MAY MEASUREMENT MONTH IN NEPAL: FIVE-YEAR COMPARISON OF BLOOD PRESSURE SCREENING RESULTS IN 2017 - 2021

Objective: Nepal has been participating in the May Measurement Month (MMM) aiming to raise hypertension awareness and improve health seeking behavior to control high blood pressure in communities and present data for policymakers. This study compares the results from 2017 to 2021. Design and Methods: Opportunistic cross-sectional surveys to measure the proportion of hypertension, its awareness, treatment, control, and risk factors among> = 18 years of age annually from 2017 to 2021 in Nepal. Although MMM was not executed globally due to the COVID-19 pandemic in 2020, it was conducted in Nepal by following safety measures. We administered the structured questionnaire and took three BP readings while sitting at 1-minutes intervals. Measures of association were calculated using the logistic regression model adjusting for age and sex. The same definition of hypertension (a mean of 2nd and 3rd BP reading> = 140/90 mmHg, or participants were treated with medicines for known hypertension) was applied for all years. Results: The summary characteristics from 2017 to 2021 are presented in Table 1. Baseline characteristics were similar for all five studies except for low tobacco use in 2017. The proportion of hypertension ranges from 20.6% to 31.3% (24.4% in 2017, 27.8% in 2018, 27.5% in 2019, 31.3% in 2020, and 20.6% in 2021). Awareness, treatment, and control were also similar across five years, ranging from 39.5% to 49.9%, 29.5% to 39.1%, and 46.0% to 56.0% respectively. Smoking, alcohol use, body mass index> = 25, diabetes, and history of myocardial infarction (MI) or stroke were associated with hypertension after adjusting for age and sex across multiple studies. Conclusions: A five-year comparison of the MMM study in Nepal showed that hypertension awareness, treatment, and control have been suboptimal, suggesting an urgent need to implement a nationwide prevention and control program together with a national screening program. (Table Presented).

Sports and the Pandemic: The Impact of COVID-19 on Active Living and Life Satisfaction of Climbers.

The COVID-19 pandemic has resulted in significant changes in every aspect of our lives. Because of the measures imposed, people were only allowed to leave their homes for certain purposes, and all types of cultural and sports events were canceled. Climbers were greatly affected by these limited options for regular physical activity outside of the home environment. Little is known about the crisis' effects on the climbing community in German-speaking regions. Thus, we surveyed 1028 German-speaking climbers (mean age 34.6 years, SD 10.4; 50.4% females) from December 2020 to February 2021. A cross-sectional online survey collected data on climbing frequency and preferences as well as levels of life satisfaction, using the standardized Short Life Satisfaction Questionnaire for Lockdowns (SLSQL) before and during the crisis. Results showed that due to the pandemic, study subjects climbed less frequently, preferred outdoor locations to climb, and showed decreased life satisfaction scores (21%, (d = 0.87, p < 0.001). In conclusion, these findings highlighted that the COVID-19 pandemic had a negative effect on climbing sports activities and life satisfaction in this study sample. To preserve physical and mental health, indoor and outdoor sport activities should be continued as much as possible with reasonable hygiene concepts in place.

Post-COVID-19 elective surgery and transformation: exploring the role of ambulatory spinals in the high-risk patient population

