Rapid exchange of a percutaneous gastrostomy tube during an early episode of COVID-19

We retrospectively report a case of rapid exchange of a percutaneous radiologic gastrostomy tube (balloon-occluded type catheter) via off-label use of a pigtail catheter for nutrition supply during a very early episode of coronavirus disease 2019 (COVID-19) in an outpatient clinic. This case demonstrates that minimally invasive percutaneous procedures might be provided safely and effectively under appropriate precautions for preventing COVID-19 transmission during the pandemic.Copyright © 2023, Society of Gastrointestinal Intervention.

Comparison of Comorbidities between Adults and Children with Glycogen Storage Disease Type Ia (GSDIA)

Objectives: Glycogen Storage Disease Type Ia (GSDIa) is a rare inherited disorder resulting in acute hypoglycemia due to impaired release of glucose from glycogen. Despite dietary management practices to prevent hypoglycemia in patients with GSDIa, complications still occur in children and throughout adulthood. This retrospective cohort study compared the prevalence of complications in adults and children with GSDIa. Method(s): Using ICD-10 diagnosis codes, the IQVIA Pharmetrics Plus database was searched for patients with >=2 GSDI claims (E74.01) from January 2016 through February 2020, with >=12 months continuous enrollment beginning prior to March 2019 (for one year of follow-up before COVID-19), and no inflammatory bowel disease diagnoses (indicative of GSDIb). Complication prevalence in adults and children with GSDIa was summarized descriptively. Result(s): In total, 557 patients with GSDIa were identified (adults, 67%;male, 63%), including 372 adults (median age, 41 years) and 185 children (median age, 7 years). Complications occurring only in adults were atherosclerotic heart disease (8.6%), pulmonary hypertension (3.0%), primary liver cancer (1.9%), dialysis (0.8%), and focal segmental glomerulosclerosis (0.3%). Other complications with the greatest prevalence in adults/children included gout (11.8%/0.5%), insomnia (10.0%/1.1%), osteoarthritis (22.0%/2.7%), severe chronic kidney disease (4.3%/0.5%), malignant neoplasm (10.8%/1.6%), hypertension (49.7%/8.7%), acute kidney failure (15.3%/2.7%), pancreatitis (3.0%/0.5%), gallstones (7.8%/1.6%), benign neoplasm (37.4%/8.1%), hepatocellular adenoma (7.0%/1.6%), neoplasm (41.1%/9.7%), and hyperlipidemia (45.2%/10.8%). Complications with the greatest prevalence in children/adults included poor growth (22.2%/1.9%), gastrostomy (29.7%/3.2%), kidney hypertrophy (2.7%/0.8%), seizure (1.6%/0.5%), hypoglycemia (27.0%/11.3%), hepatomegaly (28.7%/15.9%), kidney transplant (1.6%/1.1%), diarrhea (26.5%/18.6%), nausea and/or vomiting (43.8%/35.8%), acidosis (20.0%/17.2%), and anemia due to enzyme disorders (43.8%/40.6%). Conclusion(s): GSDIa is associated with numerous, potentially serious complications. Compared with children, adults with GSDIa had a greater prevalence of chronic complications, potentially indicating the progressive nature of disease. Children with GSDIa had more acute complications related to suboptimal metabolic control.Copyright © 2023

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.

Holy Foley: Iatrogenic Duodenal Obstruction From a Make-Shift Gastrostomy Tube

Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Evaluation of patients with negative PCR tests after COVID-19 pneumonia in intermediate-level intensive care unit

