Facial ageing . . . and other stories

When high quality photographs of the faces of 2700 middle aged and older participants in a longitudinal study were assessed by a panel without knowledge of their chronological age and medical history, people whose perceived age was lower than their chronological age were less likely to have osteoporosis, chronic obstructive pulmonary disease, hearing loss, or cataracts. Energy expenditure and incident type 2 diabetes Data from 90 000 participants in the UK Biobank study who wore an accelerometer for seven days reveal a linear relation between the amount of energy expended during physical activity and the subsequent incidence of type 2 diabetes—even after adjusting for body mass index. A study using data for 1.5 million prescriptions of PPIs in UK general practice found an increased risk of diagnosis of an inflammatory bowel disease in the first two years after treatment started.

Indirect Calorimetry Critical in Identifying Early Hypometabolism and Late-Stage Hypermetabolism in Post-surgical Patients

Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).

Norwegian students' experiences of homeschooling during the COVID-19 pandemic

Norwegian teachers and school leaders had to organise and provide homeschooling for their students from March to May 2020 due to the COVID-19 pandemic. A survey conducted in May 2020 examined lower secondary school students' experiences of distance learning. How students at different levels of academic achievement (based on grades) experienced homeschooling was compared to comparable findings from a survey conducted on students from the same schools during the autumn of 2018. The findings indicate that students experienced less support and feedback from their teachers during homeschooling, and that teachers gave more written than oral feedback to the students during homeschooling than they do in regular school. Furthermore, there was a tendency of lower efforts and self-efficacy among low-achieving students, which might be difficult to reverse when schools reopen. The findings raise growing concerns about homeschooling leading to a larger gap between high- and low-achieving students in lower secondary school. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Beneficial Flavonoid in Foods and Anti-obesity Effect

Obesity is a global health problem. In the past decades, the prevalence rate of obesity has risen sharply in epidemiology. Obesity has become an increasingly severe epidemic burden linked with different kinds of diseases, consisting of cardiovascular disease, diabetes, metabolic associated fatty liver disease, and even in COVID-19. Beneficial flavonoids in foods, as functional ingredients, combat obesity and maintain energy balance through multiple mechanisms. This review provides a brief overview of biological targets, possible mechanisms and the current therapeutic interventions including suppressing appetite, increasing energy consumption, regulating gut microbiota, inhibiting adipogenesis, anti-inflammation. In vitro and in vivo experiments as well as available clinical evidence related to the anti-obesity effects of pure flavonoid and flavonoid-rich extracts are also summarized and depicted. Furthermore, the metabolism and bioavailability of flavonoids are also concluded and discussed. Beneficial flavonoids have become promising candidates for treating and avoiding obesity, but poor bioavailability and short elimination half-life affects the absorption and efficacy. This paper reviews the different types of flavonoids and their potential effect of preventing obesity, which provide the basis for further research.

Management of obesity.

From 1975-2016, the number of people with obesity in Europe increased fivefold and the overall trend is still increasing. Obesity is the result of an imbalance between energy expenditure and caloric intake. Although the importance of genetic determinants for the variance of body mass index (BMI) is about 60-70%, overeating, lack of exercise, and psychosocial stress are influenceable risk factors. For example, during the Corona pandemic, nearly 40% of Germans gained an average of 5.6kg, and people with obesity gained as much as 7.2kg. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. A significant reduction of cardiovascular endpoints can be achieved with a weight reduction of more than 10% of the initial weight. Therapeutic measures in the context of an escalating stepwise approach should include strategies for targeted weight reduction and long-term weight maintenance.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Management of obesity.

From 1975-2016, the number of people with obesity in Europe increased fivefold and the overall trend is still increasing. Obesity is the result of an imbalance between energy expenditure and caloric intake. Although the importance of genetic determinants for the variance of body mass index (BMI) is about 60-70%, overeating, lack of exercise, and psychosocial stress are influenceable risk factors. For example, during the Corona pandemic, nearly 40% of Germans gained an average of 5.6kg, and people with obesity gained as much as 7.2kg. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. A significant reduction of cardiovascular endpoints can be achieved with a weight reduction of more than 10% of the initial weight. Therapeutic measures in the context of an escalating stepwise approach should include strategies for targeted weight reduction and long-term weight maintenance.Copyright © 2022, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

How do guideline recommended energy targets compare with measured energy expenditure in critically ill adults with obesity: A systematic literature review.

