Rare Case of Immune-Mediated Necrotizing Myopathy With Isolated Dysphagia as Presenting Symptom

Introduction: Immune mediated necrotizing myopathy (IMNM) is a rare, but progressive disease that accounts for about 19% of all inflammatory myopathies. Dysphagia occurs in 20-30% of IMNM patients. It often follows proximal muscle weakness and ensues in the later stages of the disease. We report a rare case of IMNM, presenting with dysphagia as the initial symptom, followed by proximal muscle weakness. Case Description/Methods: A 74-year-old male with a past medical history of coronary artery disease, hypertension, and hyperlipidemia presented to the ED with 2-3 weeks of intractable nausea, vomiting, and dysphagia for solids and liquids. Vital signs were stable, and initial labs displayed an AST of 188 U/L and ALT of 64 U/L with a normal bilirubin. Computed tomogram of the chest, abdomen, and pelvis were negative. An esophagram showed moderate to severe tertiary contraction, no mass or stricture, and a 13 mm barium tablet passed without difficulty. Esophagogastroduodenoscopy exhibited a spastic lower esophageal sphincter. Botox injections provided no significant relief. He then developed symmetrical proximal motor weakness and repeat labs demonstrated an elevated creatine kinase (CK) level of 6,357 U/L and aldolase of 43.4 U/L. Serology revealed positive PL-7 autoxantibodies, but negative JO-1, PL-12, KU, MI-2, EJ, SRP, anti-smooth muscle, and anti-mitochondrial antibodies. Muscle biopsy did not unveil endomysial inflammation or MHC-1 sarcolemmal upregulation. The diagnosis of IMNM was suspected. A percutaneous endoscopic gastrostomy feeding tube was placed as a mean of an alternative route of nutrition. He was started on steroids and recommended to follow up with outpatient rheumatology. He expired a month later after complications from an unrelated COVID-19 infection. Discussion(s): The typical presentation of IMNM includes painful proximal muscle weakness, elevated CK, presence of myositis-associated autoantibodies, and necrotic muscle fibers without mononuclear cell infiltrates on histology. Dysphagia occurs due to immune-mediated inflammation occurring in the skeletal muscle of the esophagus, resulting in incoordination of swallowing. Immunotherapy and intravenous immunoglobulin are often the mainstay of treatment. Our patient was unique in presentation with dysphagia as an initial presenting symptom of IMNM, as well as elevated enzymes from muscle breakdown. It is critical as clinicians to have a high degree of suspicion for IMNM due to the aggressive nature of the disease and refractoriness to treatment.

Centella asiatica extract inhibits Mycobacterium tuberculosis growth in rat tuberculosis models

Background and Aims: The covid-19 pandemic has reversed years of progress in the fight to end tuberculosis. So, the discovery of new drugs as antituberculosis is very much needed. Our previous studies have shown that the extract of Centella asiatica is able to inhibit the growth of Mycobacterium tuberculosis in vitro and requires further research. The aims of this study is to prove the effect of Centella asiatica inhibit Mycobacterium tuberculosis in rat model tuberculosis. Method(s): The protocol in this study was approved by the veterinary ethics committee of Airlangga University. The rat tuberculosis model was induced by intrathecal injection of a suspension of Mycobacterium tuberculosis strain H37 Rv. Twenty-eight tuberculosis rat were randomly divided into four groups. Groups 1,2, and 3 were treated with ethanol extract of Centella asiatica at 375 mg/kgBW, 750 mg/kgBW and 1500 mg/kgBW, and the fourth group was the control group. Centella asiatica extract is administered orally via an intragastric feeding tube for two weeks, once daily At the end of the experimental period, rats were sacrificed by cervical decapitation. The left lung tissue was taken aseptically and cultured on Middlebrook 7H10. Result(s): The results showed that there was no bacterial growth on the culture media in the group that received Centella asiatica extract at a dose of 750 and 1500 mg/kg BW. Conclusion(s): The conclusion in this study, that Centella asiatica extract inhibit the growth of Mycobacterium tuberculosis at doses of 750 and 1500 mg/kg BW. We thank the Directorate of Research and Community Services, the Directorate General of Higher Education, and Ministry of Education and Culture in Indonesia for the financial supportCopyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.

First in-neonate use of non-invasive transcutaneous auricular vagus nerve stimulation: 18-month neurodevelopmental and sensory follow-up

