded to 44.58 % of the total population. The breakthrough infection percentage was calculated as 0.036%. The mean time after vaccination to infection was 49.13 days with a standard deviation of 23.28. Conclusion. Breakthrough infections among fully vaccinated individuals in our county, have been quite rare, which points to the high efficacy of the vaccines. A complex number of factors likely contribute to this including virus-related factors i.e. variant forms and specific patient-related factors which are not a part of this study. The afore-mentioned high efficacy rate of the vaccines provides further justification, to continue to pursue a persistent vaccination strategy to mitigate the effects of the SARS-CoV-2 virus.

Role of the SARS-CoV-2 virus in the appearance of new onset type 1 diabetes mellitus in children in Gran Canaria, Spain.

OBJECTIVES: It has been hypothesized that SARS-CoV-2 may play a role in the development of different forms of diabetes mellitus (DM). The Canary Islands have the highest incidence of type 1 DM (T1DM) reported in Spain (30-35/100,000 children under 14 years/year). In 2020-2021 we observed the highest incidence so far on the island of Gran Canaria, as a result of which we decided to evaluate the possible role of COVID-19 in the increased number of onsets. METHODS: We examined the presence of IgG antibodies against SARS-CoV-2 in children with new onset T1DM between October 2020 and August 2021. We compared recent T1DM incidence with that of the previous 10 years. RESULTS: Forty-two patients were diagnosed with T1DM (48.1/100,000 patients/year), representing a nonsignificant 25.7% increase from the expected incidence. Of the 33 patients who consented to the study, 32 presented negative IgG values, with only one patient reflecting undiagnosed past infection. Forty-four percent of patients presented with ketoacidosis at onset, which was similar to previous years. CONCLUSIONS: We conclude that there is no direct relationship between the increased incidence of T1DM and SARS-CoV-2 in the region. The COVID-19 pandemic did not result in an increased severity of T1DM presentation.

Myocardial Perfusion Imaging After Severe COVID-19 Infection Demonstrates Regional Ischemia Rather Than Global Blood Flow Reduction.

Background: Acute myocardial damage is common in severe COVID-19. Post-mortem studies have implicated microvascular thrombosis, with cardiovascular magnetic resonance (CMR) demonstrating a high prevalence of myocardial infarction and myocarditis-like scar. The microcirculatory sequelae are incompletely characterized. Perfusion CMR can quantify the stress myocardial blood flow (MBF) and identify its association with infarction and myocarditis. Objectives: To determine the impact of the severe hospitalized COVID-19 on global and regional myocardial perfusion in recovered patients. Methods: A case-control study of previously hospitalized, troponin-positive COVID-19 patients was undertaken. The results were compared with a propensity-matched, pre-COVID chest pain cohort (referred for clinical CMR; angiography subsequently demonstrating unobstructed coronary arteries) and 27 healthy volunteers (HV). The analysis used visual assessment for the regional perfusion defects and AI-based segmentation to derive the global and regional stress and rest MBF. Results: Ninety recovered post-COVID patients {median age 64 [interquartile range (IQR) 54-71] years, 83% male, 44% requiring the intensive care unit (ICU)} underwent adenosine-stress perfusion CMR at a median of 61 (IQR 29-146) days post-discharge. The mean left ventricular ejection fraction (LVEF) was 67 ± 10%; 10 (11%) with impaired LVEF. Fifty patients (56%) had late gadolinium enhancement (LGE); 15 (17%) had infarct-pattern, 31 (34%) had non-ischemic, and 4 (4.4%) had mixed pattern LGE. Thirty-two patients (36%) had adenosine-induced regional perfusion defects, 26 out of 32 with at least one segment without prior infarction. The global stress MBF in post-COVID patients was similar to the age-, sex- and co-morbidities of the matched controls (2.53 ± 0.77 vs. 2.52 ± 0.79 ml/g/min, p = 0.10), though lower than HV (3.00 ± 0.76 ml/g/min, p< 0.01). Conclusions: After severe hospitalized COVID-19 infection, patients who attended clinical ischemia testing had little evidence of significant microvascular disease at 2 months post-discharge. The high prevalence of regional inducible ischemia and/or infarction (nearly 40%) may suggest that occult coronary disease is an important putative mechanism for troponin elevation in this cohort. This should be considered hypothesis-generating for future studies which combine ischemia and anatomical assessment.