BACKGROUND: Critically ill patients with obesity have unique and complex nutritional needs, with clinical practice guidelines conflicting regarding recommended energy targets. The aim of this systematic review was to 1) describe measured resting energy expenditure (mREE) reported in the literature and; 2) compare mREE to predicted energy targets using the European (ESPEN) and American (ASPEN) guideline recommendations when indirect calorimetry is not available in critically ill patients with obesity. METHODS: The protocol was registered apriori and literature was searched until 17th March, 2022. Original studies were included if they reported mREE using indirect calorimetry in critically ill patients with obesity (BMI≥30 kg/m2). Group-level mREE data was reported as per the primary publication using mean ± standard deviation or median [interquartile range]. Where individual patient data was available, Bland-Altman analysis was used to assess mean bias (95% limits of agreement) between guideline recommendations and mREE targets (i.e. ASPEN for BMI 30-50, 11-14 kcal/kg actual weight compared to 70% mREE and ESPEN 20-25 kcal/kg adjusted weight compared to 100% mREE). Accuracy was assessed by the percentage (%) of estimates within ±10% of mREE targets. RESULTS: After searching 8019 articles, 24 studies were included. mREE ranged from 1607 ± 385 to 2919 [2318-3362]kcal and 12-32kcal/actual body weight. For the ASPEN recommendations of 11-14 kcal/kg, a mean bias of -18% (-50% to +13%) and 4% (-36% to +44%) was observed, respectively (n = 104). For the ESPEN recommendations 20-25 kcal/kg, a bias of -22% (-51% to +7%) and -4% (-43% to +34%), was observed, respectively (n = 114). The guideline recommendations were able to accurately predict mREE targets on 30%-39% occasions (11-14 kcal/kg actual) and 15%-45% occasions (20-25 kcal/kg adjusted), for ASPEN and ESPEN recommendations, respectively. CONCLUSIONS: Measured energy expenditure in critically ill patients with obesity is variable. Energy targets generated using predictive equations recommended in both the ASPEN and ESPEN clinical guidelines have poor agreement with mREE and are frequently not able to accurately predict within ±10% of mREE, most commonly underestimating energy needs.

Validation of Oura ring energy expenditure and steps in laboratory and free-living.

BACKGROUND: Commercial activity trackers are increasingly used in research and compared with research-based accelerometers are often less intrusive, cheaper, with improved storage and battery capacity, although typically less validated. The present study aimed to determine the validity of Oura Ring step-count and energy expenditure (EE) in both laboratory and free-living. METHODS: Oura Ring EE was compared against indirect calorimetry in the laboratory, followed by a 14-day free-living study with 32 participants wearing an Oura Ring and reference monitors (three accelerometers positioned at hip, thigh, and wrist, and pedometer) to evaluate Oura EE variables and step count. RESULTS: Strong correlations were shown for Oura versus indirect calorimetry in the laboratory (r = 0.93), and versus reference monitors for all variables in free-living (r ≥ 0.76). Significant (p < 0.05) mean differences for Oura versus reference methods were found for laboratory measured sitting (- 0.12 ± 0.28 MET), standing (- 0.27 ± 0.33 MET), fast walk (- 0.82 ± 1.92 MET) and very fast run (- 3.49 ± 3.94 MET), and for free-living step-count (2124 ± 4256 steps) and EE variables (MET: - 0.34-0.26; TEE: 362-494 kcal; AEE: - 487-259 kcal). In the laboratory, Oura tended to underestimate EE with increasing discrepancy as intensity increased. The combined activities and slow running in the laboratory, and all MET placements, TEE hip and wrist, and step count in free-living had acceptable measurement errors (< 10% MAPE), whereas the remaining free-living variables showed close to (≤13.2%) acceptable limits. CONCLUSION: This is the first study investigating the validity of Oura Ring EE against gold standard methods. Oura successfully identified major changes between activities and/or intensities but was less responsive to detailed deviations within activities. In free-living, Oura step-count and EE variables tightly correlated with reference monitors, though with systemic over- or underestimations indicating somewhat low intra-individual validity of the ring versus the reference monitors. However, the correlations between the devices were high, suggesting that the Oura can detect differences at group-level for active and total energy expenditure, as well as step count.