Objective: Non-invasive transcutaneous auricular vagal nerve stimulation (taVNS) paired with oral feeding is a novel intervention for infants with feeding delays that may improve feeding and help avoid a gastrostomy tube (Gtube). However, the long-term impact of this neurostimulation on infant's development remains unknown. We investigated the neurodevelopmental and sensory outcomes of infants who received taVNS paired with bottle feeding. Method(s): Twenty-one of 35 toddlers who participated in the open label trial of taVNS paired with one or two feeds a day for 2-3 weeks, underwent comprehensive developmental assessments at 18 months of age using Cognitive Adaptive Test, Clinical Linguistics and Auditory Milestone, and Peabody gross motor scores. Twelve of those assessed achieved full oral feeds ('responders') and 9 had G-tube placed for feeds ('non-responders'). Before COVID, 12 toddlers (5 responders, 7 non-responders) were also assessed in the home using the Bayley-III and Sensory Profile (SP-2) assessments. Area deprivation index (ADI) was used to measure resource poor environments and relate to test scores. We used Fishers exact test and Pearson correlation coefficients to compare neurodevelopmental and sensory performance in responders versus non-responders. Result(s): taVNS responders showed significantly better general sensory processing in SP-2 than did non-responders (p =0.04). There were no significant differences in Bayley-III or CAT/CLAMS/ASQ scores in areas of cognition, receptive language, fine motor, and gross motor skills in this small sample size, but are similar to published scores for preterm infants who received G-tubes. ADI was not significantly associated with neurodevelopmental scores. Conclusion(s): These results suggest that taVNS paired with feeding may have a potential long-term positive neurodevelopmental effect on sensory processing in neonates with poor feeding. The current open-label results need testing in randomized controlled trials of taVNS paired with oral feeding in developmentally delayed infants failing oral feeds. Research Category and Technology and Methods Clinical Research: 12. Vagus Nerve Stimulation (VNS) Keywords: Neurodevelopment, taVNS, feeding, developmental delaysCopyright © 2023

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.Copyright © The Intensive Care Society 2023.

Accessible and Specialized Covid-19 Testing for Children and Youth with Medical Complexity

BACKGROUND: COVID-19 testing for symptomatic individuals is a key public health measure for infection prevention and control. However, COVID-19 testing can be uncomfortable without appropriate supports and can lead to testing hesitancy amongst certain populations such as children with medical complexity (CMC) and those with underlying neurological and respiratory conditions. To support COVID-19 testing, a specialized initiative was developed for CMC and their families onsite at The Hospital for Sick Children to enhance testing uptake, reduce barriers to access, and support a safe and accommodated testing environment for families. Multiple modalities of testing were involved and could be completed in their personal vehicle, with specialized support from nurses and child life if needed. OBJECTIVE(S): The objectives of our study were to investigate the characteristics of CMC and their families who underwent COVID-19 testing through our program, evaluate indications for testing, and collect case positivity rates. DESIGN/METHODS: Prospective data, including testing and population characteristics, were collected from December 2020-August 2021 through a centralized system, and was analyzed using descriptive methods. RESULT(S): 335 children (Table 1) with medical complexity came to the COVID-19 Assessment Center for testing. Of those who were tested 88% (294) had neurodevelopmental conditions with highly challenging behaviours (e.g. autism, developmental delay), and 12% (28) were classified as CMC (i.e. those with active use of medical technology e.g. tracheostomy, G-tube etc.). Of those tested, 6% (21) tested positive for COVID-19. Sixty percent (199) were tested due to having symptoms consistent with COVID-19, 27% (90) had a COVID-19 exposure, 8% (26) were exposed and tested as part of outbreak management and 5% were of an unknown criteria. The majority of completed tests (74%) were nasopharyngeal (NP) swabs, 18% completed saliva tests and 6% completed anterior nares/throat swab tests. Thirteen percent (43) of families requested additional supports such as extra nurses, child life specialists or other accommodations. All patients had a dedicated paediatric nurse and received testing in their personal vehicle. CONCLUSION(S): CMC and their families face unique barriers to COVID-19 testing. A specialized testing centre for CMC was able to support families by providing unique opportunities for testing, revealing a 6% COVID-19 positivity rate. NP swabs that can be painful were supported through in-vehicle testing with dedicated pediatric nurses. Robust health and safety measures, including a coordinated testing approach, are necessary to ensure accessible testing opportunities for CMC and their families. Further research is needed to be able to support this unique population.

Rehabilitation of a Rare Case of Severe Pediatric Miller Fisher Guillain Barre Syndrome After Moderate Trauma: A Case Report

Case Diagnosis: Severe Miller Fisher Guillain-Barre Syndrome (MF-GBS) following Utility Terrain Vehicle (UTV) collision in a teenager. Case Description or Program Description: A 15-yearold male driving a UTV was hit by a car. He was helmeted and restrained. He sustained a brief loss of consciousness and multiple limb, L3 compression and L4 transverse process fractures. He went home 10 days after the collision ambulating independently and dressing himself with some assistance due to an arm cast. He returned in 3 days with weakness in his neck and all limbs. This progressed rapidly to dysphonia, dysphagia, inability to move eyes, lips or tongue, severe neuropathic pain and finally respiratory failure. Neurology diagnosed post traumatic MF-GBS and treated with IVIG then plasmapheresis. Legs improved slightly but not respiratory status. Pediatric rehab was consulted. Gabapentin relieved his pain so narcotics were discontinued. Tracheostomy and G-tube were placed. Pediatric intensivists expected home on vent with G-tube feedings. The therapy team dealt with numerous challenges requiring teamwork and collaboration with various different PICU personnel. Team and care conferences were frequent. The patient moved through a variety of equipment, splints and respiratory support. His rehab was performed in the PICU due to respiratory needs, COVID precautions & staffing. Home discharge was at 3 months using vent at night, ambulating with a walker, speaking with a PMV, eating independently and requiring minimal assistance for dressing. Setting(s): Pediatric Intensive Care Unit Assessment/Results: Post traumatic GBS can occur in teenagers. The rehab team solved complex problems involving neuropathic pain and weakness, casts, the PICU setting and non-rehab personnel Discussion (relevance): Post traumatic GBS is rare, reported in adults but not in adolescents. MF-GBS severity can lead to disagreement on appropriate length of stay and expected outcome. Conclusion(s): Post traumatic GBS can occur in pediatric patients. Physiatrists see unusual cases, improve patient care, comfort, outcomes and patient/family satisfaction.