At Whipps Cross Hospital, multi-morbid (high-risk) patients undergoing urological surgery are routinely listed on the surgical inpatient pathway. The 'Getting it right first time' [1] review of anaesthesia recommended day-case surgery as the default for suitable procedures, to help with waiting lists as well as to provide patients with a safe environment. To improve patient choice and postoperative outcomes, an ambulatory spinal pathway was piloted. Methods An earlier scoping exercise identified a pool of urology high-risk patients who could potentially benefit from an ambulatory spinal pathway. Based on this, prilocaine use for ambulatory spinal anaesthetic was provisionally approved by the drugs and therapeutic committee. A pilot ambulatory pathway was put in place, which helped identify suitable patients. The pilot pathway was limited to a select group of anaesthetists to minimise variations. Postoperatively, patients were followed up at 3 and 24 h and assessed for postoperative nausea, vomiting, pain, mobilisation, neurological symptoms and cognitive impairment. Results The total number of patients was 19. Mean ASA was 2.9. Average age was 74 years. The mean dose of hyperbaric prilocaine 2% used was 2.9 ml, 21% of cases utilised additional intrathecal additives. Regarding intra-operative analgesia, only paracetamol was used in 15% of cases. There were no conversions to general anaesthetic. The most common procedure was a cystoscopy with or without biopsy (42%). With comorbidities, diabetes mellitus was the most common (58%), followed by cardiac disease (53%) and respiratory disease (42%). At 3 h, 100% of patients were eating and all sensation had returned, 0% had cognitive impairment, 47% were sitting out and 42% mobilising. Sixteen per cent had hypotension and 5% had pain at rest. At 24 h, 0% had cognitive impairment, 50% had required analgesia and 84% were mobilising. All patients reported they would have a spinal anaesthetic again in the future. Discussion With an ageing population, who have multiple comorbidities, there is huge benefit regarding providing the choice of a spinal anaesthetic rather than general anaesthetic, which allows patients to go home the same day. This will not only provide financial savings to the service provider but also help clear the backlog of surgeries due to the COVID-19 pandemic and enhance patient recovery.

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.

Comparative study of a single lead ECG in a wearable device

Background: The technological advances in electrocardiography have been substantially accelerated due to COVID-19. Furthermore, the progress in the (ECG) became possible with the introduction of integrated circuitry and wireless technologies for communication of mobile and cloud computing and of a variety of novel materials for ECG sensors. There are a number of wearables which are able to capture, monitor, record and/or remotely transmit ECG signals. Some of these devices enable non-invasive capture and storage of ECGs over a longer time period when compared to standard Holter recorders, or to acquire the ECG on demand but without the need for wet electrodes attached to the skin. Method(s): The objective of this study is to validate the ECG performance of the HeartKey Vital Signs Monitor (VSM) Watch, a dry electrode wrist wearable, against a wet electrode system whilst inducing motion noise reflective of a real-life use case. Data from each recording device was compared with the criterion in each stage of the protocol through a comparison of heart rate (HR) data. A beat rejection analysis was performed to provide insight into the degree of high frequency noise in ECG recorded from the HeartKey VSM Watch. Data from a HeartKey Reference Wrist Worn Device validation was used to compare the HeartKey VSM Watch to another wrist-based ECG wearable device. Result(s): Bland Altman analysis showed that the VSM Watch, when using HeartKey technology, had an overall mean absolute HR difference of 0.74, 1.21 and 0.80 bpm from the criterion device during the sitting, walking and standing stage respectively and within the +/-10% or +/- 5 bpm range as is recommended by ANSI EC13. ECG from the HeartKey VSM Watch had a higher beat rejection rate (8.5% vs ~0%), due to excessive high frequency noise, during the non-motion and motion-based protocol when compared to the HeartKey Chest Module. Conclusion(s): This study suggests that the HeartKey VSM Watch demonstrates medical grade HR performance when processing Lead I, dry electrode ECG data during both non-motion and motion-based testing. Further ECG signal chain development may be required to allow full usability of HeartKey Health and Wellness algorithms in a diverse population, particularly those with high skin wrist impedance. Copyright © 2022

Did the increase in sitting time due to COVID-19 lead to obesity in adolescents?

INTRODUCTION: Since adolescent with obesity is closely linked with the incidence of cardiovascular disease, it is important to identify the factors that increase the prevalence of adolescent with obesity and prevent it early. This study aimed to examine which of the demographic and lifestyle factors including sitting hours per week for purposes other than study had the greatest influence on Korean adolescents with obesity during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We used the Korean Youth Risk Behavior Web-based Survey (KYRBWS) data. The primary outcome was the relationship between sitting hours and obesity during and after the COVID-19 pandemic. Multiple logistic regression analysis was performed to examine which of the demographic and lifestyle factors including sitting hours per week for purposes other than study had the greatest influence on Korean adolescents' obesity status. RESULTS: The prevalence of obesity was significantly higher during the COVID-19 than before the COVID-19 (OR, 1.268, CI:1.232-1.305). There was a significant increase in the OR for sitting hours per week for purposes other than study (OR, 1.021, 95% CI, 1.019-1.024). Compared to low household income, the OR decreased for middle (OR = 0.798, 95% CI:0.77, 0.826) and high-income household students (OR, 0.833, 95% CI: 0.803-0.865). DISCUSSION/CONCLUSION: The results of this study confirmed the relationship between sit-ting hours and obesity in adolescents during the pandemic. To prevent adolescent with obesity, further studies are needed to focus on the importance of promoting health policy in adolescents to avoid the continuous rising of its prevalence and needed to understand whether the increase in obesity rates during the pandemic is a temporary trend.