Objectives: The need for an intensive care unit has increased during the pandemic of coronavirus disease (COVID-19). For this reason, intermediate-level intensive care units (IICUs) were established in hospitals worldwide. This study aims to evaluate the data of patients that hospitalized in IICU. Method(s): Patients under treatment for COVID-19 were followed up in IICU after the negative polymerized chain reaction test. A total of 52 patients were evaluated retrospectively between August 24, 2020 and March 1, 2021. The patients were divided into two groups according to discharge status from IICU (Group 1: exitus, Group 2: transferred to clinic, or discharged home). Demographic data, comorbidities, Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), treatments and procedures, and complications were recorded. Result(s): Seventeen (32.7%) of 52 patients who were followed up in IICU died. Thirty-five patients (67.3%) were transferred to the clinic or discharged home. The APACHE II scores at admission to IICU were higher in Group 1 (26.11 +/- 5.86) than in Group 2 (23.43 +/- 6.32) but not statistically significant. GCS was statistically significantly lower in Group 1 than in Group 2 (7.82 +/- 2.42 and 10.25 +/- 2.58, respectively, p = 0.002). Mechanical ventilation rate (82.3%) and the need for inotropic agents (76.5%) were higher in Group 1 (p = 0,034 and p < 0.001, respectively). Tracheostomy was applied to 5 of all patients, and percutaneous endoscopic gastrostomy was performed 4 of them. Conclusion(s): We think that IICU created during the pandemic provides effective treatment for patients needing intensive care. We think IICU is beneficial in providing quick patient discharge in tertiary intensive care units.Copyright © 2023 by Prusa Medical Publishing.

Severe epidermolysis bullosa acquisita in a patient with graft-versus-host disease: causal or coincidental?

Graft-versus-host disease (GvHD) is common after haematopoietic cell transplantation (HCT). Mucocutaneous manifestations are variable and may simulate autoimmune bullous dermatoses. However, the association of GvHD with autoimmune disorders, including bullous dermatoses, is also well recognized. We describe a patient with GvHD in whom severe and relapsing epidermolysis bullosa acquisita (EBA) was diagnosed 3 years after transplant and propose a causal association with GvHD. A 66-year-old woman developed GvHD following allogeneic HCT for acute myeloid leukaemia in 2016. This affected her gastrointestinal tract and skin but improved with oral corticosteroids and ciclosporin. In 2019 she presented with a widespread rash consisting of large, tense, haemorrhagic blisters. Histological features were in keeping with EBA. Direct immunofluorescence was also consistent with EBA, demonstrating linear positivity for IgG and C3 confined to the blister base, as was detection of collagen VII antibodies on indirect immunofluorescence. She was admitted and treated with high-dose oral steroids, ciclosporin and intravenous immunoglobulin (IVIg) with eventual resolution of blistering. Although further IVIg administration was planned as an outpatient, this coincided with the start of the COVID-19 pandemic and she elected not to attend and also stopped all medication. Despite this, her EBA remained quiescent until September 2021 when she was readmitted with a severe deterioration in blistering and significant dysphagia due to an oesophageal stricture, with a weight of 31.7 kg. Once again, she responded rapidly to oral prednisolone and IVIg. Dapsone was considered but precluded by G6PD deficiency and there were clinical and adherence concerns about using mycophenolate mofetil. Upon discharge she was again nonadherent to medication and failed to attend for planned IVIg. She flared and was admitted for a third time in December 2021, requiring gastrostomy for nutritional support;her weight at this time was 26.4 kg. Her EBA is currently well controlled on prednisolone and IVIg. EBA is a rare, acquired blistering disorder secondary to autoantibodies targeting type VII collagen. Previous studies have found circulating basement membrane zone (BMZ) antibodies in 24% of chronic GvHD patients, possibly generated in response to chronic BMZ damage (Hofmann SC, Kopp G, Gall C et al. Basement membrane antibodies in sera of haematopoietic cell recipients are associated with graft-versushost disease. J Eur Acad Dermatol Venereol 2010;24: 587-94). Corresponding clinical manifestations are rare, with bullous pemphigoid the most frequently reported. EBA is much less common with four previously reported cases [Brassat S, Fleury J, Camus M, et al. (Epidermolysa bullosa acquisita and graftversus- host disease). Ann Dermatol Venereol 2014;141: 369-73 (in French)]. As a fifth case of EBA, our patient provides further evidence of a likely pathophysiological relationship between GvHD and autoimmune subepidermal bullous dermatoses, and highlights the significant challenges of managing these vulnerable patient groups during the COVID-19 pandemic.

