INCREASED INTEREST IN WEIGHT LOSS AND BARIATRIC INTERVENTIONS DURING THE COVID-19 PANDEMIC: AN ANALYSIS OF INTERNET SEARCH QUERIES

Introduction: COVID-19 was declared a global pandemic in March 2020 and drastically changed daily life with ensuing stay-at-home orders. Studies have shown that adherence to healthy diet and exercise declined during this time. Internet search query data has been used to understand public interest in health-related behaviors such as smoking cessation. Therefore, the aim of this study was to examine whether internet searches for weight loss and bariatric interventions increased at the height of the pandemic. Methods: Google Ads Keyword Planner, a publicly available online tool, was used to obtain the search volumes for the keywords “weight loss,” “bariatric surgery,” “endoscopic weight loss procedure,” “gastric balloon,” and “endoscopic sleeve gastroplasty” per month from November 2017- October 2021. Search volumes were identified globally and by country (US, France, Spain, and Italy). Results: Globally, Google searches for “weight loss” peaked to 1,830,000 queries in April 2020, a 122% increase from April 2019 (Fig. 1a). By country, “weight loss” searches increased in April 2020 by 83% (1.8-fold) in the US, 311% (4-fold) in France, 679% (7.8- fold) in Spain, and 236% (3.4-fold) in Italy compared to the year prior (Fig. 1b,1c). Globally, average searches per month for “weight loss” from Mar 2020-Sep 2021 compared to prepandemic searches increased by 58% (Fig 1a). In the US, average monthly searches from Jul 2020-Sep 2021 increased by 43% for “bariatric surgery,” 16% for “gastric balloon,” 116% for “endoscopic sleeve gastroplasty,” and 309% for “endoscopic weight loss procedure” compared to Nov 2017-Jun 2020 averages (Fig. 2). Discussion: The COVID-19 pandemic heightened public interest in weight loss and endoscopic interventions. Several studies have shown that even one month into national lockdowns, people were reporting decreased physical activity, increased snack and alcohol consumption, and weight gain. This may have led to a rise in weight loss Google searches to combat these. Concurrently, research linking obesity with severe COVID-19 was publicized which may have contributed to an interest in weight loss. Elective procedures resumed in most hospitals in the US in summer 2020, possibly explaining the relative peaks in searches for bariatric procedures in July. Notably, interest in both weight loss and bariatric procedures not only increased during the height but have also remained elevated in 2021 as the planet slowly returns to a new normal. Furthermore, while total search volume is higher for ""bariatric surgery,"" there is clearly a rapidly rising interest in endoscopic procedures especially after July 2020. These data present an opportunity for gastroenterologists to provide continued patient education on optimal weight loss strategies varying from lifestyle modification, pharmacologic therapy, endobariatric therapy, and bariatric surgery. (Figure Presented) Figure 1. Google search volumes by month for the search query “weight loss” globally (1a), in the United States (1b), and in Europe (1c) from November 2017-September 2021 (Figure Presented) Figure 2. Google search volume by month for the search queries “bariatric surgery,” “endoscopic weight loss procedure,” “gastric balloon,” and “endscopic sleeve gastroplasty” in the United States from November 2017-September 2021