Sitting Time and Screen Time are not associated with Body Weight and Body Mass Index Changes during Covid-19 Pandemic

Introduction: COVID-19 pandemic has made significant changes in life. Sedentary lifestyle, increased usage of gadget, and increased sitting duration could lead to body weight and nutritional status changes. This study aimed to analyze the differences of sitting and screen time with weight changes and body mass index (BMI). Methods:: Online cross-sectional survey performed among 401 individuals older than 18 years in Surabaya. Self-administered questionnaire included questions related to sedentary activities, namely sitting and using gadget duration in a day. Self-reported weight and height before and during pandemic were used to calculate BMI before and during COVID-19 pandemic. Data analysis used the Chi-square test. Results: Study found that 47.9% of respondents did not experience significant changes in their body weight before and during COVID-19 pandemic. People who experienced no change in their body weight spent less than 6 hours sitting (50.8%) and people who experienced weight loss spent more than six hours using their gadgets (59.3%). It also found that 44.6% of respondents had normal nutritional status where 45.3% used gadgets with a duration of more than 6 hours and 45.8% used the time to sit for less than 6 hours. Body weight changes and BMI changes are not significantly different compared to sitting time (p-value=0.692) and screen time (p-value=0.099) during COVID-19 pandemic. Conclusion: There are no association between screen time and sitting time to body weight and BMI during pandemic COVID-19. © 2022 UPM Press. All rights reserved.

PROGRESSIVE ASCENDING WEAKNESS AFTER THE PFIZER/BIONTECH COVID-19 VACCINE

SESSION TITLE: Autoimmune Disorders: Both Primary and Secondary SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Myasthenia gravis (MG) occurs sporadically with no known causes. We present a rare case of new onset MG s/p COVID-19 vaccination. CASE PRESENTATION: A healthy 46-year-old female presented with progressing LE weakness for 3 months. Symptoms started 5 days after her initial Pfizer COVID-19 vaccine. Her workup showed negative neuroimaging, bland basic CSF studies from LP, with negative MS profile and AChR Ab. She presented again in 1 month with difficulty rising from a seated position, raising her arms above her head with blurry vision. Exam showed bilateral ptosis that improved with an ice pack test, weakness is worst in proximal muscles, but normal reflexes. Workup was again negative. Pyridostigmine was added after discharge (DC). 2 months after, she was admitted to the ICU for acute progressive fatiguability and dyspnea. EMG/NCS of the ulnar nerve showed 60-70% electrical decrement. She underwent therapeutic PLEX. Prednisone was added at DC followed by mycophenolate. 2 weeks later, she was again admitted with myasthenic crisis. She again underwent PLEX with improvement and intubation was avoided. Biweekly PLEX was started at DC. Testing for AChR, MuSK, and LRP4 Abs were initially negative, but AChR Abs were present 6 months later. She then underwent thymectomy showing hyperplasia. DISCUSSION: MG exacerbations have been attributable to infections (50%) and medications (30%). This has worsened during the COVID-19 pandemic especially when medications such as azithromycin were used to treat acute infections. While vaccine-induced flares or onset of autoimmune diseases have been described in literatures, new onset MG following vaccines is rare, limited to 1 to 3 case reports. No case, to our knowledge, correlated to the 1st dose like our patient. The temporal relationship between the COVID-19 vaccination and onset of MG symptoms in our patient could represent a correlation, but does not prove causality. Perhaps a more plausible theory is that the vaccine may have unmasked a previously unrecognized disease in high-risk patient. We ask if the COVID vaccine induces a similar cytokine storm, which hyperstimulates the immune system to a point that breaks immunologic self-tolerance. Interestingly, our patient was initially seronegative, but the presence of AChR Ab was confirmed after sensitive cell-based assays testing. Our patient may have had pre-existing self-antigens to the AChR that were released after receiving the Pfizer COVID-19 vaccine. CONCLUSIONS: The rate of COVID-19 vaccinations will soon surpass that of infections placing vulnerable individuals at risk for MG onset. Recognizing this risk will open discussions about vaccine safety. In doing so, we can begin to formulate new parameters for post-vaccination monitoring. The risks of and complications from acute COVID-19 still outweigh the rare adverse events from vaccines;thus, eligible patients should be offered the COVID-19 vaccine. Reference #1: Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology. 2020 Jun 2;94(22):959-969. doi: 10.1212/WNL.0000000000009566. Epub 2020 Apr 13. PMID: 32284362. Reference #2: Tagliaferri AR, Narvaneni S, Azzam MH, Grist W. A Case of COVID-19 Vaccine Causing a Myasthenia Gravis Crisis. Cureus. 2021;13(6):e15581. Published 2021 Jun 10. doi:10.7759/cureus.15581 Reference #3: Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. Journal of Primary Care & Community Health. January 2021. doi:10.1177/21501327211051933 DISCLOSURES: No relevant relationships by andrew bui No relevant relationships by Sharonya Shrivastava

