Caloric and protein intake and duration of venous-venous ECMO in covid patients in a newly implemented regional ECMO center in Brazil

Objectives: To assess protein and energy intake and duration of venous-venous ECMO in critically ill patients with covid-19 Methods: We conducted a retrospective observational analysis on the intensive care units of a large tertiary private teaching Hospital. Adult patients admitted to intensive care unit (ICU) with laboratory confirmed SARS-CoV-2 (RT-PCR), cannulated on venous-venous ECMO and on exclusive enteral feeding were included. Data between march 2020 and june 2021 were collected. Weight and height data were acquired at the time of admission in ICU. Body mass index (BMI) was subsequently calculated. We obtained delivery and adequacy of nutrition data from a enteral nutrition form routinely filled out by nutritionists during hospitalization. Other data were obtained from electronic medical record. For statistical analysis of the data, we used SPSS version 13.0. Result(s): This cohort included 39 patients. 27 (69.2%) were men, mean age was 50 (+/- 12) years and 11 (28,2%) had more than 60 years. The more prevalent comorbidities were obesity in 22 (56%), hypertension in 20 (51,3%) and diabetes in 6 (15,4%) patients. The mean time on ECMO was 24.7 +/- 15.2 days. 29 patients (74%) died. Regarding nutritional support, the average protein intake was 0,9 +/- 0.4 g/kg/day and calories 13.9 +/- 5.2 cal/kg/day. No statistically significant association was observed between the nutritional intake and the duration on ECMO and clinical outcomes of patients. Conclusion(s): There was a high mortality in our cohort. Center;s inexperience may have played a role in these results, in addition to other factors. We observed a high prevalence of obesity. Neither energy nor protein intake were associated with the duration of ECMO and clinical outcomes. These results are similar to other recent observational studies where an insufficient energy and protein intake did not affected mortality or other outcomes. Our small sample and study design prevents a definitive conclusion on the subject. Thus, we propose further studies to elucidate the role of adequate nutrional strategies to improve outcomes and reabilitation of patients on ECMO.

Increase in weight-for-age and vegetable intake in young children with cystic fibrosis treated with lumacaftor/ivacaftor for 24 weeks

Background: Modulator therapy has improved nutritional status in individuals with cystic fibrosis (CF), which is associated with favorable outcomes. Because of the high metabolic demands of CF, nutritional recommendations include energy intake of 110% to 200% of daily estimated needs for healthy individuals. With changes in energy balance after initiation of modulator therapy, these recommendations may no longer be appropriate for some people with CFand may lead to excessiveweight gain. Overweight and obesity are being reported, and nutrition concerns now include dietary quality. Dietary quality in relation to growth in young children starting lumacaftor/ivacaftor therapy has not been examined over a 24-week period and may provide new data for future nutrition guidance for individuals with CF. Method(s): The purpose of this observational study was to determine the effect of lumacaftor/ivacaftor treatment on growth and diet in medicationnaive children. Subjects aged 2 to 5 with D508/D508 mutations were recruited from the United States and Canada. Length/height, weight, and body mass index (BMI) were measured in triplicate and averaged. Z-scores were calculated using Centers for Disease Control and Prevention reference data. Dietary data were captured using 3-day weighted food records after study visits. The Healthy Eating Index (HEI) was generated using the U.S. Department of Agriculture scoring system for each recorded day and averaged. Outcomes were assessed before treatment (baseline) and 12 and 24 weeks after beginning medication. Mixed longitudinal models were used for analysis over time. Result(s): Participants (mean age 2.9 +/- 1.4, 50% female) who completed food records for at least their baseline visit plus one other visit (n = 14) had significant increases inweight-for-age z-score (WAZ) 12 (0.6 +/- 1.7, p = 0.02) and 24 (0.21 +/- 1.8, p = 0.001) weeks after therapy. There was no significant change in height-for-age (HAZ), BMI-for-age (BMIZ), or head circumference- for-age (HCZ) z-score at 12 or 24 weeks. Although not statistically significant, percentage estimated energy requirement (%EER) decreased at 12 (-7 +/- 90%, p = 0.54) and 24 (-27 +/- 90%, p = 0.08) weeks. HEI total score did not change over the 24 weeks, although vegetables and greens and beans HEI subgroup scores decreased significantly from baseline to 24 weeks (-0.73 +/- 2.2, p = 0.02;-0.68 +/- 2.1, p = 0.02, respectively). Pooled visit correlation between total vegetables and WAZ indicated a positive association (r = 0.35, p = 0.04). Conclusion(s): WAZ increased significantly over 24 weeks of lumacaftor/ ivacaftor therapy and was positively correlated with total vegetable intake, suggesting that participants with greater WAZ scores consumed more vegetables, although over the course of the study, total vegetable intake and intake of greens and beans decreased, and WAZ increased. %EER decreased over the course of the study, but not statistically significantly so, probably because of variability in energy intake within this small study sample with some COVID-19 interruptions. In summary, WAZ of children aged 2 to 5 with D508/D508 mutations increased, with no significant changes in HAZ, BMIZ, or HCZ, and they consumed fewer total vegetables and greens and beans after 24 weeks of lumacaftor/ivacaftor therapy. Acknowledgements: Supported by Vertex Pharmaceutics Inc. and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR001878.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