Acute motor and sensory axonal neuropathy in a patient with undiagnosed mixed connective tissue disease

Case Report: Acute motor and sensory axonal neuropathy (AMSAN) syndrome is a rare subtype of Guillain-Barre syndrome (GBS) with poor recovery [1]. While respiratory and gastrointestinal infections may precipitate AMSAN, an underlying autoimmune disorder is seldom reported in literature. We herein report the complex case of a patient with undiagnosed, asymptomatic mixed connective tissue disease (MCTD) who developed AMSAN syndrome. Case: A 44-year-old Asian male without medical history presented with progressively worsening weakness of both upper and lower extremities and inability to perform daily activities. His symptoms started 12 weeks prior with difficulty standing from a seated position. He felt subjectively better for some time until a week prior, when he became bedbound. He had diarrhea 6 months ago, with 5-6 loose bowel movements a day for a few weeks. Vital signs on admission was normal. On neurological examination, he was alert and oriented, with bilateral upper and lower extremity flaccid paralysis, diffuse muscle atrophy, bilateral hand and foot drop, negative Hoover sign, diffuse areflexia, and intact sensation. Cerebrospinal fluid (CSF) analysis showed WBC 0 and protein level 136. MRI cervical, thoracic, and lumbar spine were normal. EMG revealed sensory involvement with positive sharp waves in proximal muscles along with fibrillations. Intravenous immunoglobulin (IVIG) was initiated at 0.4 mg/kg for 5 days. Infectious workup for COVID-19, stool culture, HIV, TB, RPR and campylobacter jejuni antibody (Ab), was negative. ANA was positive in a speckled pattern with titres 1:1280, with a positive RNP Ab, SS-A, and RF IgM, IgG and IgA. Rest of the autoimmune workup (anti-dsDNA, anti-CCP, SS-B, aldolase, anti-Jo-1, anti-Scl-70, p-ANCA, c-ANCA, anti-GM1, anti-GQ1b, and anti-GD1a ganglioside Ab) was negative. The myositis specific 11 Ab panel was negative. Despite IVIG therapy, he developed dysphagia, respiratory distress, with a negative inspiratory force of -0, requiring intubation. He had a tracheostomy and PEG tube placed and remains quadraplegic nearly 120 days later. Discussion(s): The authors report a unique case of a patient who became progressively weak over 3 months, leading to complete quadriplegia. Interestingly, this is more consistent with chronic inflammatory demyelinating poly-neuropathy (CIDP), as AMSAN typically develops over a short period of 2 to 4 weeks [2]. Despite having negative anti-GM1 and anti-GD1a Ab (in which positive Ab are pathognomonic but not always present in AMSAN syndrome), the patient had weakness that began in the lower extremities, progressing to paralysis, along with albuminocytological dissociation on CSF analysis, pointing to a GBS diagnosis [3]. He had sensory involvement in the EMG, thus making the diagnosis as AMSAN. He had an undiagnosed, asymptomatic autoimmune process most consistent with MCTD. Whether the two disease processes are related to each other is a concept that has not yet been investigated. Pediatric Clinical Case Reports Concurrent Session Saturday February 4, 2023 1:00 PM Copyright © 2023 Southern Society for Clinical Investigation.

Unusual case of Obesity and Hypoventilation in Childhood

Objectives Childhood obesity can be monogenic or polygenic in etiology and is associated with significant morbidities. Rapid-onset obesity with hypoventilation, hypothalamic dysfunction, and autonomic dysregulation, and neural crest tumor (ROHHHAD[NET]) syndrome, is a rare autonomic and respiratory pediatric disorder presenting with rapid weight gain in early childhood, hypothalamic-pituitary dysfunction, central hypoventilation, and an association with neural crest tumors. Methods A 6-year-old Asian girl with abnormal weight gain since the age of 3 years, presented to the pediatrician's office due to pulse oximeter readings in the 60s at home. Parents were monitoring saturations at home as a way of screening for COVID-19 infection. The pediatrician confirmed hypoxemia and transferred the patient to the Children's Medical Center emergency department on oxygen via EMS. She had occasional snoring and nighttime cough, but no history of respiratory distress, or signs of infection. There was no hyperphagia, neonatal hypoglycemia, or developmental or behavioral concerns. On examination her body weight was 30 kg (+1.56 SD) and height was 113 cm (-1.46 SD) with a body mass index (BMI) of 23.4 kg/m2 (+2.33 SD). No acanthosis nigricans, cushingoid features, or respiratory distress were noted on examination. In the intensive care unit, she was diagnosed with central hypoventilation requiring mechanical ventilation. Her laboratory work-up revealed central hypothyroidism (low Free T4 of 0.64 ng/dl, TSH 1.553 microIU/L). Other anterior pituitary hormones were normal (adrenocorticotropic hormone, 16.3 pg/mL;cortisol, 10.7 mug/dL;prolactin, 9.95 ng/ml;Insulin-like growth factor-1, 83 ng/mL;and IGF binding protein 3, 3.02 mg/L). Genetic investigations revealed no known mutations in the PHOX2B gene, making a diagnosis of central hypoventilation syndrome unlikely. Results Rapid onset weight gain around 3 years of age, central hypoventilation, and anterior pituitary hormone deficiency in our patient with negative PHOX2B is consistent with a clinical diagnosis of ROHHHAD[NET]. Our patient was started on levothyroxine;received tracheostomy for mechanical ventilation;and gastrostomy for pharyngeal dysphagia. She is doing well, goes to school, and is tolerating trials off the ventilator during the day. Conclusions ROHHAD is an important differential to consider for any child with rapid and early obesity and hypoventilation as early diagnosis is critical in improving the clinical management and the prognosis.