VACCINE-INDUCED THROMBOCYTOPENIA AND THROMBOSIS: SAILING CLOSE TO THE WIND IN A PANDEMIC

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Ever since the global introduction of adenovirus-vector COVID-19 vaccines, cases of cerebral venous sinus thrombosis and thrombocytopenia after immunization has been reported, posing a challenge to global effects on vaccine implementation. CASE PRESENTATION: A previously healthy 33 year old male presented to emergency room with altered mental status after a left sided seizure episode at home. Patient had a 1week history of occipital headache after receiving Ad26.COV2·S Johnson and Johnson vaccine 2 weeks prior. MRI showed superior sagittal sinus thrombosis and right high frontal hemorrhage 8.6x4.7x4.9 cm. CT angiography confirmed nearly occlusive thrombosis of superior sagittal sinus with extension to right transverse sinus. Noted to have a hemoglobin of 15, platelet count of 74000, PT/INR 16/1.2 and PTT of 28. Started on intravenous heparin and intubated for GCS of 4. Heparin was stopped due to supra therapeutic PTT of 200 overnight, drop in platelet count to 55 and hemoglobin to 13. Repeat ct head done for change in neurological exam of dilated right pupil, showed frontoparietal hemorrhage 9.3 cmx4.1 cm and 7 mm midline shift. Heparin was reversed with protamine and transfused 1 unit platelets prior to emergent decompressive craniectomy and thrombectomy. Heparin induced platelet antibody and SRA came back positive confirming vaccine induced thrombocytopenia and thrombosis. Treatment was initiated with argatroban and IVIG. Platelet count improved with no further propagation of thrombus. Patient underwent feeding tube and tracheostomy placement after 10 days due to prolonged ventilator weaning period and poor mental status. Patient's neurological status continued to improve significantly over subsequent months in acute rehabilitation facility with only residual left sided hemiparesis. Patient was successfully decannulated and anticoagulation switched to apixaban DISCUSSION: Possible pathophysiology is thought to be due to a trigger in spike protein production after biodistribution of adenovirus vaccine and a subsequent autoimmune response resulting in thrombosis. Similar to HIT, platelet consumption leads to thrombocytopenia and the continued platelet and monocyte activation increases thrombin generation, resulting in thrombosis. CDC advices to maintain a high suspicion of cases with symptoms that may indicate an underlying thrombotic event along with simultaneous thrombocytopenia. Heparin use is discouraged, unless HIT testing is negative. The International Society on Thrombosis and Hemostasis (ISTH), recommend considering non-heparin anticoagulants and high-dose intravenous immunoglobulin (IVIG). While platelet transfusions are avoided, rapid progression with rising ICP may necessitate transfusion to enable neurosurgical intervention CONCLUSIONS: Management of complications including seizures and elevated intracranial pressure (ICP) is essential to reduce morbidity and mortality risk. Reference #1: Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384:2092–101. Reference #2: Muir KL, Kallam A, Koepsell SA, Gundabolu K. Thrombotic thrombocytopenia after Ad26.COV2.S vaccination. N Engl J Med 2021;384:1964–5 Reference #3: Pavord S, Scully M, Hunt BJ, et al. Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis. N Engl J Med 2021;385:1680–9 DISCLOSURES: No relevant relationships by Axel Duval No relevant relationships by Nadish Garg No relevant relationships by ARCHANA SREEKANTAN NAIR

Monitoring nasogastric tube (NGT) displacement using chest X-ray (CXR) requests: Influence of tube fixation

Introduction: Unplanned removal of NGTs is common and associated with multiple complications.1 Methods used to secure these tubes may influence removal rates.2 Following national guidance,3 we confirmed tube placement by CXR. We used the text of CXR requests to estimate the rates of NGT placement and to see how these were influenced by changing how NGTs were secured. We also used similar methodology to review changes to CXR requests mentioning central lines (CVCs) and endotracheal tubes (ETT). Objectives: To see how CXR requests for NGT placement were influenced by changing the method used to secure these tubes. MethodsIn a 42 bedded mixed general and neurosurgical unit, in November 2019 we changed the method to secure NGTs from Hollister feeding tube attachment devices (Hollister, IL, USA)., to handcrafted slings made from Micropore (3M, MN, USA) 1.25cm Surgical Tape.4 The text of CXR requests between October 2017 and July 2021 were analysed for text associated with NGTs, CVCs and ETTs. The number of bed days was calculated for each month from October 2017 and CXR rates per 100 bed days were calculated. Mann-Whitney U tests were used to establish if CXR rates changed significantly after November 2019 and after admitting patients with COVID-19 in March 2020. Distributions are shown as medians with [IQR]. Results: There were 15239 CXRs, a median of 330 [IQR 303-357] CXRs requested a month. The fraction mentioning each device was: ETT: 8%, CVC: 13%, NGT: 38% (18% of these also mentioning another device). The rates per 100 patient days per month were: NGT pre-Nov 2019: 15.9 [15.0-16.4]. Post-Nov 2019 11.6 [10.1-12.7] (p<0.001), Nov 2019 to February 2020: 12.0 [8.0-13.3], vs Pre Nov 2019 p=0.008. For CVCs pre-March 2019: 4.1 (3.6-4.6) post March 2019: 5.2 (4.6-5.9) (p< 0.001) for ETTs pre-March 2019: 2.8 (2.0-3.3), post-March 2019: 3.1 (2.4-3.7). Changes in monthly rates are shown in the run chart in Figure 1. Conclusions: Changing the method of securing NGTs resulted in a reduction of CXR requests mentioning NGTs, reviewing CXR requests can be used to monitor NGT displacements. The rate of CVC requests increased following March 2020.

