Left Vocal Cord Palsy Immediately After COVID-19 Despite No Tracheal Intubation.

The cases of coronavirus disease 2019 (COVID-19) typically present with pulmonary and upper respiratory tract symptoms, but may also present with neurologic complications. Because severe cases are often intubated or ventilated, there are some reports of vocal cord palsy associated with intubation; however, there are few reports of recurrent nerve palsy without intubation management. We experienced a case of left vocal cord palsy following COVID-19 in a healthy young male patient with no previous medical history. The patient became aware of hoarseness symptoms three days after he was found to be COVID-19 positive, and an endoscopic examination of the larynx revealed left vocal cord palsy. Since the patient had no previous medical history and there were no lesions that could cause recurrent nerve palsy on neck-thorax imaging, it was considered likely that the patient had unilateral recurrent nerve palsy due to acute inflammation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Medication was started and his hoarseness became relieved. In vocal cord palsy occurring after COVID-19 illness, it is necessary to consider the presence of both vocal cord palsy related to tracheal intubation and recurrent nerve palsy associated with SARS-CoV-2 infection.

S2k-Guideline SARS-CoV-2, COVID-19 and (early) rehabilitation - a consensus-based guideline for Germany.

The consensus-based guideline "SARS-CoV-2, COVID-19 and (early) rehabilitation" for Germany has two sections: In the first part, the guideline addresses infection protection-related procedures during the COVID-19 pandemic. In the second part, it provides practice recommendations for rehabilitation after COVID-19. The specific recommendations for rehabilitation after COVID-19 as issued by 13 German medical societies and two patient-representative organizations are presented together with general background information for their development.

Neurogastroenterology & Motility Manifestations After COVID-19 Infection: A Case Series

Introduction: In a subset of Covid19-convalescent patients, a multitude of long-term sequelae are increasingly being reported. We report 4 cases with varying neuro-GI and motility manifestations after recent COVID-19 infection. Case Description/Methods: Case 1: A 23-year-old man contracted COVID-19 and had a protracted course of respiratory illness. Despite resolution of respiratory symptoms and dysgeusia, he continued to experience early satiety, postprandial nausea, vomiting and unintentional weight loss. Gastric Emptying Scan (GES) revealed gastroparesis (Figure A). Dietary modification and metoclopramide led to symptomatic improvement. Case 2: A 39-year-old woman with migraines, suffered from Covid-19 infection where anosmia and respiratory symptoms lasted for 2 weeks. Despite resolution of initial symptoms, she started experiencing nausea and vomiting, and reported stereotypical symptoms with complete absence of vomiting between episodes. Endoscopic examination, CT head and GES were normal. Urine tox screen was negative for cannabinoids. She responded favorably to amitriptyline and ondansetron. Case 3: A 47-year-old man started experiencing severe constipation associated with abdominal pain and bloating soon after being diagnosed with COVID-19. Three months after resolution of respiratory symptoms, in addition to constipation, he began reporting postprandial fullness, early satiation and epigastric pain. GES showed gastroparesis ( figure B) and a Sitzmarks Study revealed delayed colonic transit (Figure C). Prucalopride was started, leading to improvement in symptoms. Case 4: A 74-year-old woman with obesity and diabetes, was hospitalized and intubated for severe respiratory distress due to COVID-19. After discharge, she had persistent symptoms of brain fog, fatigue, dyspnea as well as diarrhea and abdominal cramping, persisting despite loperamide and dicyclomine. C. difficile toxin, random colonic biopsies and H2 breath test were unremarkable. Her symptoms eventually improved with rifaximin. Discussion(s): We report 4 cases with post-COVID gastroparesis, cyclical vomiting syndrome, pan-gut dysmotility, and post-infectious IBS phenotypes.The pathophysiology of post-infectious-gut-brain disorders is still obscure. The current conceptual framework implicates acquired neuropathy, altered motility, intestinal barrier disruption and persistent intestinal inflammation. Similar pathophysiology may be involved in COVID-19 infection leading to sustained neurogastroenterological dysfunction and gut dysmotility.