Effect of COVID-19 pandemic on children undergone percutaneous endoscopic gastrostomy due to neurologic diseases

Aim: To investigate the effects of SAR-CoV-2 infection on nutritional status in patients who underwent percutaneous endoscopic gastrostomy (PEG) for neurological disorders.Methods: The clinical and laboratory follow-up data of the patients who underwent PEG in our clinic between 2002 and 2018 were evaluated before and during the pandemic. The results were analyzed statistically.Results:Twenty patients were included. They were 70.9±64.4 months old at the time of PEG, 97.9±67.8 months before the pandemic, and 105.5±60.8 months during the pandemic (p=0.048). Weight for age at the time of PEG increased from 10.7±4.6 kg to 15.6±7.2 kg before the pandemic. Hemoglobin was 12.3±1.4 g/dl at the time of PEG, 13.5±1.6 g/dl before the pandemic (p=0.045). Vitamin D was 24.1±8.9 ng/ml at the time of PEG and increased to 45.7±9.7 ng/ml during the pandemic (p=0.018). The annual number of visits before the pandemic was 9.8±5.7 and decreased to 2±1.7 during the pandemic (p=0.003). Twelve (%60) of the patients developed PEG complications, 6(30%) had their PEG replaced. Those who had developed PEG complications had low levels of albumin (3.3±0.4 vs 4±0.4 g/dl, p=0.022) and vitamin B12 (578±199 vs 1299±533 pg/ml, p=0.007).Conclusions:Even if PEG is applied late, it provides a partial improvement in patients, but the COVID-19 pandemic reversed these benefits and caused an increase in PEG complications. In order for the patient to get the maximum benefit from PEG, close follow-up is essential.

Bringing health care closer to patients - Two years of the home care ALS programme in Slovenia

Ljubljana ALS Center takes care of the majority of patients with ALS in Slovenia. Due to limited access to health care during COVID-19 pandemic, we have started a home care ALS programme to improve care of patients with ALS. We developed eligibility criteria to decide which patients could benefit from home visits. The criteria included problematic transport due to patient immobility, mechanical ventilation use, gastrostomy-related problems and need for advanced directives discussion. During March 2020 and March 2022, we performed 190 home visits in 67 patients. This represents 20% of all ALS out-patient visits and 30% of the patients treated at our center during this period. The patients were visited on average every 3.3 months (range between visits 3 days -15 months). Only 4% of the visits were done due to a sudden unexpected clinical deterioration. The neurologist that performed home visits was usually accompanied by one or two members of our multidisciplinary team (mostly by respiratory therapist and sometimes by nurse, social worker or team coordinator). 58% of the patients visited were using gastrostomy, 72% were using noninvasive ventilation (NIV) and 9% were using invasive ventilation (IV). The main procedures/tasks performed at home visits were: arterial blood gasses analysis (in 72% of all visits), assessment of NIV (in 60%), adjustment of symptomatic therapy (in 41%), advance directive regarding mechanical ventilation (in 28%), prescription of existing therapy (in 13%), discussion on possible gastrostomy (in 13%), gastrostomy assessment (in 10%), gastrostomy care (in 10%), replacement of gastric tube (in 5%), assessment of IV (in 5%), botulinum toxin application (in 5%), decision to withhold treatment (in 4%), introduction of NIV (in 2%), introduction of cough assist (in 2%), discussion on treatment withdrawal (in 1%). The home care ALS programme provides an improved health care for patients with ALS, especially for those in advance stages of the disease. Many of these patients would probably not be able to attend regular out-patient visits at the hospital. The multidisciplinary programme integrates different aspects of ALS care, the most important being home ventilation and palliative care. Based on our experience, it can be cost and time effective with appropriate planning. The programme has recently received long-term funding by the Health Insurance Institute of Slovenia as a part of mobile palliative teams initiative.