A symptom and risk factor questionnaire accurately predicts upper gastrointestinal cancer

Introduction Waiting times for endoscopy are rising rapidly following the COVID-19 pandemic. In addition, cancers may be missed as patients are placed on routine waiting lists but not monitored. Some hospitals use the Edinburgh Dysphagia Score to assess and prioritise patients for investigation. This offers a sensitivity of 98.4% and specificity of 9.3% to detect malignancy in patients presenting with dysphagia.4 However, it is not designed for detecting gastric cancer. We aimed to create a more accurate screening questionnaire as an aid to triaging referrals. Methods Patients were recruited as part of the Saliva to Predict rIsk of disease using Transcriptomics and epigenetics (SPIT) study. Patients were recruited from 2 week-wait suspected upper gastrointestinal cancer pathway referrals at 20 hospitals in the United Kingdom. The cohort was further enriched with patients found to have oesophageal adenocarcinoma on emergency hospital admission. They completed over 200 questions about a wide variety of symptoms and risk factors. After data cleaning, 800 patients were available for evaluation. Of these, 80 had upper GI cancer. A machine learning model was developed to identify those at highest risk of having upper GI cancer using a 'cost-based' approach which maximises the chance of detecting cancer. Information gain was followed by correlated feature selection and a multivariable logistic regression curve was created with scores from 0 (cancer very unlikely) to 100 (cancer very likely). The training dataset used 80% of the data and the model was tested with the other 20%. Results 20 features were found to be important and reproducible. They included age, sex, dysphagia, odynophagia, early satiety, weight loss, duration of chest pain and regurgitation, frequency of acid taste in the mouth, a previous history of smoking, cancer or psychological disorders, current anxiety level and frequency of vegetable intake. The area under the receiver operator curve to detect cancer was 0.83. 50% of cancers scored greater than 85 whereas 50% of normals scored less than 25. At a cut-off score of 10, sensitivity was 98.7% with specificity 26.8% to detect cancer (figure). Conclusions We have created a simple, reproducible risk score to identify patients at high and low risk of upper GI cancer. It performs better than previous scores but now needs testing in the real world. It might be usable to both upgrade routine patients to urgent endoscopy and remove patients at very low risk from waiting lists, thereby helping to prioritise patients with a greater clinical need and reducing the endoscopic backlog.

Aerosolised fluorescein can quantify FFP mask faceseal leakage: a cost-effective adaptation to the existing point of care fit test.

BACKGROUND: A qualitative fit test using bitter-tasting aerosols is the commonest way to determine filtering face-piece (FFP) mask leakage. This taste test is subjective and biased by placebo. We propose a cheap, quantitative modification of the taste test by measuring the amount of fluorescein stained filter paper behind the mask using image analysis. METHODS: A bitter-tasting fluorescein solution was aerosolised during mask fit tests, with filter paper placed on masks' inner surfaces. Participants reported whether they could taste bitterness to determine taste test 'pass' or 'fail' results. Filter paper photographs were digitally analysed to quantify total fluorescence (TF). RESULTS: Fifty-six healthcare professionals were fit tested; 32 (57%) 'passed' the taste test. TF between the taste test 'pass' and 'fail' groups was significantly different (p<0.001). A cut-off (TF = 5.0 × 106 units) was determined at precision (78%) and recall (84%), resulting in 5/56 participants (9%) reclassified from 'pass' to 'fail' by the fluorescein test. Seven out of 56 (12%) reclassified from 'fail' to 'pass'. CONCLUSION: Fluorescein is detectable and sensitive at identifying FFP mask leaks. These low-cost adaptations can enhance exiting fit testing to determine 'pass' and 'fail' groups, protecting those who 'passed' the taste test but have high fluorescein leak, and reassuring those who 'failed' the taste test despite having little fluorescein leak.