Environmental sustainability in healthcare: Time to make outpatient care in orthopaedics and rheumatology greener.

INTRODUCTION: Chronic musculoskeletal conditions affect billions of individuals and constitute the greatest contributor to disability worldwide. Climate change has a negative impact on these conditions, causing a rising number of patients seeking medical attention in outpatient orthopaedic and rheumatology clinics. Due to the COVID-19 pandemic, the delivery of care by these facilities tends to become more energy-intensive due to the increased usage of protective equipment and testing for the purpose of maintaining hygienic conditions. Therefore, practitioners and health bodies in the field need to take action to make their practice more environmentally sustainable and protect both the environment and their patients. METHODS: The authors searched peer reviewed and grey literature for relevant sources. RESULTS: The present review of the literature provides an overview of the environmental pollution associated with outpatient musculoskeletal care and discusses evidence-based recommendations from previous studies. CONCLUSION: Telemedicine, rationalised use of consumables and equipment, physician-led climate advocacy and patient education have a major potential to turn the tide.

Comparison of the Prognostic Value of Pulmonary Dead Space Proxies in Covid-19 Ards Outcomes

INTRODUCTION: Mortality and morbidity associated with COVID-19 acute respiratory distress syndrome (ARDS) has been associated with pulmonary vasculopathy, which has been hypothesized to increase pulmonary dead space (VD/ VT). However, VD/VT is rarely measured at the bedside. As a result, multiple proxy estimates have been developed. Our hypothesis was proxy estimates for VD/VT would have differing utilities in prognostication of COVID-19 ARDS. METHOD(S): We conducted a retrospective cohort study of patients admitted to an intensive care unit with SARSCoV- 2 ARDS who required invasive mechanical ventilation. Ventilation parameters were collected 2-8 hours after intubation. The VD/Vt proxies examined were 1) ventilatory ratio (VR), 2) estimation of VD/VT using the Harris-Benedict equation for energy expenditure (VD/VT-HB), 3) direct estimation of VD/VT using Beitler et. al.'s formula (VD/VTDir), and 4) corrected minute ventilation (VECorr). For each proxy, subjects were dichotomized using the median value. Comparisons were performed using the Wilcoxon rank-sum test with alpha=0.05. RESULT(S): For 139 subjects, mean VR was 2.08 (SD+/-0.80), mean VD/VT-HB was 0.614 (+/-0.15), mean VD/VT-Dir was 0.657 (+/-0.08), and mean VECorr was 12.2 (+/-4.6) L/min. All four proxies had strong inter-measure correlation (Pearson's r 0.748-0.881, p< 0.001 for all comparisons). No proxy was predictive of 30-day hospital mortality. High VR and VECorr were associated with increased morbidity using a composite endpoint of death or organ failure (defined as requiring renal dialysis or extracorporeal membrane oxygenation) with both having an odds ratio of 2.20 (95% CI: 1.12-4.33, p=0.022), while VD/VT-HB (p=0.552) and VD/VT-Dir (p=0.554) were not significantly associated. Of all proxies, only VR was significantly associated with increased sequential organ failure assessment (SOFA) score at 10+/-4 days post-intubation (6.2 vs. 4.8, p=0.024) and more ventilatorfree days within the 30 days after intubation (3.2 vs. 1.8, p=0.029). CONCLUSION(S): Ventilatory ratio and corrected minute volume appear to have stronger associations with morbidity in COVID-19 ARDS compared to other VD/VT estimates. Ventilatory ratio is also associated with ventilator-free days and delayed SOFA score.