Safety of Percutaneous Endoscopic Gastrostomy Placement in Patients With SARS-CoV-2 Infection.

Background: Coronavirus disease 2019 (COVID-19) can lead to ventilator-dependent chronic respiratory failure and a need for tube feeding. Percutaneous endoscopic gastrostomy (PEG) placement provides more sustainable longer-term enteral access with fewer side effects compared to the long-term nasogastric tube placement. Bleeding is a recognized complication of PEG placement, and many COVID-19 patients are on antiplatelets/anticoagulants, yet minimal data exist on the safety of PEG tube placement in this context. Methods: A retrospective chart review identified patients who underwent PEG placement between January 2020 and January 2021 at a single institution. Success was defined as PEG placement and use to provide enteral nutrition with no complications requiring removal within 4 weeks. Results: Thirty-six patients with and 104 age- and sex-matched patients without COVID-19 infection were included. More COVID-19 patients were obese, on anticoagulants, had low serum albumin levels and had a tracheostomy in place. Of those patients, 8.3% with COVID-19 developed PEG-related complications compared to 16.3% without (P = 0.28). PEG success rates in patients with and without COVID-19 were similar at 97.2% and 92.3%, respectively (P = 0.44). Conclusion: PEG tube placement is comparatively safe in COVID-19 patients who need long-term enteral access.

POST HOC ANALYSIS OF IMPLEMENTING BEDSIDE PERCUTANEOUS ULTRASOUND GASTROSTOMY IN A CRITICAL CARE UNIT: ASSESSING ADVERSE EVENTS AND SEVERITY OF ILLNESS BETWEEN GROUPS

SESSION TITLE: Late Breaking Investigations From Pulmonary and Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Critical care patients receive over 50% of gastrostomy tubes placed in the United States. Studies support performing concomitant tracheostomy and gastrostomy to improve efficiencies in care and reduce healthcare costs. Prior research has supported the safe performance of Percutaneous Ultrasound Gastrostomy (PUG) by interventional radiologists. Our recent study, Length of Stay and Hospital Cost Reductions After Implementing Bedside Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit, demonstrated that PUG placement by ICU physicians in patients with ventilator-dependent respiratory failure significantly reduced ICULOS and hospital LOS by 5 and 8 days respectively, and total hospital costs by $26,621 per patient. 70% of PUG procedures were performed concomitantly with tracheostomy (TPUG), compared to 0 in the usual care gastrostomy group. We now report a post hoc safety analysis assessing adverse events and patient comorbidity between these groups. METHODS: Post hoc analysis was performed on a retrospective cohort of patients with ventilator-dependent respiratory failure, grouped by those who received a gastrostomy consultation with gastroenterology or interventional radiology (usual care) and those who received a bedside PUG by a critical care physician. Adverse events related to gastrostomy placement were compared between groups using Fisher’s Exact tests. Charlson Scores were calculated for each patient and compared, as well as for the subgroup of patients with adverse events, using Student’s t-tests. RESULTS: There were 43 patients in the usual care group and 45 in the PUG group. Adverse events (AEs) in the usual care group totaled 16;7 major and 9 minor. AEs in the PUG group totaled 13;5 major and 8 minor. There were no significant differences between groups related to AEs (p=0.498). 28 of the usual care patients and 31 of the PUG patients were COVID-19 positive, respectively (p=0.71). The usual care and PUG groups had average Charlson scores of 2.88 (SD 2.13) and 3.23 (SD 2.32), respectively (p=0.537). The subgroup of patients with complications in each group had statistically equivalent Charlson scores (p=0.624). CONCLUSIONS: Our analysis demonstrates no difference in adverse events between PUG and usual care. PUG may be safely performed by Critical Care physicians at the bedside and in combination with tracheostomy. Performing PUG as the initial gastrostomy option in ventilatory-dependent patients decreases LOS and total hospital costs, without negatively affecting procedural adverse events. CLINICAL IMPLICATIONS: This research supports PUG as a safe method of gastrostomy placement by Critical Care physicians which may be performed at the bedside concomitantly to tracheostomy, driving reductions in ICULOS, hospital LOS, and total hospital costs per patient, with no significant increase in adverse events. DISCLOSURES: No relevant relationships by Jason Heavner No relevant relationships by Jeffrey Marshall No relevant relationships by Peter Olivieri No relevant relationships by Janelle Thomas No relevant relationships by Hannah Van Ryzin No relevant relationships by R. Gentry Wilkerson