The Leading Factors of Obesity and Severe Obesity in Korean Adults during the COVID-19 Pandemic.

(1) Background: During the coronavirus disease 2019 (COVID-19) pandemic, the prevalence of obesity or severe obesity has increased worldwide to the point that it has even been referred to as a new disease. However, the impacts of the pandemic on obesity or severe obesity remain unclear, thus requiring a thorough examination of the leading factors of obesity and severe obesity during this time. (2) Methods: The required dataset for this study was extracted from the eighth (2019-2020) Korea National Health and Nutrition Examination Survey (KNHNES). The survey's data for 2019 and 2020 were analyzed to confirm the leading factors of obesity and severe obesity before and after the outbreak of COVID-19. The samples were weighted, and the data were analyzed using multiple logistic regression. (3) Results: In 2020, the prevalence of obesity and severe obesity in the Korean adult population aged 19 and over, compared with the normal weight group, showed significant increases of 2.5% and 1.4%, respectively, compared with those rates in 2019 (p < 0.05). The main variables affecting the obesity prevalence in Korean adults aged 19 and over in 2020 were gender, age, sitting time per day, and walking time per day, and the factors affecting severe obesity were gender and age. Meanwhile, the daily energy intake variable had no impact on the prevalence of obesity and severe obesity. (4) Conclusions: These findings will serve as a basis to help the present management directions and treatment approaches for individuals with obesity or severe obesity in the post-COVID-19 era.

Case study of a long term ICU patient requiring ECMO following COVID-19 related respiratory failure