CONVERSION RATE FOR COVID19 IN NEW YORK CITY: IMPACT OF SOCIAL DISTANCING AND UNIVERSAL MASKING

We reported the results of our multicenter cohort study in all patients who presented for endoscopy between March 1 and May 17 and were evaluated before their endoscopy for SARS-CoV2 and were followed after their endoscopy for COVID-19 status. This cohort enabled us to calculate the conversion rate from COVID-19 negative to positive during the study period and evaluate the change in conversion rate with the implementation of social distancing and masking at the population level in New York City. Data were retrieved from electronic medical records systems of six tertiary care centers in New York City. We identified all adult patients who had endoscopy between March 1, and May 17, 2020. Conversion was defined as having a negative COVID-19 status before endoscopy and a positive status afterwards. Participants COVID-19 status was defined based on SARS-CoV2 PCR test or a combination of symptoms (Fever plus at least one of: dyspnea, cough, dysgeusia, or anosmia). Patients were evaluated before endoscopy and then by phone or telehealth visit afterwards. Spline regression was used to evaluate the conversion rate before and after adoption of social distancing (March 20, 2020) and mandatory masks (April 15, 2020) in New York City. Of the 1467 patients presenting for endoscopy during the study period, we had follow-up data on 1222 patients (51% outpatient and 49% inpatient endoscopies). Overall, 78 participants (6.38 %) converted after endoscopy (74 with a positive PCR, and 4 with symptoms as defined above), at a median of 23 days after endoscopy (IQR 11 to 42 days). Patients had a mean age of 62±15 years, and were 62% male (n=48). Multivariable analysis demonstrated that date of endoscopy, institution, and presence of cardiovascular disease were the independent predictors of conversion after endoscopy, with cardiovascular disease associated with a more than 2 fold increase in the risk of conversion (OR=2.1, 95%CI 1.2-3.6, p=0.009). The range of conversion from the six institutions varied widely (1 to 11%, p=0.035). Overall, participants whose endoscopies were performed later during the study period had a lower risk of conversion (OR for one week=0.87, 95%CI 0.80-0.94, p=0.001). Before social distancing, conversion rate was 8.4% on average and was increasing by 2.3% per week (p<0.001). After social distancing, the conversion rate was 6.7% on average, and started to decrease by 4.2% per week (p<0.001). After mandatory masks, the conversion rate was 2.2% on average but has started to increase slowly by 0.9% per week (p<0.001;see figure 1). These findings do support decrease in conversion rate amongst New Yorkers who presented for endoscopy with the implementation of social distancing and mandatory masking. We believe the slow but significant increase in conversion rates by the end of May reflects the relative loosening in social distancing in New York City.(Figure Presented)

RISK OF COVID-19 INFECTION TO BOTH PATIENTS AND ENDOSCOPY UNIT STAFF FOLLOWING ENDOSCOPY: A SINGLE-CENTER PROSPECTIVE COHORT STUDY

Introduction The risk of 2019 novel coronavirus (COVID-19) infection among patients and health care workers (HCWs) following endoscopy remains unclear. Methods We prospectively evaluated the incidence of COVID-19 infection among patients undergoing outpatient endoscopy and endoscopy unit staff between March and October 2020 at one tertiary care center in New York City. The primary outcome was COVID-19 infection within two weeks post-procedure. The clinical history, demographics, laboratory data, treatment, procedural data, and outcome measures were obtained from patients’ medical records. All patients had undergone nasopharyngeal nucleic-acid amplification testing swabs for COVID-19 prior to their procedures. Patients were then contacted 2 weeks after the procedure, via phone by research teams and nurses, with a specific list of questions (adapted from Repici et al.) to assess who had either tested positive for COVID-19 or developed symptoms ofCOVID-19 within 2 weeks after endoscopic procedures.1 Patients who screened positive for symptoms were directed for testing. Results A total of 850 endoscopic procedures were performed at our center between March and October of 2020. 131 were inpatients and were excluded from the analysis. Among the 719 outpatients, 231 were ERCPs, 111 were EUS, 207 were colonoscopies, and 170 were upper endoscopies. Post-procedure follow-up was obtained in 73% (n=524) of the patients. Of 719, 2 patients (0.38%) tested positive for COVID-19 within 2 weeks following endoscopy. Both patients had interval chemotherapy and were admitted to the hospital, so it is unclear when or where they converted. No advanced endoscopy attending or their associated nurses or technologists were subsequently infected with COVID-19 during the study period.Discussion Endoscopy procedures with appropriate PPE and preoperative testing appears to be associated with a low risk of periprocedural COVID-19 infection for outpatients and endoscopy unit staff. Diligence should continue with appropriate universal precaution and preoperative patient testing during this pandemic. References 1. Repici A, Aragona G, Cengia G, et al. Low risk of COVID-19 transmission in GI endoscopy. Gut. 2020;69(11):1925-1927. doi:10.1136/gutjnl-2020-321341