DISSEMINATED HERPES ZOSTER VIRUS INFECTION FOLLOWING BARICITINIB IN COVID-19

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Baricitinib with Remdesivir has been Food and Drug Administration (FDA) approved for hospitalized COVID-19 pneumonia patients requiring supplemental oxygen and is used across the United States. However, limited post-marketing surveillance data is currently available for these drugs. We present a case of an unvaccinated, immunocompetent patient with Herpes-Zoster virus (HZV) infection following baricitinib administration. CASE PRESENTATION: A 66-year-old African-American male with unknown vaccination status for Herpes zoster presented with worsening shortness of breath for 1 week. He had an SpO2 85% on presentation however had to be subsequently intubated due to worsening hypoxia in the ER. Cardiorespiratory exam was remarkable for diminished bibasilar breath sounds. Lab work was significant for positive COVID-19, elevated leukocytes and deranged inflammatory markers. CT chest showed bilateral ground glass opacities. He received a 14 day course of baricitinib, 10 days of dexamethasone and 5 days of remdesivir during his hospital stay. Tracheostomy and percutaneous endoscopic gastrostomy were performed due to prolonged vent dependence. On day 37 of hospitalization, the patient developed vesicular rashes over his left shoulder and anterior chest. Disseminated HZV infection was confirmed based on serologic testing. Patient received 7 days of valacyclovir with complete resolution. He was eventually discharged to a pulmonary rehabilitation center. DISCUSSION: Baricitinib was first developed for patients with rheumatoid arthritis and has been used in the treatment of rheumatoid arthritis and acts by reversible inhibition of JAK1 and JAK2. These proteins have been implicated in COVID-19 pathophysiology;promoting intracellular assembly of SARS-CoV-2 and subsequent cytokine release. Baricitinib in COVID-19 leads to the inhibition of proinflammatory cytokine release, antibody production, monocyte activation and viral proliferation. [1] There have been several studies published in support of Baricitinib induced HZV infection in rheumatoid arthritis patients, however there is little data available in COVID patients. Nonetheless, immunomodulatory action is the same. A study comparing the incidence rate (IR) of Baricitinib emergent HZV infection per 100 patient years (PY) vs placebo found IR/100PY 4.3 (p<_0.01) vs 3.1 (p not significant) [2]. Another study found the HZV IR vs placebo of 4.3 vs 1.0, with all-bari-RA IR was 3.2 (95% CI 2.8-3.7) [3]. In our case, the patient developed HZV infection after baricitinib treatment, demonstrating its immunomodulatory effects. CONCLUSIONS: This case demonstrates the ability of baricitinib to cause immunosuppression and hence causing HZV infection in COVID-19 affected patients. Reference #1: Schwartz DM, Bonelli M, Gadina M, O'shea JJ. Type I/II cytokines, JAKs, and new strategies for treating autoimmune diseases. Nat Rev Rheumatol. 2016;12(1):25. Reference #2: Kevin L, Masayoshi H, Mark C et al. Infections in baricitinib clinical trials for patients with active rheumatoid arthritis. Ann Rheum Dis.2020 Oct;79(10):1290-1297. Reference #3: Joseph S, Mark C, Tsutomu T et al. Safety profile of Baricitinib in patients with active rheumatoid arthritis with over 2 years median time in treatment. The Journal of Rheumatology January 2019, 46 (1) 7-18;DOI: https://doi.org/10.3899/jrheum.171361 DISCLOSURES: No relevant relationships by Mark Aloysius No relevant relationships by Gursharan Kaur No relevant relationships by Mohammed Musa Najmuddin No relevant relationships by mashu shrivastava

