Evaluating Efficacy Of Functional Luminal Imaging Probe In Preoperative Evaluation For Antireflux Procedures

Introduction: The COVID-19 pandemic caused significant decreases in outpatient procedures, many of which are required before to antireflux operation (ARS). The purpose of this study was to add functional luminal imaging probe (FLIP) to esophagogastroduodenoscopy (EGD) and esophageal pH monitoring to assess its utility in decreasing the need for follow up studies in patients being evaluated for ARS. Method(s): Retrospective observational study was performed on 81 patients being evaluated for GERD who underwent EGD, pH monitoring, and FLIP. Data collected included average distensibility index (DI) at 60 mL, presence of repetitive anterograde or retrograde contractions, hiatal hernia dimensions, pathology results, pH data, and need for follow-up testing. Result(s): Based on FLIP results, HRM was recommended in 35 patients (43.2%). This included 14 patients with DI suggestive of significant esophagogastric junction outflow obstruction, eight of whom completed HRM with four confirmed as achalasia. FLIP results were suspicious for eosinophilic esophagitis (EoE) in four patients of which one was confirmed as EoE on biopsy. Gastric emptying study was felt to be necessary for 11 patients before to ARS. Conclusion(s): FLIP identified patients with possible alternative pathologies including achalasia and EoE that would otherwise be a contraindication to ARS. FLIP at the time of EGD and pH monitoring is useful as it guides the clinical decision on need for additional outpatient procedures, which may be difficult to obtain in pandemic conditions. FLIP was effective at reducing the requirements for further follow-up testing in the majority of patients being evaluated for potential ARS.

Opportunities for Virtual Care in Eosinophilic Esophagitis: Real-World Dietary Therapy Practice

Introduction: Dietary therapy for eosinophilic esophagitis (EoE) is an effective first-line treatment aimed at identifying triggers by systematically removing then reintroducing food groups. Success on diet therapy can be augmented by working with a dietitian, but this is not a universal clinical resource. Virtual or telehealth approaches to nutrition care may offer opportunities to implement diet therapy for EoE. We conducted a retrospective study at a tertiary center with six GI dietitians to compare real-world standard in-person versus virtual EoE nutrition practices in terms of access, follow-up< and disease control. Method(s): We identified adults with EoE referred to GI nutrition through query of the electronic medical record by ICD-10 diagnoses and confirmed by chart review. As all nutrition visits prior to the COVID pandemic were performed in-person, standard care was defined as care established in January-December 2019 and virtual care in January-December 2021. Associations were analyzed using Chi-squared and Student's t test (Table). Result(s): A total of 204 patients were included;99 referred for standard in-person and 105 virtual nutrition care. The cohorts did not differ significantly by gender, age at the time of referral, race, and distance lived to our center. Of these, 55.6% (55) standard and 48.6% (51) virtual visits were completed with a dietitian (p=0.341) and 4-food elimination diet was the most commonly planned diet. The majority initiated the diet (80.0% standard, 78.4% virtual, p=0.842) and among them, half successfully attained histologic remission with the elimination phase (63.6% standard, 47.5% virtual, p=0.324). Ultimate treatments plans included remaining on dietary therapy (25.5% standard, 23.5% virtual, p=0.728), no treatment or lost to follow-up (34.6% standard, 25.5% virtual), and medication (25.5% standard, 41.2% virtual). Conclusion(s): There is a growing demand for nutrition care in EoE and in our tertiary practice, we found no differences in the success and response rate on elimination diet or follow-up between patients receiving standard or virtual nutrition care. Virtual approaches to implementing EoE dietary therapy may serve to complement in-person care and offer opportunities for those lacking local dietitian access. However, up to one-third of patients are lost to follow-up or remain untreated, also highlighting a need to identify, understand, and overcome barriers to treatment uptake and disease control .