Ndegree35 - Neurophysiology solving the vomiting dilemma

Objectives: Post Covid severe vomiting together with proximal muscle weakness is a misleading combination, this describes a rare but definite clinical association between myasthenia gravis and autonomic failure and strengthen the concept that subacute autonomic neuropathy is an autoimmune disorder. Content: A 39 ys old adult female presented with postCovid severe vomiting for one year with 40 kgs loss Upper gastrointestinal endoscopy revealed gastric dilatation associated with eosophageal and gastric stasis and hypertrophic pyloric stenosis. the gastroenterologist sought neurological consultation for the coexisting unexplained limb weakness before operation EMG & NCV was all normal except instability of the MUAPs Slow rate Repetitive supramaximal stimulation (RNS) revealed significant decremental response with no significant high rate stimulation incrementation Chest CT revealed an anterior mediastinal mass Surprisingly, She had an old CT during the covid infection that showed the same mass. Thoracoscopic resection revealed type B1 thymoma Following tumor resection, the patient improved gradually, Few months later endoscopy revealed a normal stomach with strong peristaltic waves and the patient was symptom free Infections are recognized to trigger exacerbations and crisis in MG Dysautonomia is not a commonly recognized feature of myasthenia gravis, but there have been rare reports of myasthenia gravis coexisting with autonomic failure, usually in association with thymoma. The autonomic dysfunction can present as isolated gastroparesis these observations support a rare but definite clinical association between myasthenia gravis and autonomic failure Neurophysiology could reveal undiagnosed MG with thymoma causing autonomic dysfunction in the form of gastroparesis and agonizing vomiting. Keywords: Myasthenia gravis;Gastroparesis;Autonomic failure;Thymoma;PostCovid vomiting. French language not detected for EMBFRA articles source xmlCopyright © 2023

Predicting Airflow from Measures Sensitive to Mid-cord Glottal Gap During the COVID-19 Pandemic.

OBJECTIVES: To determine if trans-laryngeal airflow, important in assessing vocal function in paresis/paralysis and presbylarynges patients with mid-cord glottal gaps, could be predicted by other measures sensitive to mid-cord glottal gap size but with smaller risks of spreading COVID-19, and if any patient factors need consideration. METHODS: Four populations were: unilateral vocal fold paresis/paralysis (UVFP, 148), aging and UVFP (UVFP plus aging, 22), bilateral vocal fold paresis/paralysis without airway obstruction (BVFP, 49), and presbylarynges (66). Five measures were selected from the initial clinic visit: mean airflow from repeated /pi/ syllables, longer of 2 /s/ and 2 /z/ productions, higher of 2 cepstral peak prominence smoothed for vowel /a/ (CPPSa), and Glottal Function Index (GFI). S/Z ratios were computed. Stepwise regression models used 3 measures and 5 patient factors (age, sex, etiology, diagnosis, and potentially impaired power source for voicing) to predict airflow. RESULTS: Log-transformations were required to normalize distributions of airflow and S/Z ratio. The final model revealed age, sex, impaired power source, log-transformed S/Z ratio, and GFI predicted log-transformed airflow (R2 = .275, F[5,278] = 21.1; P < .001). CONCLUSIONS: The amount of variance explained by the model was not high, suggesting adding other predictive variables to the model might increase the variance explained.

Guillain-Barre syndrome: An autoimmune disorder post-COVID-19 vaccination?

SARS-CoV-2 causes Coronavirus Disease 2019 (COVID-19), an infectious condition that can present none or one or more of these symptoms: fever, cough, headache, sore throat, loss of taste and smell, aches, fatigue and musculoskeletal pain. For the prevention of COVID-19, there are vaccines available including those developed by Pfizer, Moderna, Sinovac, Janssen, and AstraZeneca. Recent evidence has shown that some COVID-19-vaccinated individuals can occasionally develop as a potential side effect Guillain-Barre syndrome (GBS), a severe neurological autoimmune condition in which the immune response against the peripheral nerve system (PNS) can result in significant morbidity. GBS had been linked previously to several viral or bacterial infections, and the finding of GBS after vaccination with certain COVID-19, while rare, should alert medical practitioners for an early diagnosis and targeted treatment. Here we review five cases of GBS that developed in different countries after COVID-19 vaccination.Copyright © 2021

Telerehabilitation Initiated Early in Post-Stroke Recovery: A Feasibility Study.