Mitochondria-Lipid-droplet interaction: Where Mitochondrial Dynamics Meet Bioenergetics

Mitochondria surrounding lipid droplets (Peri-Droplet Mitochondria;PDM) maintain a unique proteome which is not equilibrated with the rest of the mitochondrial population. We find that PDM remain stationary and elongated on lipid droplets, fuel lipid droplet expansion, and do not fuse with cytosolic mitochondria. Compared to cytosolic mitochondria, PDM have higher capacity to metabolize pyruvate but reduced capacity to oxidize fatty acids. We reveal for the first time the mechanism by which the elongated mitochondrial shape of PDM differentiate their fuel preference from that of cytosolic mitochondria. We find that mitochondrial elongation reduces fatty acid utilization by inhibiting CPT1 activity. On the other hand, we find that mitochondrial fragmentation, such as observed in NASH, increases mitochondrial lipid utilization and may act as a compensatory mechanism to reduce lipotoxicity. Indeed, inhibition of fission in a model of NASH exacerbated NASH phenotype. We developed a cell-based imaging for the quantification of mitochondria-lipid droplet association and identified a set of small molecules that detach mitochondria from lipid droplets (PDM-Detachers). New unpublished data demonstrate PDM detachers induce lipolysis and lipid droplet shrinkage. Using these tools we assessed the role of lipid droplets in SARS-CoV2 expansion. We find that proliferation of various coronaviruses can be strongly inhibited by PDM-detachers and enhanced by attaching mitochondria to lipid droplets. We demonstrate that PDM can be found in humans. We studied adipose tissue from pheochromocytoma patients, a model of white adipose browning characterized by enhanced capacity for energy expenditure. Remarkably, bioenergetic changes associated with browning were primarily localized to PDM. Similar changes were found in a mouse model of re-browning, where PDM increased in whitened brown adipose tissue upon reducing housing temperature. Copyright © 2022

Consumer-Based Activity Trackers as a Tool for Physical Activity Monitoring in Epidemiological Studies During the COVID-19 Pandemic: Development and Usability Study.

BACKGROUND: Consumer-based physical activity trackers have increased in popularity. The widespread use of these devices and the long-term nature of the recorded data provides a valuable source of physical activity data for epidemiological research. The challenges include the large heterogeneity between activity tracker models in terms of available data types, the accuracy of recorded data, and how this data can be shared between different providers and third-party systems. OBJECTIVE: The aim of this study is to develop a system to record data on physical activity from different providers of consumer-based activity trackers and to examine its usability as a tool for physical activity monitoring in epidemiological research. The longitudinal nature of the data and the concurrent pandemic outbreak allowed us to show how the system can be used for surveillance of physical activity levels before, during, and after a COVID-19 lockdown. METHODS: We developed a system (mSpider) for automatic recording of data on physical activity from participants wearing activity trackers from Apple, Fitbit, Garmin, Oura, Polar, Samsung, and Withings, as well as trackers storing data in Google Fit and Apple Health. To test the system throughout development, we recruited 35 volunteers to wear a provided activity tracker from early 2019 and onward. In addition, we recruited 113 participants with privately owned activity trackers worn before, during, and after the COVID-19 lockdown in Norway. We examined monthly changes in the number of steps, minutes of moderate-to-vigorous physical activity, and activity energy expenditure between 2019 and 2020 using bar plots and two-sided paired sample t tests and Wilcoxon signed-rank tests. RESULTS: Compared to March 2019, there was a significant reduction in mean step count and mean activity energy expenditure during the March 2020 lockdown period. The reduction in steps and activity energy expenditure was temporary, and the following monthly comparisons showed no significant change between 2019 and 2020. A small significant increase in moderate-to-vigorous physical activity was observed for several monthly comparisons after the lockdown period and when comparing March-December 2019 with March-December 2020. CONCLUSIONS: mSpider is a working prototype currently able to record physical activity data from providers of consumer-based activity trackers. The system was successfully used to examine changes in physical activity levels during the COVID-19 period.