Dupilumab efficacy and safety up to 52 weeks in adult and adolescent patients with eosinophilic esophagitis: Results from parts B and C of the randomized, placebo-controlled, three-part, phase 3 LIBERTY EoE TREET Study

Introduction (contexte de la recherche): In Parts A and B of the 3-part phase 3 LIBERTY EoE TREET study (NCT03633617), dupilumab 300 mg weekly (DPL qw) vs. placebo (PBO) demonstrated significant efficacy and acceptable safety up to 24 weeks (wks) in adults and adolescents with eosinophilic esophagitis (EoE). For patients (pts) who completed Parts A or B, Part C was an extended active treatment period for 28 wks. Objectif: To assess the safety and efficacy of DPL in pts who completed Part B and continued to Part C, up to 52 wks. Methodes: Of 80 DPL qw pts in Part B, 74 continued DPL qw in Part C (DPL/DPL). Of 79 PBO pts in Part B, 37 pts received DPL qw in Part C (PBO/DPL). Part B co-primary endpoints were proportion of pts achieving peak esophageal intraepithelial eosinophil (eos) count <= 6 eos/high power field (hpf) and absolute change from Part B baseline (BL) in Dysphagia Symptom Score (DSQ) score at Wk 24. Secondary endpoints included peak eos count, EREFS, and HSS grade and stage scores. In Part C, all co-primary and secondary endpoints were assessed at Wk 52 as secondary endpoints. Safety was also assessed. Resultats: Part B BL characteristics were similar across groups. At Wk 52 of Part C, 84.6% of DPL/DPL and 67.6% of PBO/DPL groups achieved peak eos count of <= 6 eos/hpf and mean (SD) absolute change from Part B BL in DSQ score was -30.26 (15.39) for DPL/DPL and -27.25 (11.46) for PBO/DPL pts. At Wk 52, peak eos count, EREFS, HSS grade and stage scores were reduced, compared with Part B BL, and EDP and T2 NESs were suppressed in DPL/DPL and PBO/DPL groups. Dupilumab demonstrated an acceptable safety profile in Part C;the most common (occurring >= 10%) treatment-emergent adverse events in DPL/DPL and PBO/DPL groups were injection-site reactions (13.5% and 10.8%), COVID-19 (9.5% and 10.8%) and nasopharyngitis (4.1% and 10.8%). Conclusion(s): As observed in Part A/C, dupilumab qw demonstrated persistent improvements in clinical, symptomatic, histologic, endoscopic and molecular features of EoE up to 52 wks and had an acceptable safety profile. PBO pts from Part B who received dupilumab in Part C showed similar efficacy to dupilumab qw pts of Part B.Copyright © 2023

Eosinophilic Oesophagitis in Children: A Single Uk Tertiary Centre Experience

The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/6 food), steroids etc. It is recommended to perform endoscopies between each reintroduction to assess disease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagia was the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FED achieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following re-introduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding during endoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.

Duodenal Stricture as a Rare, Possible Complication of Eosinophilic Gastrointestinal Disease (Egid)

EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.

Worsened Fibrostenotic Outcomes in Eosinophilic Esophagitis Patients Due to COVID-19-Related Endoscopy Cancellations.

BACKGROUND: Indirect consequences of COVID-19 in eosinophilic esophagitis (EoE) are not known. AIM: To determine the impact of COVID-19-related endoscopy cancellations on outcomes in EoE patients. METHODS: In this retrospective cohort study, we assessed whether adult EoE patients who had routine endoscopy scheduled from mid-March 2020 to May 2020 (pandemic start) were canceled or proceeded, and if canceled, ultimately returned. We extracted clinical, endoscopic, and histologic data for their pre-COVID procedure as well as the next procedure performed, if a patient returned. Outcomes included histologic response (< 15 eos/hpf) and endoscopic severity. Those with delayed care were compared to those who returned as scheduled. RESULTS: Of 102 patients identified, 75 had procedures canceled, and 20 (27%) never returned. For the 55 who were canceled but returned, mean time between procedures was 1.1 ± 0.7 years with a delay of 0.5 ± 0.3 years. While treatment rates were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%; p = 0.05) and their esophageal diameter had significantly decreased (16.8 mm to 15.0 mm; p < 0.001). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation. CONCLUSION: Of EoE patients with canceled endoscopies during the beginning of the COVID-19 pandemic, > 25% never returned for care, which is a previously unmeasured impact of the pandemic. Those who returned had > 1 year between procedures with progression of fibrotic features and need for esophageal dilation.