BACKGROUND: Enhanced neural plasticity early after stroke suggests the potential to improve outcomes with intensive rehabilitation therapy. Most patients do not get such therapy, however, due to limited access, changing rehabilitation therapy settings, low therapy doses, and poor compliance. OBJECTIVE: To examine the feasibility, safety, and potential efficacy of an established telerehabilitation (TR) program after stroke initiated during admission to an inpatient rehabilitation facility (IRF) and completed in the patient's home. METHODS: Participants with hemiparetic stroke admitted to an IRF received daily TR targeting arm motor function in addition to usual care. Treatment consisted of 36, 70-minute sessions (half supervised by a licensed therapist via videoconference), over a 6-week period, that included functional games, exercise videos, education, and daily assessments. RESULTS: Sixteen participants of 19 allocated completed the intervention (age 61.3 ± 9.4 years; 6 female; baseline Upper Extremity Fugl-Meyer [UEFM] score 35.9 ± 6.4 points, mean ± SD; NIHSS score 4 (3.75, 5.25), median, IQR; intervention commenced 28.3 ± 13.0 days post-stroke). Compliance was 100%, retention 84%, and patient satisfaction 93%; 2 patients developed COVID-19 and continued TR. Post-intervention UEFM improvement was 18.1 ± 10.9 points (P < .0001); Box and Blocks, 22.4 ± 9.8 blocks (P = .0001). Digital motor assessments, acquired daily in the home, were concordant with these gains. The dose of rehabilitation therapy received as usual care during this 6-week interval was 33.9 ± 20.3 hours; adding TR more than doubled this to 73.6 ± 21.8 hours (P < .0001). Patients enrolled in Philadelphia could be treated remotely by therapists in Los Angeles. CONCLUSIONS: These results support feasibility, safety, and potential efficacy of providing intense TR therapy early after stroke. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov; NCT04657770.

An Overview About Pediatric Type 1 Diabetes Mellitus

Background: Diabetes mellitus (DM) represents one of the most common metabolic diseases in the world, with rising prevalence in recent decades. Most cases are generally classified into two major pathophysiological categories: type 1 diabetes mellitus (DM1), which progresses with absolute insulin deficiency and can be identified by genetic and pancreatic islet autoimmunity markers, and type 2 diabetes mellitus (DM2), which is the most prevalent form and involves a combination of resistance to the action of insulin with an insufficient compensatory response of insulin secretion. In the last two decades, in parallel with the increase in childhood obesity, there has also been an increase in the incidence of DM2 in young people in some populations. Other forms of diabetes may affect children and adolescents, such as monogenic diabetes (neonatal diabetes, MODY – maturity onset diabetes of the young, mitochondrial diabetes, and lipoatrophic diabetes), diabetes secondary to other pancreatic diseases, endocrinopathies, infections and cytotoxic drugs, and diabetes related to certain genetic syndromes, which may involve different treatments and prognoses. DM1 is considered an immuno-mediated disease that develops as a result of gradual destruction of insulin-producing pancreatic beta cells that eventually results in their total loss and complete dependence on exogenous insulin. Clinical presentation can occur at any age, but most patients will be diagnosed before the age of 30 years

A prospective clinical study on the mechanisms underlying critical illness myopathy-A time-course approach.

BACKGROUND: Critical illness myopathy (CIM) is a consequence of modern critical care resulting in general muscle wasting and paralyses of all limb and trunk muscles, resulting in prolonged weaning from the ventilator, intensive care unit (ICU) treatment and rehabilitation. CIM is associated with severe morbidity/mortality and significant negative socioeconomic consequences, which has become increasingly evident during the current COVID-19 pandemic, but underlying mechanisms remain elusive. METHODS: Ten neuro-ICU patients exposed to long-term controlled mechanical ventilation were followed with repeated muscle biopsies, electrophysiology and plasma collection three times per week for up to 12 days. Single muscle fibre contractile recordings were conducted on the first and final biopsy, and a multiomics approach was taken to analyse gene and protein expression in muscle and plasma at all collection time points. RESULTS: (i) A progressive preferential myosin loss, the hallmark of CIM, was observed in all neuro-ICU patients during the observation period (myosin:actin ratio decreased from 2.0 in the first to 0.9 in the final biopsy, P < 0.001). The myosin loss was coupled to a general transcriptional downregulation of myofibrillar proteins (P < 0.05; absolute fold change >2) and activation of protein degradation pathways (false discovery rate [FDR] <0.1), resulting in significant muscle fibre atrophy and loss in force generation capacity, which declined >65% during the 12 day observation period (muscle fibre cross-sectional area [CSA] and maximum single muscle fibre force normalized to CSA [specific force] declined 30% [P < 0.007] and 50% [P < 0.0001], respectively). (ii) Membrane excitability was not affected as indicated by the maintained compound muscle action potential amplitude upon supramaximal stimulation of upper and lower extremity motor nerves. (iii) Analyses of plasma revealed early activation of inflammatory and proinflammatory pathways (FDR < 0.1), as well as a redistribution of zinc ions from plasma. CONCLUSIONS: The mechanical ventilation-induced lung injury with release of cytokines/chemokines and the complete mechanical silencing uniquely observed in immobilized ICU patients affecting skeletal muscle gene/protein expression are forwarded as the dominant factors triggering CIM.