Nutritional adequacy and accuracy in long-stay critically ill patients as measured by indirect calorimetry

Introduction: Nutritional optimisation is recognised as having significant impact on clinical and functional outcomes of critically ill patients.1 Clinical recommendations suggest use of indirect calorimetry guided nutrition in the intensive care unit (ICU),2 and a recent systematic review demonstrated improved outcomes from its use.3 The COVID-19 pandemic has seen a greater proportion of patients with prolonged critical illness, a cohort for whom nutritional optimisation is a key unmet need.4 Objectives: To assess rates of over and underfeeding in a tertiary centre ICU and how these relate to markers of catabolism and persistent critical illness. Methods: Serial measurements of REE (resting energy expenditure) and RQ (respiratory quotient) by indirect calorimetry were performed using Q-NRG+ device (COSMED, Rome, Italy). Nutritional intake and estimations of requirements were recorded concurrently together with routine clinical observations, and markers of critical illness, catabolism and over or underfeeding. Results: Across 30 patients, REE was lower than estimated energy requirements, 24.2 (IQR 20.0-28.1) kcal/ day/kg IBW vs. 29.1(IQR 25.4-33.1) kcal/day/kg IBW, p<0.001. 41.8% of measurements showed overfeeding (actual calorie intake >110% of REE), and 23.3% showed underfeeding (actual calorie intake <85% of REE). Obese patients (n=15) were underfed (-98kcal/day deficit) compared to non-obese patients (n=15), who were on average overfed (+256kcal/day surplus), p=0.021. Overfeeding was also associated with greater length of ICU admission (R2 0.159, p<0.005). Median day of ICU admission in overfed patients was 39 days (IQR 24-56), and in underfed patients 21.5 (IQR 7.5-45.25). However, there was no significant association between calorie surplus or deficit, and other markers of overfeeding PaCO2, insulin use, ureacreatinine-ratio. Conclusion: This service evaluation recorded measurements of REE and RQ in critically ill patients with high lengths of ICU stay (up to 66 days). We observed increased rates of overfeeding with increased duration of ICU admission, and increased overfeeding in non-obese patients.

The Apple Watch for Monitoring Mental Health-Related Physiological Symptoms: Literature Review.

BACKGROUND: An anticipated surge in mental health service demand related to COVID-19 has motivated the use of novel methods of care to meet demand, given workforce limitations. Digital health technologies in the form of self-tracking technology have been identified as a potential avenue, provided sufficient evidence exists to support their effectiveness in mental health contexts. OBJECTIVE: This literature review aims to identify current and potential physiological or physiologically related monitoring capabilities of the Apple Watch relevant to mental health monitoring and examine the accuracy and validation status of these measures and their implications for mental health treatment. METHODS: A literature review was conducted from June 2021 to July 2021 of both published and gray literature pertaining to the Apple Watch, mental health, and physiology. The literature review identified studies validating the sensor capabilities of the Apple Watch. RESULTS: A total of 5583 paper titles were identified, with 115 (2.06%) reviewed in full. Of these 115 papers, 19 (16.5%) were related to Apple Watch validation or comparison studies. Most studies showed that the Apple Watch could measure heart rate acceptably with increased errors in case of movement. Accurate energy expenditure measurements are difficult for most wearables, with the Apple Watch generally providing the best results compared with peers, despite overestimation. Heart rate variability measurements were found to have gaps in data but were able to detect mild mental stress. Activity monitoring with step counting showed good agreement, although wheelchair use was found to be prone to overestimation and poor performance on overground tasks. Atrial fibrillation detection showed mixed results, in part because of a high inconclusive result rate, but may be useful for ongoing monitoring. No studies recorded validation of the Sleep app feature; however, accelerometer-based sleep monitoring showed high accuracy and sensitivity in detecting sleep. CONCLUSIONS: The results are encouraging regarding the application of the Apple Watch in mental health, particularly as heart rate variability is a key indicator of changes in both physical and emotional states. Particular benefits may be derived through avoidance of recall bias and collection of supporting ecological context data. However, a lack of methodologically robust and replicated evidence of user benefit, a supportive health economic analysis, and concerns about personal health information remain key factors that must be addressed to enable broader uptake.

Are We Feeding Our Critically Ill Covid Patients, Right?