Comfort in Telemedicine Based on Diagnosis and Reason for Referral in Pediatric Gastroenterology

Background: Telemedicine can provide increased patient access to care, cost savings and high patient satisfaction. Payors have extended reimbursement for telemedicine and although few pediatric gastroenterologists had experience with telemedicine before the COVID-19 pandemic, many practices continue to offer this as a care modality model. Comfort in practicing telemedicine for specific conditions amongst NASPGHAN members is not known. This study evaluates comfort in practicing telemedicine for common indications for outpatient GI consultation referral and follow up visit diagnoses. Method(s): In June-August 2020, we surveyed members of NASPGHAN with an instrument that included two multi-select questions: 1) Which of the following reasons for referral would you feel comfortable completing with telemedicine? 2) Which of the following conditions would you feel comfortable using telemedicine for a routine follow up? Results: 136 participants answered the two survey items. Constipation (n=121, 89%), heartburn (n=109, 80%), and infant reflux (n=109, 80%) were the reasons for referral most frequently selected. Referral of jaundice (n=26, 19%), second opinion (n=45, 33%), and poor weight gain (n=51, 38%) received the least mentions. For follow up appointments, diagnoses of celiac disease (n=126, 93%), functional gastrointestinal disorders (n=126, 93%), eosinophilic esophagitis (n=120, 88%) were the three most frequent, while liver transplantation (n=24, 18%), intestinal failure (n=26, 19%), and short bowel syndrome without intestinal failure (n=34, 25%) were the diagnoses selected the least. 14 respondents selected comfort with all new patient reasons for referral and follow up visits. Conclusion(s): There is variability in provider comfort to utilize telemedicine for providing consultation or follow up care based on reason for referral or patient diagnosis. Provider comfort in providing care should be considered when offering telemedicine as a practice model moving forward. Reasons underlying provider dis/comfort should be explored using qualitative methods. (Figure Presented).

Medical Treatment of Eosinophilic Esophagitis: A Cochrane Review

Background Current therapies for pediatric and adult eosinophilic esophagitis (EoE) include dietary elimination, proton pump inhibitors, swallowed corticosteroids, and biologics. Our aim is to systematically assess the efficacy and safety of published randomized controlled trials (RCTs) of medical therapies for EoE that compare active treatments to placebo or to an active comparator. We consider RCTs that target the induction and maintenance phases of therapy, separately. Methods A search was designed by a Cochrane information specialist and included Cochrane Gut Register, CENTRAL, MEDLINE, Embase, and clinicaltrials.gov databases, from inception to May 2022. Studies that met our search criteria were imported into Covidence for title and review. All authors participated in study screening, and each study was independently evaluated by two authors. Reports of RCTs that met the inclusion criteria were selected for full text review. Multiple reports of the same RCT were collapsed into the parent study. Data from these studies was then extracted to RevMan Web to assess study characteristics, including study design, EoE definition, inclusion / exclusion criteria, age range, interventions, number of patients randomized, number of patients who completed the study, primary and secondary outcomes and conflicts of interest. Studies were also assessed for potential sources of bias including baseline imbalance, selection, performance, detection, attrition, and reporting biases. We used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) to assess the overall certainty of evidence supporting the primary outcome. Results As of May 2022, we identified 2,638 reports that met our search criteria of which 14 were duplicates, giving a total of 2,624 reports that were imported into Covidence for further review. Following title and screening, 259 reports were selected for full text review, which were collapsed into 46 distinct RCTs that met the inclusion criteria. The primary outcomes for our systematic review were histological improvement, endoscopic improvement, and clinical symptom improvement, all as defined by the study at study endpoint, and withdrawals due to adverse events. The secondary outcomes of our analysis were serious adverse events, endocrine complications, growth concerns, infections, and health-related quality of life. Study outcomes were analyzed on an intention-to-treat basis. Risk ratios (RRs) and corresponding 95% confidence intervals (95% CI) are reported for dichotomous outcomes, and mean difference and standard deviation are reported for continuous outcomes. The data will be presented in full. Conclusions Results of this analysis inform clinicians about the efficacy and potential side effects of different medical therapies for EoE in both pediatric and adult populations. Deficiencies in our current knowledge will be highlighted and will provide direction for design of future RCTs in the field. Future research should continue to explore factors that influence initial and subsequent medical therapy selection for people with EoE.