Acute Macroglossia: The Conspicuous Brunt of Proning

Introduction: Macroglossia is defined as an enlargement of the tongue in the resting position, protruding beyond the teeth. Many cases have been reported secondary to patient positioning while under anesthesia, post oro-pharyngeal packing, trauma or surgery, and allergic or non-allergic angioedema. However, acute macroglossia in the ICU is a rare situation. In COVID-19 related severe ARDS, endotracheal intubation and prolonged proning is an important part of management of hypoxemic respiratory failure Prone positioning also has the potential to independently cause macroglossia. Awareness of this complication of proning could help mitigate morbidity in patients. Case report: A 53-year-old diabetic, hypertensive overweight female with OSA presented with progressive shortness of breath and productive cough. She was mechanically ventilated in ICU in view of respiratory distress secondary to COVID-19 pneumonia. Intubation was minimally traumatic with minimal oral bleeding settling over few minutes. Though managed with medications as per COVID-19 management protocol, she progressed to severe ARDS hence proned on hospital day 1 for 16 hours - PaO2/FiO2 ratio improved. She was not proned further. Acute macroglossia (3 inches outside the oral cavity) with lower facial edema was noted 4 days post proning. Saline moistened gauze was loosely wrapped around the tongue every hour. Circumferential ecchymosis was noticed around her neck on the 6th day. On day 8, macroglossia did not show signs of resolution. Hence, the tongue was pushed in manually every 2 hourly and the position was maintained manually for 10 minutes. The swelling decreased gradually with the tongue staying in a retracted position on treatment day 2. On day 3, there was a complete resolution of the swelling. However, she had persistent swallowing difficulty causing difficulty in weaning from tracheostomy. MRI of neck and chest showed large pre-vertebral collection from the upper border of C2 inferiorly across the thoracic inlet to the posterior mediastinum with thin linear extension up to the lower border of T4. Mass effect with airway compression, displacement, and compression of esophagus and neck vessels was seen. Trans-oral exploration revealed mucosal rent and bulge in the posterior pharyngeal wall. The hematoma was evacuated by ENT specialists. She was discharged on tracheostomy and feeding tube. Tracheostomy decannulation was done after 1 month. Discussion: In our practice of proning patients with ARDS for >10 years, this is the first case of macroglossia as a complication of proning that we encountered. Other factors that could have contributed to this patient are obesity and mildly traumatic intubation. Development of macroglossia 4 days after proning and resolution over a short period of time is rare and suggests lymphatic and vascular compression as the cause. Later development of ecchymosis and dysphagia may be due to the posterior pharyngeal injury. Conclusion: Proning, especially in obese patients, can be a challenge. Positioning of the face and avoidance of injury to any of the structures is vital to the care of the proned patient. Medical staff involved in patient care should be aware and vigilant to pick up this condition early to avoid further injury.

PEG placements during the COVID-19 pandemic An audit of the procedures performed by a single consultant operator at a tertiary teaching hospital

PEG feeding provides a valuable nutritional access for patients with a functional gastrointestinal tract. The aim of this project was to audit all the PEG procedures performed by a single consultant operator during the Covid-19 pandemic including the indications, outcomes and complications. All the procedure reports were accessed to identify the patients, indications and immediate outcomes. For every patient, all the letters from all specialties were accessed for the dates following the procedure through the clinical records platforms to identify any later complications. A total of 92 procedures were performed between 15/3/2020 and 31/4/2021 in a total of 84 patients. Lists were operating at less than half capacity compared to pre Covid-19. 65 were planned PEG insertions, 17 were planned removals, and 10 were planned replacements. 5 of the procedures were for PEG-J insertion or replacement. The main indication was Head and Neck Ca in 59/92 procedures followed by CVA 9/92, chronic nausea/vomiting/gastroparesis in 6/92, dysphagia with or without aspiration risk in 4/92, MND in 4/92, CNS tumour post-op (pineal gland) in 2/92, cerebral palsy in 1/92, multiple sclerosis in 1/92, neurodegenerative disorder in 1/92, neuromuscular disorder in 1/92, chronic pancreatitis in 1/92, cystic fibrosis in 1/92, depression with poor oral intake in 1/92 and learning difficulties in 1/92. 83/92 procedures were completed successfully. 2 procedures had a failed intubation, 1 because of a subglottal stricture. The rest of the abandoned procedures were due to patient distress (2/92), high oesophageal stricture (1/92), failed cannulation (1/92), body habitus (1/92), stomach not translluminated and patient desaturation (1/92). One of the planned replacements failed because of a buried bumper. In two patients there was a small leak around the PEG site, 1 identified in the endoscopy room, 1 a few weeks later but both were managed conservatively and the PEG was kept in place. No other complications identified. From October 2020 the consistent use of Corflo PEGs reduced the service demands as these can be easily removed in the community. Lists during the COVID-19 pandemic were significantly impacted, especially UGI procedures, as these are aerosol generating procedures. The vast majority of the procedures are completed successfully and there are no significant complications. Most failed procedures are due to patient related factors such as tolerance and anatomical factors. The use of PEGs that can be removed in the community avoiding further endoscopic procedures is a valuable tool especially in this pandemic and early post-pandemic setting.