Development and Implementation of DIGEST: The Digital Interactive Gastroenterology Education Suite for Trainees

Purpose/Objectives: Clinical clerkship curricula should exist to provide rotating learners on subspecialty rotations with consistent exposure to specific topics geared towards the discipline of interest, such as Pediatric Gastroenterology (GI). In the spring of 2020, the COVID-19 pandemic forced the medical community to pivot to both virtual patient care and medical education. Many teachers were forced to transition their curricula away from traditional, in-person didactics to asynchronous, on-line learning. We developed the Digital Interactive Gastroenterology Education Suite for Trainees (DIGEST) a novel pediatric gastroenterology curriculum on GOOGLE classroom for rotating learners. Our aims were to assess the curriculum and to study learning outcomes amongst trainees. Design/Methods: A general needs assessment in 2019 identified a lack of standardized educational experience amongst the rotating learners on Pediatric GI service. We developed DIGEST to provide a standardized educational experience for all learners. Our resource acquisition method included interrogation of the Pediatrics in Review (PIR) subject collections, review of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) CPG repository, and a search for topics of interest on MedEd Portal. We organized these resources using a simple, subject-based (i.e. Constipation) format for the classroom: Required readings, Supplemental (optional) readings, Videos & Podcasts and simulations (Figure 1). Next, a “Rotation Passport” was created to guide learners' expectations during the rotation, to facilitate a balance between educational activities and patient care, and to eliminate differences in educational exposures, or clinical opportunities which could be affected by seasonal variations in disease processes or presentations. DIGEST addressed procedural skills using low-fidelity human patient simulation (LFHPS) scenarios from MedEd Portal including: nasogastric tube placement, gastrostomy replacement, and abdominal radiograph interpretation. The COVID-19 pandemic compelled us to transition this program from our departments' secure share drive to the GOOGLE classroom. Learners assessed DIGEST and the LFHPS using the physician assistant clinical rotation evaluation (PACRE) instrument and the Student Satisfaction and Self-Confidence in Learning scale (SSSCL), respectively. We targeted a composite score > 4 (Likert scale 1- 5;1-Strongly Disagree, 5-Strongly Agree) for all questions. Finally, the curriculum quality of DIGEST was evaluated by a Health Professions Education expert using the Course Review Report Rubric. Results: 7 possible learners participated and responded to the questionaires (100% response rate). Learners reported a superior learning experience and increased confidence with DIGEST (Table 1). The HPE expert reported that the course design of DIGEST met or exceeded expectations in all categories. Conclusion/Discussion: DIGEST is a novel pediatric gastroenterology curriculum for rotating learners could be easily deployed, or replicated, for civilian Pediatric GI divisions to use with their learners or expanded on a larger platform to enhance learning for a wider audience. (Table Presented).