In this issue: Graphical abstract

Moritz M. Hollstein, Lennart Münsterkötter, Michael P. Schön, Armin Bergmann, Thea M. Husar, Anna Abratis, Abass Eidizadeh, Meike Schaffrinski, Karolin Zachmann, Anne Schmitz, Jason S. Holsapple, Hedwig Stanisz-Bogeski, Julie Schanz, Andreas Fischer, UWE GROß, Andreas Leha, Andreas E. Zautner, Moritz Schnelle, Luise Erpenbeck Booster with BNT162b2 elicits strong humoral and cellular immune responses independent of the prime vaccination, whereas ChAdOx1 nCoV-19 booster does not further enhance the cellular response. We demonstrate that the vaccine candidate (CuMV SB TT sb -RBD) is highly immunogenic in mice and is capable of inducing mucosal and systemic RBD as well as spike specific antibody responses. GRAPH Abbreviations: CDX-0159, anti-KIT inhibitory monoclonal antibody;FcR, Fc receptor;KIT, KIT proto-oncogene, receptor tyrosine kinase;MRGPRX2, mas-related G protein-coupled receptor-X2;SCF, stem cell factor. [Extracted from the article] Copyright of Allergy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

EOSINOPHILIC OESOPHAGITIS IN CHILDREN: A SINGLE UK TERTIARY CENTRE EXPERIENCE

The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/ 6 food), steroids etc. It is recommendedto perform endoscopies between each reintroduction to assessdisease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives: We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods: Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagiawas the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FEDachieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following reintroduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding duringendoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.

WORSENED FIBROSTENOTIC OUTCOMES IN EOSINOPHILIC ESOPHAGITIS PATIENTS DUE TO COVID-19-RELATED ENDOSCOPY CANCELLATIONS

Background: Although there is ongoing research into the effects of COVID-19 infection in patients with EoE, the non-infection-related impact of COVID-19 is not known. In particular, the impact of postponing endoscopy due to the pandemic has not been studied. Aim: To determine the impact of COVID-19-related endoscopy cancellations on clinical outcomes in EoE patients. Methods: In this retrospective cohort study, we identified adult patients with a diagnosis of EoE who had a routine endoscopy scheduled from mid-March 2020 to May 2020, the timeframe at the beginning of the pandemic when most procedures were stopped at our center. We determined if procedures were cancelled or proceeded, and if canceled, we determined which patients were rescheduled and returned. We extracted clinical, endoscopic, and histologic for the last procedure completed prior to the pandemic, and well as the next procedure performed during the pandemic, if a patient returned. Outcomes included histologic response (<15 eos/hpf), endoscopic severity (EREFS), and global symptoms response. Patients who had delayed care were compared to those who returned as scheduled. Results: Of 102 patients with an endoscopy scheduled within our time frame, 27 had the planned procedure and 75 were cancelled. Of these 75, 20 (27%) never returned for their EGD despite attempts to contact them. When compared to those who were cancelled, those who underwent their procedure had more severe fibrosis (predilation esophageal diameter 13.6 vs 15.1mm;p=0.04) and were more commonly treated with an elimination diet (56% vs 33%;p=0.04);the remainder of clinical features were similar (Table 1). For the 55 patients who were canceled but ultimately returned for their EGD, the mean time between procedures was 1.1±0.7 years. While treatment rates and endoscopic features were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%;p=0.05) and their esophageal diameter had significantly decreased from the size achieved at the prior procedure (16.8mm to 15.0mm;p<0.001) (Table 2). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation. Conclusion: A large number of EoE patients had their endoscopies cancelled during the initial part of the COVID-19 pandemic. Those who were not cancelled had more severe fibrostenosis. Greater than 25% of those cancelled never returned for care, which is an unmeasured impact of the pandemic, and it is uncertain whether EoE findings have worsened in this group. Of those who returned, there was a delay of greater than one year, associated with progression of some fibrotic features and an increased need for esophageal dilation. (Table Presented) (Table Presented)