Evaluation of a new enteral feeding tube nurse clinic at the Weston Park Hospital Radiotherapy department

The Trust provides cancer services for patients across the region. Approximately 300 patients each year receive radiotherapy for head and neck cancer, approximately 50% of these patients have enteral feeding tubes placed. Historically, Dietitians provided support for all patients with enteral feeding tubes receiving radiotherapy treatment and the local nursing service provided by the enteral tube feeding contract provider provided community clinical support. Due to increasing patient numbers and increased Dietetic workload, a new “enteral feeding tube nurse clinic” was introduced, run by the local enteral tube feeding homecare nurse, with the intention of supporting patients with enteral feeding tubes. This clinic has been running since 2019 and is a “drop-in clinic” which both staff and patients’ can access for support, including troubleshooting advice on feeding tubes, moving patients from bolus feeding to pump feeding or even giving patients reassurance that they are caring for their enteral feeding tube correctly. This is a unique service built in conjunction with the Dietetic team, designed to meet local patient’s needs. In 2020 a review took place to evaluate the level of patient satisfaction of care from the enteral feeding tube nurse clinic, to establish the confidence of patients in caring for their feeding tubes and to explore feedback from patients to develop the service further. The review took the form of a patient questionnaire, given to patients during the last week of their radiotherapy treatment. Survey questionnaire forms assessing: the patient’s satisfaction with the support and service (5-point scale: 1 not at all satisfied -5 very satisfied);how confident they felt after receiving the support (5-point scale: 1 not at all satisfied -5 very satisfied), and;about their experience overall (free text), were handed out to patients in clinic over a 6-week period. The questionnaire was completed by 12 patients. For satisfaction with the support and service 10/12 (83%) of patients scored 5: very satisfied, with the remaining 2 patients scoring 3: neutral. Comments from patients included: “nurses always willing to help”, “excellent nurses, great, quick, professional job-no fuss”, “help available whenever it is needed”, “very happy with the care provided”, “every time I have requested their help, I have had a prompt reply and always each problem has been addressed”. For confidence with enteral tube feeding procedures, 100% of patients scored 5: very confident. Comments from patients included: “I feel much happier with the tube”, “very confident in cleaning and rotation, and excellent instructions from nurses”. When asked about their experience overall, patient comments included “Thank you for all your support”, “expert care, friendly, informative”, “fantastic prompt treatment”, “grateful that I have had the support”, “friendly, professional staff are always willing to help and always have said ‘if you need me, just ask, at any time”. Due to Covid-19 the clinics had to temporarily stop, however the Dietitians and Consultants missed the instant and direct access to the homecare nurse for enteral feeding tube support, suggesting that the clinic was also highly valued by the healthcare professionals working at the clinic. In August 2021 the clinics started again and there are plans to expand the service later this year. In summary, the enteral feeding tube nurse clinic was positively evaluated by the patients attending the radiotherapy clinic. The overwhelming feedback was that having contact with an enteral tube feeding homecare nurse at least weekly throughout their radiotherapy treatment allowed them to have rapid access to support, advice, reassurance, and training if their feeding requirements changed. Due to the success of this clinic, development of similar clinics in other areas should be considered.

Is nasojejunal feeding as effective as we think? An evaluation of nasojejunal feeding in the Intensive Care Unit