Assessment of the effectiveness of laryngeal protection mechanisms in patients with iatrogenic, unilateral laryngeal paralysis

Introduction: Postoperative paresis of the laryngeal nerves may disrupt the protection function of the larynx during swallowing. Aim: The aim of the study was to evaluate the effectiveness of defense mechanisms in patients with iatrogenic paralysis, unilateral larynx, both in patients with isolated palsy of the laryngeal nerves and in patients with polyneural paralysis. The prospective part of the study (stage 2) was discontinued due to the COVID-19 pandemic. Material and method: Stage 1: Retrospective analysis of FEES reports in patients with unilateral laryngeal paralysis (n = 99) in terms of the occurrence of penetration or aspiration of saliva and liquid and solid food. Stage 2: Prospective analysis of the results of the EAT-10 screening questionnaire and reports (n = 12) of FEES examination performed in the early postoperative period (up to 7 days after surgery) in patients with iatrogenic palsy of the X cranial nerve. Assessment of: sensory function of the larynx, effectiveness for cough and pressure tests, presence of „white out”, PAS scale for a regular diet according to IDDSI (ST 0;ST 7). Results: Stage 1: Penetration or aspiration was found in 65% of patients;in 29% of patients there were silent symptoms. Salivary penetration or aspiration concerned 60.60% of patients. Among people who developed silent disorders, 20 had isolated n. X paralysis, and 79% polyneuric palsy. The PAS level between 2–8 was found in 65% of patients. Stage 2: 11/12 patients obtained a result of the EAT 10 questionnaire of > = 3. „White out” elongation and sensory loss were found in 75% of patients, ineffective cough in 33%. In oral trials, residue (50% ST0), premature swallowing (8% ST0), penetration (33% ST0, 8% ST7) and aspiration (16% ST0, 8% ST7) were found. Adaptive and compensatory techniques were the most frequently combined ones (66%), and the dominant technique was turning the head towards the affected side. Conclusions: In every sixth patient with iatrogenic laryngeal paralysis, aspiration of non-condensed fluids occurs early after surgery, and the penetration of these contents into the larynx occurs in every third patient. It is therefore advisable to improve the comfort associated with the quality of life dependent on swallowing and to prevent complications of dysphagia in the study group. Therefore, it is justified to extend diagnostics to include clinical assessment of swallowing and qualify patients for FEES assessment. Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o.

Successful Treatment of Paraplegia Caused by Venous Hypertension Secondary to Extensive Iliocaval Deep Venous Thrombosis in the Absence of Phlegmasia Cerulea Dolens

Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]

Guillain-Barré Syndrome After Receiving the First Dose of Oxford– AstraZeneca SARS-CoV-2 Vaccine

Safety monitoring of COVID-19 vaccination is paramount of importance. There are limited reports of Guillain-Barré syndrome (GBS) associated with the COVID-19 vaccination. The present study reported a case of GBS following the first dose of the Oxford-AstraZeneca SARS-CoV-2 vaccine. A 32-year-old man presented a history of progressive descending weakness and autonomic features within a month after receiving the Oxford-AstraZeneca SARS-CoV-2 vaccine. The neurological examination was consistent with acute polyneuropathy. The para-clinical investigations were in favor of acute demyelinating polyneuropathy. The patient was diagnosed with GBS, and IVIG was initiated as an acute treatment, which led to significant clinical recovery. We reported a case of GBS after receiving the Oxford-AstraZeneca vaccine. However, our findings dose not conclude a causal association between GBS and COVID-19 vaccination.

RISK AND PATTERN OF INFECTIONS IN NEWLY DIAGNOSED PATIENTS OF MULTIPLE MYELOMA VACCINATED UPFRONT AGAINST PNEUMOCOCCUS & INFLUENZA