TREATMENT SUCCESS IN A RESISTANT CASE OF INSOMNIA WITH AN IRREGULAR CIRCADIAN RHYTHM DISORDER

Introduction: A 19-year-old non-verbal male with history of CHARGE syndrome, severe autism, intellectual disability, coloboma with blindness OD and severely imparied vision OS, deafness, self-injurious and aggressive behavior, Tetralogy of Fallot status post repair, pulmonary valve replacement, hypertension, hypothyroidism, megacolon, gastrostomy tube dependence, eosinophilic esophagitis and chronic kidney disease with an irregular sleep cycle who has failed multiple medications for insomnia has shown treatment success with suvorexant. Report of Cases: This patient's sleep schedule ranges from 1.5 to 5 hour segments at various times of day or night including naps at school with occasional longer periods of sleep up to 10 hours and longer periods of wakefulness up to 22 hours who has been treated with the following medications: trazodone, clonidine, hydroxyzine, diphenhydramine, quetiapine, gabapentin, mirtazapine, eszopiclone, melatonin and ramelteon. His behavioral problems have been treated with olanzapine. He continued to be aggressive and difficult to direct. His parents reported exhaustion. Then, suvorexant 5mg was added at bedtime while the following sleep medications were continued: gabapentin total daily dose of 1500mg (300mg in morning and 3pm;900mg at bedtime, 300mg one hour later if still awake), ramelteon 8mg, mirtazapine 7.5mg and olanzapine 10mg at bedtime and bid prn aggressive behavior. He also takes the following daily medications: bisacodyl, polyethylene glycol, simethicone, hyoscyamine, cholecalciferol, aspirin, levothyroxine, hypoallergenic nutritional formula, starch and albuterol prn. With the addition of suvorexant 5mg, he had been able to get 9.5 hours of consolidated sleep at night with improvement in his behavior until he contracted Covid-19 and regressed. The suvorexant dose was increased to 10mg which again improved his insomnia and behavior. Conclusion: Various medications have either not worked at all or have worked suboptimally for insomnia in this medically complex patient who has an irregular Circadian rhythm disorder. Adding an orexin receptor antagonist as a novel mechanism to his regimen has shown promise. At this time, this patient has been stable for one month with suvorexant 10mg at bedtime after regression on the 5mg dose that coincided with a Covid-19 infection. We are proceeding with cautious optimism.

Prescrire's ratings of new drugs in 2021: A brief review

Three new drugs, all based on messenger RNA or small interfering RNA technology, represented a major therapeutic advance in 2021. But the bigger picture is that most of the new authorisations that advanced patient care were adaptations of existing drugs. And that more than half of this year's new authorisations were not advances, and in fact about one-tenth represented a step backwards compared to existing options.

Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy.