Introduction: Due to the COVID-19 pandemic there has been an unprecedented number of hospital and Intensive Care Unit (ICU) admissions for respiratory failure. This has required a significant and sudden increase in ICU capacity. 1,2 Due to severe pulmonary infection and inflammation, patients have presented with acute respiratory distress syndrome (ARDS) with an associated inability to ventilate lungs with poor compliance. This has led to an increased requirement for extra corporeal membrane oxygenation (ECMO) support. This is only available in six commissioned centres across the United Kingdom.3 Objectives: The objective of this is to present a case study of a long-term patient in ICU with a prolonged duration on ECMO. This highlights the complex, mutli-dimensional physiological and psychological impact of recovery and rehabilitation in patients following a severe physical illness. Methods: Figure 1 shows the timeline of significant events during the patient's hospitalisation and admission at the ECMO centre. Due to the nature of a long ICU admission, the patient's condition fluctuated throughout their stay. Rehabilitation was impacted physically by the patient's limited ventilatory reserve caused by lung damage due to COVID. A severe sacral moisture lesion also limited their ability to sit in a chair for longer than one hour and perform sustained sitting on the edge of the bed activities. Psychologically the patient was limited due to significant anxiety and agitation. There were a number of barriers and challenges to rehabilitation whilst the patient was on ECMO as well as post ECMO decannulation. These challenges are detailed in Figure 2. Results: Despite the challenges, the patient was able to participate in physical rehabilitation and was provided psychological support by the psychology team. At their peak ability, the patient was able to perform 12 steps with maximal assistance of three staff. The patient's Chelsea Critical Care Physical Assessment Tool (CPAx) scores can be seen in Figure 3. There was marked difference in the patient's ability to meet the physiological demand of rehabilitation with the ECMO support and without. Following ECMO decannulation the patient struggled with fatigue, hypercapnia and increasing dependency on the ventilator. These issues led to a decline in ability and longer periods of tachypnoea and recovery. Conclusion: Supporting patients after a critical illness requires physical and psychological rehabilitation from the whole MDT. This example of a patient's recovery both during and post ECMO support due to COVID-19 shows the complex relationships affecting the patient's ability to improve and progress.

Functional Outcomes of COVID19 Patients Receiving Extra Corporeal Membrane Oxygenation-A Single Centre Observational Study

Introduction: As of March 2020, COVID-19 pneumonia was declared a global pandemic by the World Health Organisation (WHO).1 COVID19 pneumonia typically presents with systematic and/or respiratory manifestations, with a large percentage requiring advanced respiratory support.2 In severe cases COVID-19 pneumonia can induce acute respiratory distress syndrome leading to refractory hypoxaemia and the use of extra-corporeal life support (ECLS) may be appropriate as a rescue therapy.3 The functional outcomes of patients receiving extra-corporeal membrane oxygenation (ECMO) for COVID are unknown and this observational study will present data from the first and second wave of the pandemic. Objectives: To describe the demographics, functional outcomes and discharge needs of patients receiving ECMO for COVID-19. Methods: Adults admitted to ICU for ECMO with a confirmed diagnosis of COVID19 were included. Functional outcomes were measured using the Chelsea Physical Assessment Scale (CPAx)4 and ICU mobility score.5 Measurements were taken once patients were deemed appropriate for rehabilitation up to discharge from the hospital. Data collection and analysis was performed by two independent unblinded reviewers. Results: A total number of n34 patients were included in the review, n21 survived to hospital discharge and were included in the analysis. 71% of patients were male with an average age of 46 (±9.9) The predominant method of ECMO was veno-venous (90%). Mean duration of ECMO was 25.1 days (±19.6) The average time to mobilise post decannulation from ECMO was 10.86 days (±6.61), with an average CPAx score of 30.10 (±8.94) and ICU mobility score of 6.14 (±2.33) on ICU discharge. Functional milestones included on average achieving independent sitting balance at ∼4 weeks and mobilising +/-an aid at ∼6 weeks. There were no significant differences between patients who were mobilised within 7 days of decannulation of ECMO (P= 0.9) Patients who did not require a tracheostomy had reduced ICU length of stay (P= 0.006). There was nil significant difference between patients who received steroids for ICU length of stay (P = 0.143), CPAx (P= 0.357) or ICU mobility scores (P= 0.414) on discharge from ICU. On discharge from hospital 95% of patients required ongoing support which included the following-discharge home with community therapy, in-hospital transfer and referral to a rehabilitation centre. Conclusions: This data is the first of its kind to present the functional outcomes of patients receiving ECMO during the COVID19 pandemic. Patients receiving ECMO for COVID19 present with high acuity of illness with prolonged mechanical ventilation and ongoing rehabilitation needs at discharge from hospital. Despite a surge in ECMO bed occupancy and redeployment of staff, the therapy team were able to provide high level rehabilitation to patients and a follow up clinic was established to support ongoing needs post hospital care.