The impact of rotational shift work schedules on energy intake: a systematic review and meta-analysis

Shift workers are known to have poorer metabolic health outcomes compared to day workers,(1) whilst those who work in rotating shift work roles have the highest risk.(2) To date, overall energy intake in shift workers has been found to be similar to day workers,(3) but it is unknown whether energy intake in workers on rotating shift schedules may be a contributing factor to the observed higher chronic disease risk. A systematic review and meta-analysis were conducted to explore how rotating shift work schedules impact total energy intake compared to fixed day/morning work schedules. Intra-person differences in energy intake amongst rotating shift workers on day/morning versus night shifts was also examined. Searches were conducted on CINAHL, Cochrane, Embase, MEDLINE PsycINFO and Scopus databases to identify articles reporting energy intake for rotating shift workers and fixed day workers. Articles were screened in duplicate against inclusion criteria using Covidence software. Data were extracted by one reviewer and checked independently by one of three reviewers. Quality assessment of included studies was assessed in duplicate using the American Dietetic Association (ADA) Quality Criteria Checklist for Primary Research. Meta-analyses were performed in RevMan using a random effects model, to compare mean difference in 24-hour energy intake with 95% confidence intervals. Heterogeneity was assessed with the I-squared test (I2). Thirty-one studies (n = 18196 participants) met the inclusion criteria and were included in the review with data for the two meta-analyses comprising 18 studies and seven studies, respectively. Overall, rotating shift workers had significantly higher average 24-hour energy intake compared to fixed day or morning work schedules (weighted mean difference [WMD] = 264 kJ;95% CI [70, 458], p < 0.008;I2 = 63%). Within rotating shift workers, the mean difference in 24-hour energy intake across morning/day shifts compared to night shifts was not statistically significant (WMD = 101 kJ;95% CI [-651, 852];p = 0.79;I2 = 77%). Results indicate workers on rotating shift schedules had a higher average 24-hour energy intake compared to their fixed day schedule counterparts. However, energy intake across shift schedules did not differ for individuals working this pattern. A higher 24-hour energy intake in rotating shift workers can contribute to gradual weight gain and higher metabolic risk in rotating shift work populations.

Assessment of Lifestyle Changes and Their Effect on Health among Children of <=15 Years during Covid-19 Pandemic, in North India

Objective: The objectives of the study were: (1) To assess life style changes among children of <=15 years of age during COVID-19 pandemic and (2) to find out the effect of the life style changes on health of children of <=15 years of age. Method(s): The cross-sectional comparative study conducted at department of pediatrics, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow for duration of 1 year and sample size found to be 276 on calculation by applying the formula. Result(s): Out of 278 children, about 39% (108) were female children. Most of children were studying in primary level classes (52.51%) and most of enrolled children had joint family (66.18%). Level of physical activity reduced significantly due to closure of school and restriction on outdoor activities. Weight of children increased significantly during COVID-19 pandemic seems to be due to decreased in physical activities and consumption of more fast food/fried food (high calorie intake) and sedentary life style. Conclusion(s): During COVID-19 pandemic due to closure of schools and restricted outdoor activities results in decrease level of physical activities, increased consumption of high calorie food and sedentary behavior lead to increase in weight of children and changes in sleeping pattern of children.Copyright © 2023 The Authors. Published by Innovare Academic Sciences Pvt Ltd.