Diagnostic unsedated transnasal endoscopy (uTNE) has been proven to be a safe and well-tolerated procedure. Although its utilization in the United Kingdom (UK) is increasing, it is currently available in only a few centers. Through consideration of recent studies, we aimed to perform an updated review of the technological advances in uTNE, consider their impact on diagnostic accuracy, and to determine the role of uTNE in the COVID-19 era. Current literature has shown that the diagnostic accuracy of uTNE for identification of esophageal pathology is equivalent to conventional esophagogastroduodenoscopy (cEGD). Concerns regarding suction and biopsy size have been addressed by the introduction of TNE scopes with working channels of 2.4 mm. Advances in imaging have improved detection of early gastric cancers. The procedure is associated with less cardiac stress and reduced aerosol production; when combined with no need for sedation and improved rates of patient turnover, uTNE is an efficient and safe alternative to cEGD in the COVID-19 era. We conclude that advances in technology have improved the diagnostic accuracy of uTNE to the point where it could be considered the first line diagnostic endoscopic investigation in the majority of patients. It could also play a central role in the recovery of diagnostic endoscopic services during the COVID-19 pandemic.

COVID-19 INFECTIONS IN THE EOSINOPHILIC GI DISEASE POPULATION ARE NOT SEVERE: INITIAL REPORT FROM A GLOBAL ONLINE REGISTRY

Background: The impact of COVID-19 infection on patients with eosinophilic esophagitis (EoE) and other eosinophilic GI diseases (EGIDs) is not known. Aim: To determine the characteristics of EoE and EGID patients who have COVID-19, assess severity COVID-19 in the EGID population, and evaluate for COVID-19-induced EGID flares. Methods: We established an online global registry (covideoeegid.org) where health care providers could report details of COVID-19 infection in EoE and EGID patients. The registry was publicized and reminders were sent via worldwide patient advocacy groups, professional organizations, and research collaborative groups. De-identified data were entered into the website related to patient demographics, EGID disease features and activity, comorbidities, and treatments. Data collected related to COVID-19 included source of exposure, symptoms, illness severity, hospitalizations, and deaths. Descriptive statistics were used to summarize the findings. Results: A total of 40 cases of COVID-19 in EoE/EGID patients were reported as of November, 2020 (Figure). Patients had a mean age of 25 (±11) years at the time of COVID-19 diagnosis, the majority were male (73%) and had atopy (73%), and nearly all (95%) had EoE, though some non-EoE EGIDs were reported (Table). At the time of COVID-19 infection, EGID disease activity was reported as in remission in 18 (45%) and moderate in 13 (33%). EGID treatments at the time of COVID-19 included PPIs (58%), swallowed/topical steroids (45%), and/or dietary elimination (42%) (Table). Most common exposures for COVID-19 were either unknown (30%) or from household contacts (30%);34 of the reported cases were confirmed with testing, while 6 were suspected based on clinical presentation. Common symptoms included cough (63%), fever (50%), anosmia (20%), and ageusia (18%);15% of cases were asymptomatic. No COVID-19 infections were classified as severe, and 32 (80%) were deemed mild (Table). Only 1 patient was hospitalized (received lopinavir and hydroxychloroquine), and no ICU admissions or deaths were reported. The mean number of days from infection to symptom resolution was 9.8±8.3. No EGID disease activity flares were reported due to COVID-19. Conclusions: In a global EoE/EGID registry, relatively few COVID-19 cases have been reported over an initial 8 month period, despite extensive efforts at outreach. The reported cases of EGID/COVID-19 are mild, with only one hospitalization and no deaths. Despite concerns of possible reporting bias and that EGID patients tend to be younger, based on this registry it does not appear that EGID patients are at increased risk for severe COVID-19 infection or that COVID-19 leads to EGID flares. Future serologic studies are needed to determine the prevalence of COVID in EGIDs. We ask providers to continue to report cases (covideoeegid.org). (Image presented) (Table presented)