THE IMPACT OF THE COVID-19 PANDEMIC ON LIVER BIOMARKERS AND QUALITY OF LIFE IN PATIENTS WITH NAFLD

Background: The coronavirus disease 2019 (COVID-19) pandemic has been detrimental to those with chronic diseases, even those without infection. Management of non-alcoholic fatty liver disease (NAFLD) centers on weight management and optimization of metabolic risk factors, requiring a multi-disciplinary approach. Periods of quarantine and inactivity therefore pose limitations on lifestyle modifications and potentially impact both liver-related and health-related quality of life (HRQOL) outcomes. This study aims to identify the effects of the COVID-19 pandemic and alterations in healthcare access on patients with NAFLD. Methods: This study utilized a prospectively enrolled cohort of patients with NAFLD seen at the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), a multidisciplinary clinic which targets treatment of obesity and related diseases in New York. Patients included had a comprehensive initial evaluation during the pre-pandemic period within six months of the first COVID-19 case at our institution (October 1, 2019 to March 3, 2020) and had follow-up with repeat laboratory data. Studied outcomes included changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), metabolic markers (hemoglobin A1c and lipids), weight and body composition. 16 patients had follow-up HRQOL data measured by the Chronic Liver Disease Questionnaire (CLDQ) and Short-Form 26 (SF-36) Health Survey. Secondary analysis compared those with at least three provider visits to those with fewer to evaluate for impact of medical care during this period. Analysis was performed using the Wilcoxon signed-rank test and the Mann-Whitney U test. This study was approved by the Institutional Review Board of Weill Cornell Medicine. Results: Of the 29 patients included patients, the mean age was 52 years and pre-pandemic body mass index 33.54 kg/m2 (Table 1). Overall, there was no significant change in weight during this period (p= 0.07), though skeletal muscle and truncal fat mass both decreased (p=0.02). Hemoglobin A1c and AST decreased upon follow-up (p=0.002 and p=0.04, respectively), though there was no significant change in ALT or lipids. There was an increase in both CLDQ and SF-36 total and composite activity and emotional scores though not to a significant degree, and was irrespective of the number of provider visits (Table 2). Conclusion: This cohort of motivated patients with NAFLD following within a resource abundant multidisciplinary clinic showed mild improvement in select biomarkers and body composition, though there was no significant improvement in the remainder of objective measures to the degree expected, which may have been limited by the COVID-19 pandemic. Though not significant in this cohort, the overall trend in improvement in HRQOL highlights the importance of ongoing targeted care within this at-risk group. (Table presented.)

THE OBSERVED RISK OF RECURRENT BLEEDING AND THROMBOEMBOLIC DISEASE IN COVID-19 PATIENTS WITH GASTROINTESTINAL BLEEDING

Background: COVID-19 patients are at increased risk of venous thromboembolism (VTE) requiring the use of anticoagulation. Gastrointestinal bleeding (GIB) is increasingly being reported, complicating the decision to initiate or resume anticoagulation as providers balance the risk of thrombotic disease with the risk of bleeding. Aim: Our primary aim is to assess rebleeding rates in COVID-19 patients with GIB and determine whether endoscopic evaluation and anticoagulation use affects these rates. Our secondary aim is to determine the 30-day VTE and mortality rates in this cohort. Methods: This is a retrospective study that reviewed 56 cases of COVID-19 patients with GIB admitted to the hospital between March 4th – May 25th. All patients tested positive for COVID 19 with reverse transcriptase polymerase chain reaction nasopharyngeal swabs. The cases were reviewed for the following outcomes: rates of therapeutic intervention, 30-day rebleeding, 30-day VTE events and 30-day mortality. Results: 23/56 (41%) of COVID-19 patients with GIB rebled within 30 days. There was no reduction in rebleeding rate with endoscopic therapy compared to medical management alone (39% vs. 42%, p=0.81). There was no difference in 30 day rebleeding rate among patients restarted on anticoagulation after endoscopy compared to those that were restarted on anticoagulation after medical management alone (41% vs 29%, p = 0.47). 15/56 (27%) of the cohort had VTE during their hospitalization, 53% of which were diagnosed after anticoagulation was held due to GIB. Patients that undergone endoscopy were more likely to be initiated or resumed on anticoagulation after bleed then those that did not (87% vs 55%, p=0.02). The all-cause 30-day mortality and GI-bleeding related deaths were 32% and 9% respectively. There was no difference in 30 day mortality rate among patients that were restarted on anticoagulation after endoscopic management compared to those restarted on anticoagulation after conservative management alone (24% vs 29%, p=0.70). Conclusions: In this cohort, while there was no difference in rebleeding rate when comparing endoscopic therapy to conservative management, patients who underwent endoscopy were more likely to be restarted on anticoagulation. Given that there was no difference in rebleeding or mortality rates among those restarted on anticoagulation after endoscopy compared to patients that were restarted on anticoagulation after conservative management, it seems reasonable to re-challenge COVID-19 patients who have stopped bleeding with anticoagulation even if endoscopy cannot be performed. However, larger studies are needed to guide management of these complex patients.(Table Presented) (Table Presented)