Objective: Primary objective: To study the energy expenditure in a significant number of mechanically ventilated COVID-19 patients in ARDS. Secondary objective: 1. To compare the deviations seen with predictive equations based on actual and ideal body weight. 2. To compare the EE derived versus the VCO2 based estimation. Materials and methods: The Resting Energy expenditure (REE) of 60 patients was measured with the help of the ESCOVYX-module for indirect calorimetry using the GE CARESCAPE R860 ventilator. The steady-state was validated by ensuring a respiratory quotient of 0.7-0.8 and variation of 5% for VCO2 and VO2 for at least 30 minutes. It was ensured that for 60 minutes the patient was not disturbed by endotracheal tube suction, no ventilatory changes were performed, and no vasopressors alteration was done. The absence of a leak was ascertained on the ventilator. The calculation was done from day 2 onwards after mechanical ventilation and subsequently every 2nd day till the patient was on ventilator. The resting energy expenditure was also calculated by the simple predictive equations as per ESPEN COVID-19 guidelines, i.e., 25-30 kcal/kg of which the mean of 27 kcal/kg was chosen. Bodyweight was estimated by height equation 50 kg for 5 ft plus 2.3 kg for each inch >5 feet. The quantitative measures were studied by Bland and Altman plot to describe an agreement between the two by constructing a line of agreement. The limits were calculated by using the mean and standard deviation of the difference between the two measurements. Statistics: The EE derived from the two methods is compared by Bland and Altman plots. Reliability and adequacy between the methods are tested using ROC curves with kappa coefficient (reliability coefficient). For the coefficient of variation, ANOVA is used when applicable. IBM SPSS Statistics for Windows, version 24.0 (IBM Corporation, Chicago, USA) was used to perform analyses. MedCalc version 19 (MedCalc bv, Ostend, Belgium) was used to create BlandeAltman plots. Results: No 1: The estimated mean energy expenditure derived from weight-based calculations was 2576 ± 469 kcal/24 hours, which was significantly higher when compared with an estimation of EE from indirect calorimetry of 1507 ± 499 kcal/24 hours (15-20 kcal/kg/day). This correlation is significant but not useful for prediction (R = 0.345). No 2: The estimated mean EEVCO2 was 1388 ± 467 kcal/24 hours compared with an estimation of EE from indirect calorimetry of 1507 ± 499 kcal/24 hours. The Bias and precision, as visualized by the limits of agreement, are shown in the Bland-Altman plot where there was a significant bias of only 118 kcal/day (95% CI (-187 to 422 kcal);p < 0.001. The regression analysis reveals that for every one unit change in EEVCO2 value, there is one unit change in EE by IC. This correlation is significant (R = 0.951). Similarly, the Bland-Altman plot was tested between the estimated mean EEVCO2 and EE derived from weight-based calculations. The difference was wide with significant bias of 1187 kcal/day (95% CI (-2256 to (-118) kcal);p < 0.001). Conclusion: The ESPEN guidelines (30 kcal/kg through the disease state) for energy estimation may not be right in COVID-19 patients and the study calls for more personalisation of energy estimation by the correct use of indirect calorimetry.

Dietetic-led nutrition interventions provided to patients recovering from critical illness from COVID-19 in a large London teaching Hospital from March 2020 to April 2021