Background: Infections contribute to an early mortality risk of 15 percent in newly diagnosed multiple myeloma(NDMM) cases. There is a limited literature on the type of infections in fully vaccinated NDMM patients. Aims: To study epidemiology, clinical profile and predictors of infection in NDMM who are immunised against pneumococci and influenza. Methods: NDMM patients were prospectively studied for 6 months for the pattern of infections . All patients were vaccinated with pneumococcal and Influenza vaccine at diagnosis. PJP prophylaxis and fluconazole prophylaxis was given for patients receiving high dose steroids while acyclovir was given to all. Infections were classified as microbiologically defined, clinically defined and fever of unknown focus according to definitions published by the International Immunocompromised Host Society. Severity of infections were graded according to the NCI CTCAE Ver5. Results: Forty-eight NDMM patients with a median age 55 years comprising of 26 males and 22 females were enrolled. Renal involvement was noted in 42% of enrolled patients and two third of them required renal replacement therapy. ISSIII and R-ISS III were 70.8 % and 62.5 % respectively. 85% had poor performance status(ECOG ≥2) at baseline. RVD was the most common regimen (37%)used. 6 patients received daratumumab based regimen. Treatment response of atleast VGPR was seen in 97 % of NDMM patients. A total of 19 episodes of infections were observed during 6 months. All episodes of infections were reported in the first 45 of myeloma diagnosis(Median 6 days;Range 0-45). Ten of these episodes of infection were diagnosed during the initial evaluation for myeloma defining events. Microbiological diagnosis was possible in 63 %. Commonest infectious agent was COVID 19(n=8) followed by Gram negative bacteria (n=5) viz E.coli and Klebsiella pneumoniae . None of the eight patients who developed COVID 19 infection had received COVID vaccine as they antedated the operationalisation of national guidelines for immunisation. Respiratory and the urinary tract were the most common focus of infection. All critically ill COVID patients succumbed to progressive respiratory failure and all patients with mild and moderate COVID illness recovered uneventfully. Early mortality in our cohort of forty eight patients was twenty percent(n=10). Three fourths of infections in our cohort were Grade≥3 severity. A total of seven deaths were attributable to infectious diseases in this cohort of NDMM patients. Imune paresis was seen in eighty four percent of patients at diagnosis. On follow up at 6 months;immune paresis had persisted in only thirty seven percent. Regression analysis of variables with odds of infection is shown in Table 1 Baseline BMI<18.5 kg/m2;albumin<3g/dl and ISS or R-ISS stage ≥ 2 was found to be have statistically significant odds of predicting infection risk in the cohort of patients. The choice of myeloma regimen, presence of high risk cytogenetics and response to therapy did not correlate with increased odds of infection in our cohort. Summary/Conclusion: Conclusion In this prospective study of NDMM patients vaccinated against pneumococci and influenza at baseline;infection attributable early mortality was 14.5 %. Advanced stage of presentation, hypoalbuminemia and baseline BMI < 18.5 kg/m2 correlated with increased odds of infection. COVID vaccination and COVID appropriate behavioural practices may mitigate COVID related outcomes including deaths in myeloma patients.

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.

Critically ill patients with and without SARS-CoV-2 better achieve energy and protein targets with a high-energy, high-protein peptide-based enteral tube feed;insights from a multicentre clinical audit performed during the COVID-19 pandemic

Meeting energy and protein requirements in critically ill patients is important for prognosis, yet difficult to achieve as a consequence of disease, management and/or altered nutritional intake[1]. Improvements in achieving energy and protein requirements with a high-energy, high-protein peptide-based tube feed were observed in community patients with impaired gastrointestinal function[2]. To establish whether this remained true in the critical care setting, where feeding intolerance is observed frequently in patients with[3] and without SARS-CoV-2[4], a retrospective multicentre audit was performed. Adults (> 18years) with or without SARS-CoV-2, admitted to critical care across 6 UK hospitals between May 2020 and December 2020, were retrospectively included if they received a peptide-based enteral tube feed (Nutrison Peptisorb Plus HEHP®, Nutricia Ltd), containing 1.5kcal/ml and 7.5g protein/100ml (herein referred to as HEHP). Data were collected from 15 critically ill patients (52±12y;87% male), with mean length of hospital stay being 26days (range: 7-49days). Of these, 10 were SARS-CoV-2 positive, with the remainder having pancreatitis (n=3), delayed gastric emptying (n=1) or unconfirmed diagnosis (n=1). HEHP was used second line (after whole protein) and indications (multiple were cited for some) for use included tolerance issues (n=10), elevated energy and protein requirements (n=5) or due to primary diagnosis (n=2). Estimated energy and protein intakes (% of requirements achieved) were recorded before and during use of HEHP. In addition, Dietitians were asked whether HEHP allowed patients to better meet their nutrient target Mean intake of HEHP was 2008±461kcal/day and 100±23g protein/day provided over a mean of 12days (range: 3-29days). The percentage of estimated energy and protein targets achieved increased albeit non significantly with the use of HEHP (from 76% before vs 87% during use of HEHP for both) and the direction of effect remained true regardless of SARS-CoV-2 status. Two thirds (67%, n=10 of 15) of Dietitians reported HEHP helped patients better meet their nutrient targets and 87% (n=13 of 15) of Dietitians perceived the high protein content of HEHP as beneficial for this patient group. Gastrointestinal tolerance (anecdotal reports) remained largely unchanged in approximately half of SARS-CoV-2 positive patients when using HEHP yet improved for others including non-SARS-CoV-2 patients. Enteral tube feeding in critically ill patients poses numerous difficulties, especially in SARS-CoV-2 positive patients. This audit in critically ill patients demonstrates that a high-energy, high-protein, peptide-based enteral tube feed can help complex patients better achieve energy and protein targets in patients with and without SARS-CoV-2. References 1.Pullen K, Colins R, Stone T et al. Are energy and protein requirements met in hospital? Clin Nutr 2017;31(2): 178-187. 2.Green B, Sorensen K, Phillips M et al. Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study. Nutrients. 2020, 12, 3538. 3.Liu R, Paz M, Siraj L et al. Feeding intolerance in critically ill patients with COVID-19. Clin Nutr 2021. 4.Gungabissoon U, Hacquoil K, Bains C et al. Prevalence, Risk Factors, Clinical Consequences, and Treatment of Enteral Feed Intolerance During Critical Illness. J. Parenter. Enteral. Nutr. 2015, 39, 441–448.