Overview of Lifestyle and Anthropometry of Students of the Faculty of Medicine Airlangga University During COVID-19 Pandemic

Background: The COVID-19 pandemic has spread worldwide, forcing governments to implement quarantines as a preventive measure against the spread of the virus. Quarantine causes changes in lifestyle and anthropometry status among communities. Objective: To describe the lifestyle and anthropometric status of medical students batch 2018 FM UA during the pandemic. Methods: This was a descriptive study using online questionnaires from September 2020 to February 2021. Results: There were variations in students’ anthropometry. Students’ average height is 161.110 cm, the average weight is 60.308 cm, the average body mass index is 23.193 cm, the average upper arm circumference is 27.846 cm, and the average abdominal circumference is 79.621 cm. Furthermore, 145 respondents (81.9%) stated that they experienced changes in their lifestyle during the pandemic. A total of 89 respondents (50.3%) continued to exercise and the other 88 respondents (49.7%) did not. Regarding the sleep pattern, 108 respondents (61%) had quite good sleep quality and 50 respondents (28.2%) had quite poor sleep quality. For the food consumption pattern, 46 respondents (26%) ate more sweet foods. Furthermore, 156 respondents (88.1%) did sedentary activities, with 77 respondents (43.5%) doing sedentary behavior for more than 6 hours a day. Conclusion: During the COVID-19 pandemic, the anthropometric status of medical students batch 2018 FMUA varied;and tend to maintain their physical activity, have quite good sleep quality, prefer eating sweet foods, and do a sedentary behavior for a longer duration

Musculoskeletal health complaints: A growing concern that should be investigated elaborately in Bangladesh.

Evidence from the past few decades suggests that the most increases in disability-related musculoskeletal health complaints (MHC) have occurred in low-income and middle-income countries (LMICs). Past studies identified long sitting, higher commute time to the office, and traffic congestion predictors of MHC in Bangladesh. Additionally, post-acute COVID-19 patients reported MHC at a higher rate in Bangladesh. Further studies are needed to recommend exclusive initiatives from authorities to tackle the upcoming tsunami of MHC in LMICs, for example, in Bangladesh.

Critical Illness Myopathy in COVID-19 Patients: A Case Series

Aim and background: Management in COVID-19 includes the use of steroids, prolonged hospital stay, and long-term ventilatory care using muscle relaxants for lung-protective ventilation. These patients are subjected to fluctuating hemodynamics, blood sugar levels, secondary sepsis, systemic inflammatory response syndrome, and multi-organ dysfunction. This causes an increased risk for developing critical illness polyneuropathy and myopathy. Objectives: The literature assessing the effect of these risk factors on mortality in patients with COVID-19 is scarce. Hence, we assessed the effect of various risk factors and interventions on the long-term outcome in these patients. Materials and methods: We collected retrospective data of critically ill COVID-19 patients who developed from critical illness myopathy. The demographic details, clinical parameters, laboratory values, effect of protocol-based physiotherapy intervention, and long-term outcome of patients in term of residual weakness, dependency, and mortality was collected. Results: Out of the total 324 critically ill COVID-19 patients, 11 patients were diagnosed with critical illness myopathy and were included for data collection. Among the patients who developed critical illness myopathy, in-hospital mortality was around 36.4%. The use of protocol-based physiotherapy interventions like long sitting (P = 0.007) and, chair mobilization (p = 0.001) led to a significant reduction in mortality in COVID-19 patients. Conclusion: In patients with COVID-19 related critical illness myopathy, the use of protocol-based physiotherapy interventions leads to improved survival. Key messages: In patients with COVID-19 related critical illness myopathy, the use of protocol-based physiotherapy interventions has survival benefits.