Critically-ill COVID-19 patients experience elevated metabolic response (1;2), alterations to gastrointestinal function and deficits in nutritional delivery throughout critical illness and the recovery phase. These contribute to a decline in nutritional status and poorer functional ability on step down to the ward (3) especially in those found to be malnourished on admission (4). The nutrition patients receive in their post Intensive Care Unit (ICU) phase of recovery is now considered equally as important as that received on the ICU, particularly for those already nutritionally compromised, frail or with sarcopenia (5). Guidelines produced by the British Dietetic Association (6) explicitly state the potential role of dietitians in nutritional recovery following COVID-19 critical illness. The aim of this study is to evaluate to role of the dietitian in the nutrition interventions provided patients with COVID-19 during ward-based rehabilitation following a critical care admission, making comparisons with these guidelines. Data was collected and analysed for adult patients with COVID-19 who left ICU during March 2020 to April 2021. Patients were followed from ICU step down to hospital discharge. The study was performed using a prospective observational methodology. Data was available on 177 patients. Demographics presented as mean (SD). ICU admission weight mean 89kg (20.9), BMI 30 kg/m2 (6.7), age 60 years old (12), 67% male, ward length of stay 11days (8.4) and total hospital stay 35.6days (21). 111 (63%) went home, 31 (18%) were transferred to another acute hospital and 27 (15%) discharged to rehabilitation hospital. On step down from ICU patients had lost 8.2kg (6.4) and 8.8% (6.9) weight loss and total stay loss of 9.3kg (6.8) and 9.8% loss (6.8). Guidelines(6) recommend supplemental use of enteral nutrition (EN) and/or high protein supplements to meet nutritional targets where required, enteral feeding tubes should not be removed without dietetic input and ensure community follow up is arranged when required. On discharge from ICU, 37 (21%) were exclusively on EN, 70 (40%) were on Supplementary EN and 68 (38%) needed Oral Nutritional Supplements (ONS). The majority of patients (90%) received dietetic interventions, all were seen within 48 hours of ICU step down and an average of 3 times (2.5). Those who required ENS received it for 6 days (5.5). Nasogastric tubes were removed without dietetic involvement in 58 (54%) patients. For the 107 patients that needed ENS, 34 (40%) used a high protein feed (6.3-7.5grams protein per 100ml), 24 (22%) a high energy feed (150 kcal per 100ml) and 12 (11%) concentrated feed (200 kcal per 100ml). 117 (66%) patients needed ONS over their admission with the majority (62%) using a compact high protein product. 125 (70%) patients needed dietetic follow up on discharge from hospital - 15 for continued EN (12%);68 ONS (54%);and 42 (34%) received healthy eating advice. This study demonstrated that 90% of patients who survived critical illness due to COVID-19 received individualised nutrition interventions from the dietitian to support rehabilitation. Due to the impact of the COVID-19 infection on the ability to eat and drink, EN and/or ONS were clinically appropriate throughout the duration of the ward stay. Dietetic provision met the recommended guidelines for nutrition support in hospital and facilitated further dietetic input on discharge. Feeding tubes were removed in half of patients without dietetic input which may have been premature in some cases and warrants further work on decision making. Patients lost weight over the ICU stay, but this was halted under dietetic-led care post ICU. References 7. Yu, P.J., Cassiere, H., DeRosa, S., et al. Hypermetabolism and Coronavirus Disease. JPEN 2019: 44(7), 1234-1236. 8. Whittle, J., Molinger, J., MacLeod, D. et al. Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19. Critical Care 2020: 24(1) 1-4. 9. Zhu N, Zhang D et al. A novel coronavirus from patients with pneumonia in China. NEJ 2020:382, 727-33 10. Eden, T. and McAuliffe, S. Critical care nutrition and COVID-19: a cause of malnutrition not to be underestimated. BMJ NPH, 2021. 11. Singer P. Preserving the quality of life: nutrition in the ICU. Critical Care 2019: 23 (1) 1-5 12. Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic. 2020. (accessed 24.6.21)

Dietetic-led critical care nutrition interventions provided to critically ill patients with COVID-19 in a large London teaching hospital from March 2020 to April 2021