IMPACT OF GERD ON PATIENTS UNDERGOING LUNG TRANSPLANTION FOR COVID-19: A SINGLE INSTITUTION RETROSPECTIVE STUDY

Background: Optimizing management of gastroesophageal reflux disease (GERD) is important to preserve graft function after lung transplantation as patients with GERD are at higher risk of rejection. Patients with COVID-19 associated respiratory failure undergoing lung transplantation is an emerging subset of patients in which GERD pre- or post-transplant is not well characterized. Aim: To evaluate the prevalence and adverse effects of GERD both pre- and post-transplant in patients undergoing lung transplantation for severe COVID-19 infection. Methods: A retrospective review was conducted at a single academic medical center with a large multi-organ transplant program. All patients undergoing lung transplant due to COVID-19 from 2020-2021 were included in the study, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. All patients were male;52.9% (9/17) were Hispanic, 35.3% (6/17) Caucasian and 11.8% (2/17) Black. Median age was 50 (24- 70 years) with median time to transplant from documented infection of 131 days. A prehospitalization GERD diagnosis was found in 29.4% (5/17) patients, and two patients (11.8%) were taking prescribed proton-pump inhibitor (PPI) prior to their COVID-19 associated hospitalization. No patient underwent pre-transplant GERD testing, although three patients did undergo upper endoscopy for GI bleeding prior to transplant. Post-transplant, all patients were immediately treated with PPI per institutional protocol. 70.5% (12/17) patients reported post-transplant foregut symptoms including heartburn, regurgitation, dysphagia, early satiety, abdominal bloating/cramping, nausea and vomiting. All 17 patients had at least one symptomdriven foregut study such as a gastric emptying study, barium esophagram, upper endoscopy, esophageal manometry or pH testing. Three patients were referred for anti-reflux surgery (ARS) based on results of testing, including delayed gastric emptying, abnormal pH testing and bronchoscopy findings concerning for aspiration pneumonia. All three underwent Toupet fundoplication with or without hiatal hernia repair;one was performed early (< 3 mo) posttransplant, two occurred late (> 6 mo), and none had complications or symptom-based recurrence of reflux. Discussion: In this large single-center series of COVID-19 associated respiratory failure and lung transplant, pre-operative reflux testing could not be performed;however, post-transplant GERD symptoms were still routinely assessed and evaluated, prompting management with ARS in a small subset of patients, both early and late posttransplant, with resolution of GERD symptoms. Long-term outcomes of this unique group and comparison with others requiring transplant will necessitate further investigation to assess impact of GERD on allograft dysfunction.