LARGE ISCHEMIC STROKE AS A COMPLICATION OF COVID-19

CASE: Patient is a 67-year-old white male who is from Ohio who has a past medical history significant for diabetes mellitus type 2, essential hypertension and hyperlipidemia. He presented to the emergency department with complaints of generalized weakness and shortness of breath. He was vaccinated against COVID about 3-4 months ago. Dyspnea has been progressive over several days. Initial laboratory values and vital signs in the emergency department were pertinent for a heart rate 92/min, blood oxygen saturation of 93% on 5 L nasal cannula, ESR 40, CRP 22.9, D-dimer 21.1, positive for COVID-19 on PCR. Chest x-ray showed developing multifocal infiltrates consistent with COVID-19 pneumonia. Patient was started on dexamethasone, remdesivir, ceftriaxone, azithromycin and was placed on low molecular weight heparin for DVT prophylaxis regimen during the first few hours of admission. We continued standard therapies but the patient's oxygen requirements increased. During this hospitalization patient became acutely unresponsive and was noticed that he was not moving his right side. A stroke work-up was undertaken MRI brain/head without contrast showed large left MCA territory infarction, no acute hemorrhage has been identified, loss of flow void within the left intracranial ICA, suggesting obstruction versus high-grade stenosis. Echo showed normal LV systolic function. MRA of the head and neck showed occluded left ICA and left MCA. Unfortunately due to the size of the infarction the patient was not a candidate for full dose anticoagulation.Eventually patient was not following commands, remained unresponsive and had persistent dysphagia for which he had PEG tube placement. Family has been updated on his clinical status and overall prognosis is poor. IMPACT/DISCUSSION: The incidence of stroke has been reported in 5.7% of patients with severe COVID-19 and in 0.8% of patients with nonsevere infection.The frequency of stroke detected in hospitalized COVID-19 patients was 1.1% associated with older age and stroke risk factors.Early-onset cerebrovascular disease is more common in COVID- 19 patients with underlying cerebrovascular risk factors including older age (>65 years).The significant increase in D- dimer levels like our patient suggests that COVID-19 can induce an inflammatory response and trigger a hypercoagulable state causing an acute ischemic stroke .The hypercoagulable state in patients with COVID-19 supports the formation of small and/or large blood clots in many organs such as the brain, which have the potential to cause cerebrovascular disease.Increased D-dimer levels confirm the theories of endothelial activation and hypercoagulability. CONCLUSION: Our case report highlights the fact that COVID-19 is a risk factor for acute ischemic stroke along with other underlying cerebrovascular risk factors such as diabetes, hypertension and hyperlipidemia like in our patient. We should be aware of these neurological symptoms and act promptly in the evaluation of stroke in COVID-19 patients.

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)

PERCUTANEOUS GASTROSTOMY PLACEMENT IN PATIENTS WITH COVID-19 INFECTION: CLINICAL OUTCOMES AND THE INFREQUENT NEED FOR LONG-TERM ENTERAL ACCESS

Introduction: The global pandemic caused by SARS-CoV-2 (COVID-19) has caused respiratory failure and prolonged intubation in millions of patients. As rates of new hospitalizations in America for COVID-19 decline, clinicians must now address maintenance management of a prolonged illness. Gastrostomy tubes provide a method for enteral feeding over a prolonged period of critical illness and recovery. Understanding outcomes in COVID-19 infected patients after gastrostomy tube placement and rates of long-term enteral feeding requirements is necessary in order to ensure proper allocation of a limited resource and guide patient decision making, and has not been previously studied. We sought to identify clinical factors associated with in-hospital mortality after gastrostomy tube placement and describe rates of long-term gastrostomy tube requirements. Methods: All adult patients undergoing gastrostomy tube placement admitted with COVID-19 between 1/1/2020-5/1/ 2021 at two of Northwell Health tertiary referral centers in New York were identified. We analyzed medical history, hospital course, procedural details, respiratory status at time of gastrostomy, long-term gastrostomy needs as well as risk factors for mortality. Results: A total of 155 patients underwent gastrostomy tube placement during the study period. The mean age was 64 years old, 61% were male, and mean duration of time from intubation to gastrostomy tube placement was 35 days. 73% of patients were ventilator dependent at time of gastrostomy tube placement. (Table 1) Overall, 27% (n=42) of patients expired during index admission after gastrostomy tube placement. In-hospital mortality was associated with ventilator dependence at time of gastrostomy placement (OR 4.8133, 95% CI, p=0.005). In-hospital mortality was not associated with age, elderly status, obesity, medications, or duration of intubation. (Table 2) Among the 113 patients discharged from index admission, post-discharge follow-up was available for 111 patients, with average follow-up time of 127 days. Among patients with follow-up, 61% (n=68) no longer required gastrostomy tube at follow-up visits. Discussion: Gastrostomy tube placement is often performed in patients with prolonged critical illness. With limited clinical clues to predict recovery from COVID- 19 induced respiratory failure, physicians should attempt to optimize respiratory status prior to gastrostomy tube placement, as ventilator dependence is associated with in-hospital mortality after gastrostomy placement. Families should be counseled that the majority of COVID-19 patients surviving the hospitalization will not require long-term gastrostomy tube feeding.(Table Presented)(Table Presented)