Early enteral feeding is important in maintaining the integrity of the gastrointestinal tract mucosal barrier and associated with less bacterial translocation and decreased stimulation of the systemic inflammatory response and subsequent improved outcomes in intensive care (ICU) patients. Enteral feeding by nasogastric (NG) tubes is the preferred route of nutritional support for most ICU patients. However, ICU patients with delayed gastric emptying and poor intestinal motility may not tolerate gastric feeding and may therefore benefit from post-pyloric feeding via nasojejunal (NJ) tubes1. We reviewed the effectiveness of 35 NJ tube placement in 24 patients on ICU between January and March 2021. The M:F ratio was 4:1, median age 69 years (30–80 years) and 54% of patients were non-White British. 10 patients (42%) had diabetes and 54% had COVID-19 as part of their admitting diagnoses. The median BMI was 25 (range 20 – 32.3) and none of the patients were identified as high risk for refeeding syndrome at the time of NJ tube insertion. Nutritional information was unavailable on 5 patients. Of the remaining 19 patients, 26% of patients (n=5) were commenced on parenteral nutrition (PN) within 48 hours of NJ insertion. Only 1 patient was able to meet their nutritional requirements enterally via NJ tube at 5 days;a further 2 patients had their nutritional requirements met with supplemental PN. In 8 of 22 referrals the indication for NJ tube insertion was because an NG tube could not be passed. The evaluation revealed discrepancies in adherence to protocols for high gastric residual volumes and prokinetic use. Documentation surrounding decision making, requesting and inserting an NJ tube was poor and probably reflects the complexity of the patients, involvement of multiple clinical teams, and various documentation modalities (i.e., verbal, written and different electronic systems). There was clinical dispute regarding the indication for NJ tube insertion in 23% of cases (documented in 3 of 13 referrals for NJ tube insertion). Where documentation was available 43% of patients (n=10) had an NJ tube placed on the day of request;the median time from request to insertion was 1 day (range 0-10). 5 patients had more than one NJ tube inserted (median 3;range 2–5). There was variation in experience and expertise of the endoscopists placing the NJ tubes. NJ tube feeding is considered to be less expensive and have less complications than PN2. However, our evaluation has revealed a range of issues relating to both the insertion and use of NJ tubes in an ICU setting. The true resource ‘cost’ of NJ tube insertion is probably underestimated in the literature and the complications of PN probably overestimated in the context of modern ICU and nutrition support team clinical practices. We suspect that our clinical experience is not unique and that more research is needed in this area. We are using this work to educate clinical teams, standardise documentation, provide better support and supervision for endoscopists, and raise awareness of the benefit and need for supplemental PN where nutritional requirements are not consistently reached enterally. 1 Schröder S, Hülst S V, Claussen M et al. Postpyloric feeding tubes for surgical intensive care patients. Anaesthetist 2011;60 (3): 214-20. 2 Lochs H, Dejong C, Hammarqvist F et al. ESPEN Guidelines on enteral nutrition: Gastroenterology. Clin Nutr 2006;25(20: 260-74.

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)

A Weighty Matter:Quality Improvement Project in Pediatric Obesity During COVID-19 Pandemic at a Federally Qualified Health Center(FQHC)

Purpose/Objectives: Understand the rates of pediatric obesity in the Inland Empire of Southern California, in the context of COVID quarantine, to improve counseling and treatment of these patients. Design/Methods: A retrospective chart review was performed on all patients seen at a FQHC in Southern California. Patients between 5 and 18, who had a clinic visit between 6/1/2020 to 7/31/2020 for a well-child visit, with at least one other well-child visit in calendar year 2019 and 2018 were included. Patients with congenital heart disease, short gut syndrome, ADHD on stimulant medications, G tube dependence, diseases affecting growth or stature, complex syndromes (CHARGE, VACTERL, DiGeorge), syndromes affected growth, oncologic conditions, intellectual disability, transplant recipients, incomplete BMI data or malnutrition (BMI Z score <= -1) were excluded. BMI values, Z-scores, and percentiles, as well as relative changes from 2018 to 2019, and 2019 to 2020 were analyzed using one-way ANOVA and Tukey post hoc test. Results: There was a statistical difference in BMI between years as determined by a one-way ANOVA (F(2,509) = 2.811, P = 0.05). A Tukey post hoc test revealed that the BMI of students in 2020 was statistically higher (19.87.65, p = 0.05) compared to the BMI in 2018 (18.25.71). There was no statistical difference in BMI between 2020 and 2019, and 2019 and 2018 (Figure 1). When groups were stratified into morbidly obese (BMI >= 99%), obese (BMI >=95% & <99%), overweight (BMI >=85% & <95%), and healthy weight (BMI >=5% & < 85%), patients who were not at a healthy weight increased from 36.8% in 2018 to 40.4% in 2019, to 44.7% in 2020 (Figure 2). As shown in the SANKEY diagram (Figure 3), while there was an initial decline in morbidly obese patients in 2018 to 2019 (-8.3%), there was a relatively large increase from 2019 to 2020 (+45.5%). From 2018 to 2019, 75 out of 141 patients (53.2%) had a decrease in BMI, while in 2019 to 2020 there were 56 out of 141 patients (39.7%) who had a decrease in BMI. Out of the 75 patients who had a decrease in BMI from 2018 to 2019, 49 (65.3%) had a rebound increase in BMI from 2019 to 2020. Conclusion/Discussion: There was a significant increase in overall BMI from 2018 to 2020 with an overall increase in patients who fall into the obese and overweight categories in 2020. 65.3% of patients who had a decreasing BMI from 2018 to 2019 have a rebound increase in BMI in 2020. This can likely be contributed to the COVID-19 pandemic and stay-at-home orders leading to a more sedentary lifestyle. More research should be performed to elicit multifactorial (physical activity, diet, and psychosocial factors) etiology of the worsening obesity epidemic during the COVID-19 pandemic.