COVID AND COVID VACCINATION AMONG OUTPATIENTS WITH FUNCTIONAL GI AND GI MOTILITY DISORDERS;EFFECTS ON GI SYMPTOMS

Introduction: The ongoing COVID pandemic from SARS-CoV-2 infection has posed healthcare challenges. COVID and even COVID vaccines have been reported to have effects on underlying GI conditions. Several efficacious vaccines with infrequent side effects are available. However, many eligible recipients are not getting vaccinated. Aims: The aims of this study were threefold: 1) Determine the prevalence of prior COVID infection and COVID vaccination in patients within a GI practice seeing primarily functional GI and GI motility disorders;2) Inquire as to why patients do not get vaccinated;and 3) Assess if COVID-19 illness or COVID vaccination provoked patient typical GI symptoms. Methods: Patients seen in clinical practice either in person or telemedicine were asked about COVID vaccination and prior COVID infection. If patients had not been vaccinated, they were asked the reasons for that decision. If patients had COVID and/or COVID vaccination, they were asked if either caused worsening of their typical GI symptoms. Results: 538 patients (414 females and 124 males;average age 49.1±17.7 years) were questioned about COVID vaccination and prior COVID-19 acquisition. Of these 538 patients, 105 had esophageal disorders, 358 had gastric disorders, and 88 had colonic disorders. 456 of the 538 (83.8%) had received a COVID-19 vaccination (Table 1). Of the 82 people not getting COVID vaccination, 13 people did not receive vaccine due to medical reasons (allergies, immune system disorders), 46 people were afraid or skeptical of the vaccine/the side effects, and 22 people considered it unnecessary. 72 of the 538 (13.4%) had contracted COVID at some time (7 after their COVID vaccine [breakthrough COVID]) (Table 2). 23/72 (32%) said their GI symptoms were exacerbated during their COVID infection, whereas 49/72 said there was no effect on their GI symptoms. Of the 23 patients who had their GI symptoms exacerbated by COVID, 3 had esophageal disorders,17 had gastric disorders (11 had idiopathic gastroparesis, 5 diabetic gastroparesis, and 1 with chronic abdominal pain), and 0 had colonic disorders. 8 of 456 (1.8%) vaccinated patients said their GI symptoms were exacerbated with the COVID vaccine (0 had esophageal disorders, 7 had gastric disorders [5 with idiopathic gastroparesis, 1 with cyclic vomiting syndrome, and 1 with diabetic gastroparesis], and 2 had colonic disorders). Conclusions: In this outpatient practice setting of functional and GI motility patients, 84% had been vaccinated and 13% had previously contracted COVID. Among patients with functional and GI motility disorders, naturally acquired COVID infection caused an aggravation of symptoms in an important proportion of patients (32%), especially in those with gastric disorders, particularly gastroparesis. Aggravation of symptoms rarely (<2%) occurred following administration of COVID vaccine. (Table Presented) (Table Presented)

COVID-19 EXACERBATES EXISTING DIGESTIVE DISORDERS AND TRIGGERS NEW DIGESTIVE SYMPTOMS AND DIAGNOSES: RESULTS FROM AN INTERNATIONAL PATIENT SURVEY

Background/Aims: COVID-19 infection can affect nearly every organ system including the gastrointestinal (GI) tract. GI symptoms such as nausea, pain and diarrhea are common and may be due to infection and/or increased stress and isolation from the pandemic. It is well known that stress affects GI function and sensation, particularly in patients with irritable bowel syndrome (IBS). The aim of the study was to elucidate the impact of the COVID-19 pandemic on GI symptoms. Methods: An international online survey (Alchemer) was available via the International Foundation of GI Disorders (IFFGD) website from August 11, 2021- November 17, 2021. There were 57 questions exploring demographics, GI symptom/disorder classification, care delivery, administration and perceptions of COVID-19 vaccination, and health experiences during the pandemic. No compensation was provided for survey completion and patients were able to selectively answer questions, with some questions not analyzed for this report. Results: Survey data was included from 210 patients with GI symptoms (mean age 47.7 yrs, 83% female, 80% Caucasian). Participants' primary GI conditions included 36% IBS, 26% gastroparesis, 6% constipation, and 9% acid reflux (figure 1). Seventy percent reported the pandemic impacted their GI health and nearly 3 out of 4 (73%) reported increased pandemic-related anxiety or depression. COVID-19 was diagnosed in 40 (19%) participants. Nearly 3 out of 4 (74%) experienced new or worsening GI symptoms after a COVID-19 diagnosis. Almost a third (30%) with COVID-19 were diagnosed with post-infection (PI) IBS and 38% were diagnosed with a new GI disorder other than PI-IBS. New GI diagnoses after COVID-19 included gastroparesis (53%), GERD (13%), and diarrhea (7%) (figure 2). Prior to diagnosis of PI-IBS, 58% did not have a GI diagnosis. Almost half (46%) of patients reported new acid reflux symptoms after COVID-19. Almost 3 out of 4 patients (72%) with COVID-19 noticed changes in digestion and/or bowel movements. More than two thirds (67%) noted COVID-related GI symptoms lasted >3 months. Nearly 3 out of 4 (72%) patients felt their GI symptoms were harder to manage after COVID-19. Conclusions: Our results highlight the significant burden of GI illness imposed by the COVID-19 pandemic. COVID-19 exacerbated existing GI conditions, increased anxiety and depression, and led to a wide range of new GI issues, led by but not limited to PI-IBS. New diagnoses of upper GI disorders including gastroparesis and GERD were surprisingly common. Further prospective studies to validate these observations and understand their pathogenesis are warranted. (Figure Presented) Figure 1: Participants primary gastrointestinal condition or disorder prior to the COVID- 19 pandemic. (Figure Presented) Figure 2: New GI disorders diagnosed after being diagnosed with COVID-19