TRANS-NASAL OESOPHAGOGASTRODUODENOSCOPY (OGD): CHALLENGING THE STATUS QUO - A DISTRICT GENERAL HOSPITAL CASE SERIES

Introduction Oesophagogastroduodenoscopy (OGD) is commonly performed and trans-oral OGD is a very safe procedure. However, it requires nursing support, patient sedation, a dedicated endoscopy suite, and is disliked by patients. The national census by the Joint Advisory Group on Gastrointestinal Endoscopy reported 860,000 OGDs were performed across the UK in a calendar year. of these, only 26,685 were trans-nasal despite having a similarly low risk profile and being preferred by patients. We compared comfort score, sedation, and safety to show trans-nasal OGD is a feasible alternative to trans-oral OGD reducing nursing burden, avoiding endoscopy suites, and reducing procedure length. Methods A single centre retrospective analysis was performed comparing all OGDs performed by a single endoscopist at Whipps Cross and Mile End Hospitals between 01/06/2021 and 24/11/2021. Demographic data, route of entry, indication, comfort score (scale of 0-3), sedation agent and dose, and any complications were recorded for each procedure. The data sets were compared using paired t-test for statistical significance. Results There was 110 OGDs performed (table 1);73 transoral (66%) and 37 trans-nasal (34%). of those trans-nasal OGD 18 (49%) were completed seated. The trans-nasal route had mean comfort score of 0.29 compared with 0.85 for trans-oral route (p = 0.001). There was no statistical difference in xylocaine application with either route. The mean dose of both fentanyl and midazolam was statistically higher in the trans-oral route compared with trans-nasal (p = 0.0001). There were only two complications reported in the cases reviewed. Conclusions Trans-nasal OGD caused significantly less discomfort than trans-oral OGD and required significantly less sedation, and almost half of patients undergoing trans-nasal OGD were able to tolerate the procedure in a seated position. This has advantages for patient safety, as the risk of aspiration is greatly reduced, but is also much less resource intensive. Given the current pressure on endoscopy services nationwide, amplified by COVID-19, trans-nasal endoscopy is safe, less resource intensive, and can be performed outside of a dedicated endoscopy suite. This may be a useful tool in alleviating waiting list pressure and should be discussed with patients and service leads.

HEPATO-PULMONARY SYNDROME: LOOK CLOSELY OR YOU MIGHT MISS IT

CASE: A Hispanic-speaking 63-year-old lady presented with left shoulder pain and dyspnea since two weeks. Past history was significant for cirrhosis due to autoimmune hepatitis and portal hypertension diagnosed 1.5 years prior. Upon further questioning, she revealed that she had exertional dyspnea for 2 years, which got progressively worse after her COVID-19 infection, 14 months prior. On initial exam, her hemoglobin levels were unchanged with previous. Troponin and BNP levels were unremarkable. CT Pulmonary Embolus scan and shoulder X-ray were negative. However, her SpO2 which was 90% on lying flat, fell to 84% on walking and she was admitted for further workup. On exam, she had a loud S2, spider angioma, and clubbing. ABG showed an alveolar-arterial oxygen gradient of 54.7 mm and PO2 of 61.7 mm. A contrastenhanced transthoracic echo with saline showed significant shunting with dilated pulmonary veins. Upon close inspection, she had a small right to left intracardiac shunt through an incidental PFO and a rather large intrapulmonary shunt. This was confirmed on trans-esophageal echo. Right heart catheterization showed a high cardiac index (5.3 L/min) suggestive of a high-output state, as typically seen with cirrhosis. It also revealed increased right-sided oxygen saturations, confirming the presence of a significant left to right shunt. Finally, pulmonary CT angiography was negative for AVMs. These findings were congruent with hepato-pulmonary syndrome (HPS) and based on her presenting symptoms she was referred to hepatology for consideration of liver transplantation. IMPACT/DISCUSSION: HPS is characterized by abnormal oxygenation due to intrapulmonary vascular dilations (IPVD) in the setting of advanced liver disease. Diagnosis needs an elevated A-a gradient (≥ 15mm or ≥ 20 mm if >64 years). IPVDs may not be seen on CT scans and are optimally detected on CE-TTE. The delayed appearance of injected microbubbles in the left heart, 3 or more cardiac cycles after visualization in the right heart signifies abnormally dilated pulmonary capillaries which don't trap the bubbles. TTE can help differentiate intracardiac and intrapulmonary shunts, by revealing the source of the microbubbles entering into the left atrium (across the atrial septum vs pulmonary veins). Shunting classically causes platypnea-orthodexia (worsening dyspnea on standing or sitting, alleviated by lying down). Alterations in lung parenchyma due to COVID-19 could have increased the flow through intrapulmonary AVMs and contributed to the worsening of symptoms. Management of HPS is supportive. Liver transplantation improves survival. CONCLUSION: Evaluation and management of HPS involves multiple modalities of testing and specialists in gastroenterology, cardiac imaging, interventional cardiology, interventional radiology, and transplant surgery. The diagnosis of HPS should escalate referral to a liver transplant center. Engaging medical interpreters can help elicit more detailed history and improve clinical outcomes.