SAFETY AND EFFICACY OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) PLACEMENT IN PATIENTS WITH SARS-COV-2 INFECTION

Introduction: Coronavirus Disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a worldwide pandemic. It is primarily a pulmonary disease which can lead to respiratory distress syndrome;some go on to develop ventilator dependent chronic respiratory failure. In these patients, enteral feeding is critical and initially provided by nasogastric (NG) or orogastric (OG) tubes. However, feeding tubes are associated with local complications such as nasopharyngeal/oropharyngeal erosions and esophageal/gastric cardia ulceration. Percutaneous endoscopic gastrostomy (PEG) tube placement facilitates longer-term enteral access. Minimal data exists on the safety and efficacy of PEG tube placement in patients with SARS-CoV-2 infection. Methods: A retrospective chart review was performed to collect data for patients who underwent PEG tube placement between January 2020 to January 2021 at Houston Methodist Hospital. Inclusion criteria included patients who had endoscopic PEG tube placement during this time interval. Exclusion criteria included patients who underwent PEG placement via interventional radiology or surgically. Approval for study was obtained from the Institutional Review Board at Houston Methodist Hospital. Success was defined as PEG placement and use to provide enteral nutrition with no complications over a 4-week period after placement. Results: 36 patients with (mean age 63.6 years;38.8% females) and 104 patients without COVID-19 infection (mean age 64.9 years, 44.2% females) were included in the study. 25 patients were excluded who had missing data, had PEG-J tube placed, or had it placed by interventional radiology initially and exchanged endoscopically during the study period. Table 1 summarizes the main demographic and clinical characteristics of participants. COVID-19 patients were more likely to be obese, be on anticoagulants and have a tracheostomy in place. 11.1% of the patients with COVID-19 developed PEG-related complications compared to 16.3% patients without COVID-19 χ2 with Yate's correction (1, N=140) = 0.23, p=0.65. The success rates of PEG placement in patients with and without COVID -19 were similar at 97.2% and 90.3%, respectively,, χ2(1, N=140) =1.7, p=0.18. Conclusion: This is, to our knowledge, the first study to assess the safety and efficacy of PEG tube placement in patients with SARSCoV- 2 infection. The study demonstrates that despite high BMI and rate of anticoagulant therapy, PEG placement was universally successful, and complication rates no different from those of age- and gender-matched non-COVID-19 patients. PEG tube placement offers a safe and effective means of providing longer term access for enteral nutrition in COVID- 19 patients. (Table Presented)

Stressors Experienced by Primary Caregivers of Severe Acute Brain Injury Patients Recovering from Coma in Neurointensive Care Units: Preliminary Findings from a Multicenter Qualitative Study

Objective: To understand the psychosocial stressors reported by caregivers of severe acute brain injury (SABI) patients recovering from coma in neuroICUs. Background: Caregivers of SABI patients are at risk of developing long-term adverse psychological outcomes following neuroICU discharge, particularly those of patients admitted in a comatose state and remaining disabled. Understanding the top psychosocial stressors reported by these caregivers is critical for design of interventions to improve psychological outcomes. Design/Methods: At the time of neuroICU discharge, we conducted semi-structured, recorded interviews with 15 primary caregivers of SABI patients, all of whom were comatose for greater than 24 hours and needed tracheostomy and/or feeding tube placement. Participants were recruited as a convenience sample from 6 US centers. A codebook for psychosocial stressors was developed from open coding of the first 5 interview transcripts amongst 9 study team members. Using NVivo software, two team members then independently coded each transcript, refined the codebook, and resolved coding discrepancies. Results: Fourteen of 15 caregivers provided demographic data: 13 (92.9%) were female, 5 (35.7%) were racial minorities, and 9 (64.3%) reported fewer than 4 years of college. Six of the 15 (40.0%) patients had recovered to a Glasgow Coma Scale of 9 or higher at the time of interview. The psychosocial stressors most commonly reported by participants were: navigation of the healthcare system, including hospital visitor restrictions due to COVID-19;uncertainty about prognosis;communication with healthcare providers;juggling of practical matters beyond the hospitalization;and navigation of social relationships. Caregivers also referenced challenges with direct caregiving responsibilities, changes to the relationship dynamic with the hospitalized patient, and loss of normality. Conclusions: Across multiple US centers, caregivers of SABI patients in various stages of coma recovery at time of neuroICU discharge share a wide variety of psychosocial stressors. Interventions designed to improve psychological outcomes will need to acknowledge these stressors directly.

Acute food refusal in 12 year old with anorexia nervosa requiring sedation and mechanical ventilation for enteral feedings