A SINGLE-CELL SURVEY OF GASTRIC MUSCULARIS MACROPHAGES IN DIABETIC GASTROPARESIS

Background: Gastric muscularis propria immune cells play an instrumental role in homeostasis and disease. A subset of these cells, muscularis macrophages (MMs) are involved in the pathobiology of diabetic gastroparesis (DG) but are poorly understood. This study aims to survey transcriptional and functional profiling of gastric MMs in DG and diabetes. Methods: Full-thickness gastric body biopsies were obtained from patients with DG and diabetic controls. CD45+ cells were isolated from dissociated muscle tissue using magnetic beads. 10xGenomics was used for scRNA-seq library prep and cells sequenced by Illumina HiSeq4000. Bioinformatic analyses was performed using Suite and Seurat. Myeloid cells were annotated through a pseudogating strategy that identifies cells by differential expression levels of HLA-DR, CD14, CD11b, and CD11c based on flow cytometry-based gating utilized in a recent analysis of human small intestinal MMs. Canonical signaling pathways were determined using Ingenuity Pathway Analysis (IPA). Results: A total of 21,740 high-quality single-cell transcriptomes were generated from 16 subjects (DG=6, age 32±8 yr, BMI 23.7±3.9, 48.2±40.1% 4 hr gastric retention, average GCSI score 3.7±0.5;Diabetic controls= 10, age 53±13 yr, BMI 42.2±5.7). Through annotating 8,693 myeloid cells (DG 1509, Controls 7184), we characterized 1,788 as MMs (CD45+HLA-DR+) and 448 as dendritic cells (CD14-CD11c+). Utilizing a priori markers for pseudogating, the MMs were divided into four populations (Figure 1): subset 1 (CD14+CD11c+HLA-DRint, 5.6%), subset 2 (CD14+CD11c+HLA-DRhi, 36.0%), subset 3 (CD14+CD11c-CD11b-, 41.8%), and subset 4 (CD14+CD11c-CD11b+, 16.6%). The overall proportions of cells in the 4 subsets were similar to a prior approach in small bowel using gating. The expected ratio of cells from DG/diabetic control was 21% based on imputed cells. Subsets 1 and 4 were significantly decreased in DG compared to controls with ratios 15% and 14% respectively while subsets 2 and 3 were unchanged (21% and 20%). On IPA, phagosome formation and immune cell trafficking represented canonical signaling pathways of subset 1 and coronavirus phagocytosis pathway and phagosome formation of subset 4. Canonical genes of subset 1 included S100A12, A8, A9, and CSTA and subset 4 as LYVE1, MAF, MRC1 (CD206), MS4A4, and A2M. Subset 4 also had the highest expression of neuron-related genes (NPTX2, BMP2) similar to that observed in the small intestine. Conclusions: Pseudogating based on the transcriptomic expression of gastric immune cells reveal MM clusters similar in gene expression and proportions to previously characterized MMs in human small bowel using gating. The reduction of MM clusters associated with anti-inflammatory, phagocytosis, and neuronal signaling in specialized MMs subsets may suggest candidate targets in the pathophysiology of DG. Supported by NIHDK074008. (Figure Presented) Figure 1. Single-Cell RNA-Seq Profiling of Human Gastric Muscularis Macrophages in DG and Diabetes. T-distributed Stochastic Neighbor Embedding (tSNE) plot of muscularis macrophages in DG and diabetic control subjects by their differential genes from MAST (FDR < 0.05), color-coded by Status. *Mf1 and Mf2 not visualized as distinct clusters due to inadequate separation of overall gene expression in cells distinguished by HLA-DRint (Mf1) and HLA-DRhi (Mf2)