What works to reduce sedentary behavior in the office, and could these intervention components transfer to the home working environment?: A rapid review and transferability appraisal.

Background: Working patterns have changed dramatically due to COVID-19, with many workers now spending at least a portion of their working week at home. The office environment was already associated with high levels of sedentary behavior, and there is emerging evidence that working at home further elevates these levels. The aim of this rapid review (PROSPERO CRD42021278539) was to build on existing evidence to identify what works to reduce sedentary behavior in an office environment, and consider whether these could be transferable to support those working at home. Methods: The results of a systematic search of databases CENTRAL, MEDLINE, Embase, PsycInfo, CINHAL, and SportDiscus from 10 August 2017 to 6 September 2021 were added to the references included in a 2018 Cochrane review of office based sedentary interventions. These references were screened and controlled peer-reviewed English language studies demonstrating a beneficial direction of effect for office-based interventions on sedentary behavior outcomes in healthy adults were included. For each study, two of five authors screened the title and abstract, the full-texts, undertook data extraction, and assessed risk of bias on the included studies. Informed by the Behavior Change Wheel, the most commonly used intervention functions and behavior change techniques were identified from the extracted data. Finally, a sample of common intervention strategies were evaluated by the researchers and stakeholders for potential transferability to the working at home environment. Results: Twenty-two studies including 29 interventions showing a beneficial direction of effect on sedentary outcomes were included. The most commonly used intervention functions were training (n = 21), environmental restructuring (n = 21), education (n = 15), and enablement (n = 15). Within these the commonly used behavior change techniques were instructions on how to perform the behavior (n = 21), adding objects to the environment (n = 20), and restructuring the physical environment (n = 19). Those strategies with the most promise for transferring to the home environment included education materials, use of role models, incentives, and prompts. Conclusions: This review has characterized interventions that show a beneficial direction of effect to reduce office sedentary behavior, and identified promising strategies to support workers in the home environment as the world adapts to a new working landscape.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021278539, identifier CRD42021278539.

Comparisons of physical activity, sitting time, and substance use among college students before and during the COVID-19 pandemic.

Objective: To compare physical activity (PA), sitting time, and substance use pre-COVID-19 and during COVID-19 pandemic among US college students. Participants: 484 students from a large Western university (20.6 ± 1.4 years, 80.0% female) were recruited. Methods: Self-reported online surveys were completed in June-August 2020. T-tests and non-parametric analyses were conducted for continuous and ordinal variables respectively. Results: Vigorous PA, moderate PA, and light PA decreased significantly by 32%, 27%, and 21% and sitting time increased significantly by 49% from pre-COVID-19 to during COVID-19 pandemic. Wine consumption was less during COVID-19 than pre-COVID-19 among female, non-first-generation, and White students. Sleep aids use was more frequent during COVID-19 than pre-COVID-19 pandemic among non-first-generation and White students. Conclusion: COVID-19 pandemic may influence college students' health behaviors including physical activity patterns, sitting time, and substance use. Effective health promotion and coping strategies should be widely available to college students during times of change and uncertainty.

THE CHAIR STAND TEST IS A RELIABLE FRAILTY METRIC FOR PREDICTING WAITLIST MORBIDITY AND MORTALITY IN PATIENTS WITH CIRRHOSIS

Background Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations. Objective To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis. Methods 822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis. Results Patients were divided into three groups: group 1, <10 seconds (n = 276);group 2, 10-15 seconds (n = 290);and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16-4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73-2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01-3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48-2.29, p<0.001) when compared to patients with times less than 15 seconds. Conclusion A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform. (Figure Presented)