Many patients admitted to critical care with COVID-19 were at risk of malnutrition due to pre-existing chronic diseases associated with underlying poor nutritional intake and sarcopenia (1). Combined with increased energy expenditure and catabolism (2), alterations to gastrointestinal function and deficits in nutritional delivery during critical illness all risked declining nutritional status and subsequent poorer functional ability. International nutrition guidelines (3-6) recommend providing early enteral nutrition support using protocols. The UK and Australian versions created during the pandemic (3;4) recommend for individualised nutrition therapy by registered dietitians to anticipate and manage the complications commonly seen in these patients that can impact on the provision and type of nutrition support. The aim of this study is to evaluate the role of the dietitian in the nutrition interventions provided to patients with COVID-19 during critical illness and compare with recommended guidelines (3;4). Data was collected and analysed for adult patients with COVID-19 admitted to the intensive care units (ICU) requiring advanced respiratory support and enteral or parenteral nutrition support for longer than 48 hours during the period March 2020 to April 2021. Patients were followed from ICU admission to ward step down. Data was available for 453 critically ill patients. Demographic data presented as mean (SD);age 60 years old (12), 67% male, weight 84kg (20), BMI 29kg/m2 (6) for 20 ICU days (18), mortality of 55%. 167 patients (37%) were classified as high nutritional risk as determined by experienced critical care dietitians for whom nutritional requirements were individually determined by the dietitian within 24 hours of ICU admission. The remaining patients were seen within a mean of 72hrs. 99% (447/453) were enterally fed and the remaining received parenteral nutrition. Patients received on average 5.2 (4.5) dietetic interventions over the ICU stay, irrespective of nutritional risk. Reasons for dietetic interventions were adjustment of feed to account for calorie provision according to metabolic phase (74%);calories derived from sedation (55%);gastrointestinal dysfunction (32%);weaning from enteral nutrition to oral (32%);and renal, fluid and electrolyte adjustments (26%). A range of enteral feeds were used - the majority of patients (93%) received high protein (6.3-7.5grams protein per 100ml), concentrated (18.5%) (200 kcal per 100ml), peptide (9.5%) and protein supplementation (60%). On average those patients who survived lost 8.2kg (6.4) equating to 8.8% (6.9) of total weight over the ICU stay. A dietetic handover was provided for 100% of patients who transferred to the ward. In this study 100% of patients required dietetic input as their nutritional needs could not be met with protocol alone. A significant number were identified as nutritionally at risk, were prioritised as urgent and seen within the guideline timeframes. The dietitian was needed to tailor dietetic interventions to manage complications common in patients with COVID-19. They were also actively involved in adjusting nutrition interventions to facilitate patients’ nutritional recovery and rehabilitation. Patients lost weight over the ICU stay and all patients were handed over to ward dietitians for further dietetic management. References 1. Zhu N, Zhang D et al. A novel coronavirus from patients with pneumonia in China. NEJM 2020:382:727-33 2. Whittle, J., Molinger, J., MacLeod, D., et al. Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19. Critical Care 2020: 24(1) 1-4. 3. Critical Care Specialist Group (CCSG) of the BDA Guidance on management of nutrition and dietetic services during the COVID-19 pandemic. 2020. (accessed 24.6.21) 4. Chapple, L. A. S., Fetterplace, K., Asrani, V., et al. Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand. Nutrition & Dietetics,2020: 77(4), 426-436. 5. Barazzoni, R., Bischoff, S. C., Breda, J et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition, 2020: 39 (6), 1631-1638 6. Martindale, R., Patel, J. J., Taylor, B., et al. Nutrition Therapy in Critically Ill Patients with Coronavirus Disease (COVID-19). Journal of Parenteral and Enteral Nutrition. 2020: 44 (7), 1174-1184

EXPLORING PATIENT EXPERIENCES WITH A TELEHEALTH BEHAVIOURAL SWALLOWING INTERVENTION FOR THE PRO-ACTIVE TRIAL IN PATIENTS WITH HEAD AND NECK CANCER

Introduction In response to COVID-19, a rapid shift was made to deliver behavioural swallowing therapy in the PRO-ACTIVE trial via a TeleHealth (TH) approach. Patient experiences with TH were explored. Methods A theory-guided qualitative approach explored the perspective of consenting participants who received at least one TH swallowing therapy session. Patients participated in a one-time semi-structured interview. Interview transcripts were analyzed for content and theme using a multi-step consensus process to build a coding framework and key messages. Results Eleven participants recounted their TH experiences and reported feeling satisfied, comfortable and confident with the session(s). Facilitating factors included: previous experience with teleconferencing, access to optimal equipment, clinician skill, and caregiver assistance. TH was considered beneficial to reduce commuting time, potential exposure to COVID19, energy expenditure and also allow caregiver participation. Limitations were also identified, including lack or poor previous experience with technology, and less opportunity for personalization. Participants indicated that use of audio alone was less preferred than an audio/video platform. Conclusions Patients reported overall that TH sessions did not compromise their clinical learning experience when compared to in-person sessions. Patient feedback about TH provides an important perspective to inform best practices for care delivery.