A symptom and risk factor questionnaire accurately predicts upper gastrointestinal cancer

Introduction: Waiting times for endoscopy are rising rapidly following the COVID-19 pandemic, leading to significant backlogs.1 Modelling has demonstrated that delays in presentation to health services and delays in completing diagnostic procedures will lead to excess mortality.2 In addition, many cancers are likely to be missed as patients are placed on routine waiting lists but are not regularly monitored. Some hospitals use the Edinburgh Dysphagia Score to risk assess and prioritise patients for investigation.3 This offers a sensitivity of 98.4% and specificity of 9.3% to detect malignancy in patients presenting with dysphagia.4 However, it is primarily not designed for detecting gastric cancer. We aimed to create a more accurate screening questionnaire to risk assess patients and prioritise those who need early endoscopy. Aims & Methods: Patients were recruited as part of the Saliva to Predict rIsk of disease using Transcriptomics and epigenetics (SPIT) study. Ethical approval was gained from the Coventry and Warwickshire Regional Ethics Committee (17/WM/0079). Patients were recruited from 2 week-wait pathway referrals at 20 hospitals in the United Kingdom, which is used by physicians to refer patients who have may suspected cancer for further investigation The cohort was further enriched with patients found to have oesophageal adenocarcinoma on emergency hospital admission. They completed over 200 questions about a wide variety of symptoms and risk factors. After data cleaning, 800 patients were available for evaluation. Of these, 80 had upper GI cancer. A machine learning model was developed to identify those at highest risk of having upper GI cancer using a 'cost-based' approach which maximises the chance of detecting cancer. Information gain was followed by correlated feature selection and a multivariable logistic regression curve was created with scores from 0 (cancer very unlikely) to 100 (cancer very likely). The training dataset used 80% of the data and the model was tested with the other 20%. Results: 20 features were found to be important and reproducible. They included age, sex, dysphagia, odynophagia, early satiety, weight loss, duration of chest pain and regurgitation, frequency of acid taste in the mouth, a previous history of smoking, cancer or psychological disorders, current anxiety level and frequency of vegetable intake. The area under the receiver operator curve to detect cancer was 0.83. 50% of cancers scored greater than 85 whereas 50% of normals scored less than 25. At a cut-off score of 10, sensitivity was 98.7% with specificity 26.8% to detect cancer. Conclusion: We have created a simple, reproducible risk score to identify patients at high and low risk of upper GI cancer. It performs better than previous scores but now needs testing in the real world. It might be usable to both upgrade routine patients to urgent endoscopy and remove patients at very low risk from waiting lists, thereby helping to prioritise patients with a greater clinical need and reducing the endoscopic backlog.

Medical care disruptions during the first six months of the COVID-19 pandemic: the experience of older breast cancer survivors.

PURPOSE: Older cancer survivors required medical care during the COVID-19 pandemic, but there are limited data on medical care in this age group. METHODS: We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors aged 60-98 from five US regions (n = 321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included interruptions in seeing or speaking to doctors, receiving medical treatment or supportive therapies, or filling prescriptions since the pandemic began. Logistic regression models evaluated associations between care disruptions and education, medical, psychosocial, and COVID-19-related factors. Multivariate models included age, county COVID-19 death rates, comorbidity, and post-diagnosis time. RESULTS: There was a high response rate (n = 262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4-73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were higher with each year of education (OR 1.22, 95% CI 1.08-1.37, p = < 0.001) and increased depression by CES-D score (OR 1.04, CI 1.003-1.08, p = 0.033) while increased tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97-0.99, p = 0.012). There was a trend between disruptions and comorbidities (unadjusted OR 1.13 per comorbidity, 95% CI 0.99-1.29, p = 0.07). Adjusting for covariates, higher education years (OR1.23, 95% CI 1.09-1.39, p = 0.001) and tangible social support (OR 0.98 95% CI 0.97-1.00, p = 0.006) remained significantly associated with having care disruptions. CONCLUSION: Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions. CLINICALTRIALS. GOV IDENTIFIER: NCT03451383.