PERCEPTIONS OF COVID-19 IN THE EOSINOPHILIC ESOPHAGITIS POPULATION

Background: The medical and psychological impacts of the COVID-19 pandemic on individuals affected by eosinophilic esophagitis (EoE) remain largely unknown. We seek to describe the current perceptions of COVID-19 in the EoE population of the United States (US). Methods: For this cross-sectional study, we anonymously surveyed individuals aged 18 years or older who self-identified as having EoE or as being a caregiver for someone with EoE. This survey was sent via an invitation and link to email subscribers of the American Partnership for Eosinophilic Disorders in November 2020. Our primary aim was to describe patients’ and caregivers’ perceptions of COVID-19. We collected patient demographics and asked five multiple-choice questions that assessed the responder’s anxiety related to the pandemic, belief on whether patients with EoE are at higher risk of acquiring COVID-19, willingness to take an approved vaccine, experiences with access to medical care during the pandemic, and use of social media to learn about the impact of COVID-19 on EoE. Our secondary exploratory aim was to identify patient characteristics associated with a positive response to each question. All variables were treated as categorical variables (with age dichotomized into age <48 and >48). Variables were analyzed with proportions and compared using chi-square tests. Results: The majority of responders were female (84.7%) and white (91.9%) (Table 1). The responses to COVID-19 questions are shown in Figure 1. Notably, majority (53%) of responders are anxious about the pandemic, 20% believe that patients with EoE are at higher risk of acquiring COVID-19, 41% are agreeable to taking an approved vaccine, 44% report interruptions in EoE-related care (either missed upper endoscopy or clinic visit) for themself or the person they care for, and only 24% have found social media to be useful to learn about the impact of COVID-19 on the EoE population. Caregivers are more concerned than patients that EoE patients are at higher risk of acquiring COVID-19 (OR 3.65, 95% CI 1.25-12.02). The older age group is less likely to use social media to learn about COVID-19 in the context of EoE (OR 0.35, 95% CI 0.13-0.90). There is a trend toward females being more likely to have interruptions in EoE-related care compared to males (OR 2.95, 95% CI 0.83-12.15). Conclusion: Our pilot data suggests that COVID-19 has led to anxiety and interruptions in care in the EoE population of the US. EoE care providers should take measures to address anxiety and create care plans that decrease pandemic-related delays. Further efforts should be made to study the risk of COVID-19 in EoE patients and to disperse such research on social media for easy accessibility. If and when a safe and efficacious vaccination is approved, providers will be critical in educating the EoE population on risks and benefits of vaccination. (Table presented) Baseline characteristics of all survey responders (Figure presented) Percentage of participants who responded “Yes” to each COVID-19 related question

INCREASED BURDEN OF SWALLOWING DISORDERS DURING THE COVID-19 PANDEMIC: A HOSPITAL SYSTEM-WIDE AUDIT

BACKGROUND: The indirect health impact of COVID-19 caused by delayed access to care or deferred medical procedures is yet to be fully appreciated. METHODS: We conducted a hospital system-wide audit of all inpatient gastrointestinal (GI) consults performed during the lockdown phase (3/23/2020 – 5/10/2020, n = 558) and the reopening phase (6/1/2020 –7/19/2020, n = 713) of the pandemic and compared against data from 2019 in order to discover any changes in disease burdens. GI diagnoses were derived from the patients' discharge summaries and verified by an independent review of the associated GI consult notes. RESULTS: The volume of inpatient consults was reduced by 27.7% during the lockdown phase compared to the same period in 2019. Yet, the proportion of consults for swallowing disorders (food impaction or chronic dysphagia from eosinophilic esophagitis or achalasia) was increased by 50.9% (p = 0.04). Coincidentally, all outpatient esophageal motility study or elective endoscopic dilation procedures at our hospital system were post-poned during this phase. While the volume of consults was restored during the reopening phase to 101% of that of the same period in 2019. The proportion of consults for swallowing disorders remained elevated by 47.7% (p = 0.02). In comparison, there was no significant change in the proportions of consults for foreign/caustic substance ingestion, inflammatory bowel diseases, or gastrointestinal bleeding during either the lockdown phase or the reopening phase. CONCLUSIONS: There was a significant surge in the demand for inpatient consults for swallowing disorders following the onset of the COVID-19 pandemic, coinciding with the postponement of elective endoscopic procedures. Resources should be allocated to manage patients with underlying esophageal motility disorders more effectively as the pan-demic continues.