Case Report Anorexia Nervosa is a mental health disorder with significant morbidity and mortality. Acute food refusal is one of the indications for admission. We present a patient who went to extreme lengths to restrict food intake, requiring intensive care sedation and ventilation to enable enteral feedings. 12 year old male, was admitted with symptoms of anorexia nervosa and BMI of 12.0, (<1%ile) with baseline BMI of 16 (25%ile), K of 3.3 and glucose of 54. He was treated with supervised eating on an inpatient pediatric floor with no need for enteral feeding. Psychiatry consultation confirmed the diagnosis of anorexia nervosa and recommended the addition of Olanzapine to his Sertraline. He was discharged pending placement in an eating disorder center after 21 days of hospitalization with discharge BMI of 14. He was followed as an outpatient by his pediatrician, dietician and counselor but unfortunately, he required readmission 11 days after discharge due to acute food refusal, with BMI that had dropped to 13.1. Patient was readmitted and started on nasogastric (NG) feeds but he became severely agitated, pulling NG out multiple times and continued to lose weight with BMI dropping to 12. Sedation was attempted to facilitate maintenance of NG feedings, with Benadryl, Haldol and Ativan, but was ineffective at levels deemed safe without compromising his airway and breathing. Due to severe malnourishment and unsuccessful NG feeds he was transferred to PICU for sedation, endotracheal intubation and continuous nasoduodenal (ND) tube feedings on two separate occasions while inpatient. He was able to wean from the ventilator but once awake he found ways to manipulate delivery of his calories, even finding scissors and cutting the ND tube. The patient ultimately agreed to eat in order to avoid replacement of the feeding tube. He was finally transferred to an eating disorder facility, with a BMI of 13.9 and persistent anorexia thinking with restriction of eating anything but pizza. Patient completed three months of an inpatient program and had significant improvement in BMI to 19.3 (70%ile). He was subsequently discharged for continued outpatient follow-up and since discharge from the eating disorder center, his BMI has shown steady improvement in outpatient follow-up. He shows no signs of food refusal and is doing well with Family Based Therapy. This case highlights several unique characteristics in management of eating disorder patients. The age and being male along with extreme food refusal and resistance to enteral feeding that led to the requirement of deep sedation are quite unusual and not well described in the medical literature. The severity of his illness was a significant barrier to inpatient placement. In addition, despite a nationwide attempt to find an inpatient facility for him, which took several weeks, we identified shortages in eating disorder beds that have been exacerbated by the COVID-19 pandemic.

Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen.

BACKGROUND: To meet the surging demands for intubation and invasive ventilation as more COVID-19 patients begin their recovery, clinicians are challenged to find an ultra-brief and minimally invasive screen for postextubation dysphagia predicting feeding-tube dependence persisting for 72 h after extubation. METHODS: This study examined the predictive validity of a two-item swallowing screen on feeding-tube dependence over 72 h in patients following endotracheal extubation. Intensive-care-unit (ICU) patients (≥ 20 years) successfully extubated after ≥ 48 h endotracheal intubation were screened by trained nurses using the swallowing screen (comprising oral stereognosis and cough-reflex tests) 24 h postextubation. Feeding-tube dependence persisting for 72 h postextubation was abstracted from the medical record by an independent rater. To verify the results and cross-check whether the screen predicted penetration and/or aspiration during fiberoptic endoscopic evaluation of swallowing (FEES), participants agreeing to receive FEES were analyzed within 30 min of screening. RESULTS: The results showed that 95/123 participants (77.2%) failed the screen, which predicted ICU patients' prolonged (> 72 h) feeding-tube dependence, yielding sensitivity of 0.83, specificity of 0.35, and accuracy of 0.68. Failed-screen participants had 2.96-fold higher odds of feeding-tube dependence (95% CI, 1.13-7.76). For the 38 participants receiving FEES, the swallowing screen had 0.89 sensitivity to detect feeding-tube dependence and 0.86 sensitivity to predict penetration/aspiration, although specificity had room for improvement (0.36 and 0.21, respectively). CONCLUSION: This ultra-brief swallowing screen is sufficiently sensitive to identify high-risk patients for feeding-tube dependence persisting over 72 h after extubation. Once identified, a further assessment and care are indicated to ensure the prompt return of patients' oral feeding. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

A multi-centre survey reveals variations in the standard treatments and treatment modifications for head and neck cancer patients during Covid-19 pandemic.

BACKGROUND: The onset of the COVID-19 pandemic necessitated rapid changes to the practice of head and neck oncology in UK. There was a delay between the onset of the pandemic and the release of guidelines from cancer societies and networks, leading to a variable response of individual centres. This survey was conducted to assess the pre-Covid-19 pandemic standard of practice for head and neck oncology patients and the treatment modifications introduced during the first wave of the pandemic in UK. METHODOLOGY: The UK National Cancer Research Institute (NCRI) Head and Neck Clinical Studies Group initiated a multi-centre survey using questionnaire to investigate the effect on feeding tube practice, radiotherapy (RT) fractionation and volumes, use of chemotherapy in the neo-adjuvant, concurrent and palliative setting, the use of immunotherapy in the palliative setting, access to radiology and histopathology services, and availability of surgical procedures. RESULTS: 30 centres were approached across UK; 23 (76.7%) centres responded and were included in the survey. There were differences in the standard practices in feeding tube policy, RT dose and fractionation as well as concurrent chemotherapy use. 21 (91%) participating centres had at least one treatment modification. 15 (65%) centres initiated a change in radical RT; changing to either a hypofractionation or acceleration schedule. For post-operative RT 10 centres (43.5%) changed to a hypofractionation schedule. 12 (52.2%) centres stopped neo-adjuvant chemotherapy for all patients; 13 (56.5%) centres followed selective omission of chemotherapy in concurrent chemo-radiotherapy patients, 17 (73.9%) centres changed first-line chemotherapy treatment to pembrolizumab (following NHS England's interim guidance) and 8 (34.8%) centres stopped the treatment early or offered delays for patients that have been already on systemic treatment. The majority of centres did not have significant changes associated with surgery, radiology, histopathology and dental screening. CONCLUSION: There are variations in the standard of practice and treatment modifications for head and neck cancer patients during Covid-19 pandemic. A timely initiative is required to form a consensus on head and neck cancer management in the UK and other countries.