The Socioeconomic Determinants of Food and Nutritional Security in Rural and Urban Area of Pakistan during Covid-19

Food insecurity and poor health is turning out to be one of the biggest global issues especially during the pandemic period. Food value chains of developing countries has drastically affected and linked with the problem of food insecurity and malnutrition during covid-19. Keeping in view the importance of this key issue, the present study aimed to investigate the impact of covid-19 on food and nutritional (macro and micro nutrition) status by using the calories and nutrition intake method in the rural and urban areas of district Faisalabad. Food security index was used to estimate the absolute food security status and Logistic Regression Model was employed to examine the effect of covid 19 on food security. Primary data set of almost 500 households were collected from the rural and urban areas. The results show that calories and macronutrient's security status was better in the urban areas while the situation of micro nutrients was better in rural areas. It was found that nearly 49 percent households in rural areas and 43 percent households in urban areas were food and nutrition secure during covid-19. The impact of covid-19 was evident in urban areas especially in low-income households and people who earn daily wages. The regression analysis showed that prevalence of disease, education, household income, family size, number daily intake meals, age of household head and land size have shown significant effects on the food and nutrition security status in both rural and urban areas.Copyright © 2022 Institute of Biotechnology and Genetic Engineering. All rights reserved.

The association among circadian rhythm, circadian genes and chrononutrition, its effect on obesity: a review of current evidence

Circadian rhythms, also known as circadian clocks, are cyclic endogenous biological patterns of an approximately 24-hour cycle which regulate the timing of physiology, metabolism, and behavior. Recent research in the field of circadian science has suggested that the timing of food intake may also play a role in markers of health, in addition to food choice and food quantity. There is emerging evidence suggesting that the timing of dietary intake, so-called chrono-nutrition, may be influenced by an individual<apos;>s chronotype. For example, the evening type has been linked to unhealthy diet, which could indicate a higher possibility of obesity. On the other hand, the continuum of chronotype diversity is largely mediated by genes. The presence of single nucleotide polymorphisms (SNP) of clock genes have been associated with obesity, chronotype, metabolic disturbances, and dietary habits (e.g., breakfast skipping, meal timing, energy/macronutrient intake). In this review, we outline the current knowledge of the interactions between clock genes, chronotype, dietary intake and chrono-nutrition.Additionally, it is emphasized that the COVID-19 pandemichas had a significant impact on the circadian system, dietary choices and meal timing. For this reason, the current review aims to focus on how chronotype/sleep and chrono-nutrition are affected during the COVID-19 pandemic.Copyright © 2022 Informa UK Limited, trading as Taylor & Francis Group.

Management of obesity.

From 1975-2016, the number of people with obesity in Europe increased fivefold and the overall trend is still increasing. Obesity is the result of an imbalance between energy expenditure and caloric intake. Although the importance of genetic determinants for the variance of body mass index (BMI) is about 60-70%, overeating, lack of exercise, and psychosocial stress are influenceable risk factors. For example, during the Corona pandemic, nearly 40% of Germans gained an average of 5.6kg, and people with obesity gained as much as 7.2kg. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. A significant reduction of cardiovascular endpoints can be achieved with a weight reduction of more than 10% of the initial weight. Therapeutic measures in the context of an escalating stepwise approach should include strategies for targeted weight reduction and long-term weight maintenance.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Management of obesity.

From 1975-2016, the number of people with obesity in Europe increased fivefold and the overall trend is still increasing. Obesity is the result of an imbalance between energy expenditure and caloric intake. Although the importance of genetic determinants for the variance of body mass index (BMI) is about 60-70%, overeating, lack of exercise, and psychosocial stress are influenceable risk factors. For example, during the Corona pandemic, nearly 40% of Germans gained an average of 5.6kg, and people with obesity gained as much as 7.2kg. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. A significant reduction of cardiovascular endpoints can be achieved with a weight reduction of more than 10% of the initial weight. Therapeutic measures in the context of an escalating stepwise approach should include strategies for targeted weight reduction and long-term weight maintenance.Copyright © 2022, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Changes in Body Mass, Physical Activity, and Dietary Intake during the COVID-19 Pandemic Lockdowns in Canadian University Students.

This study examined changes in body mass and body mass index (BMI), physical activity, and dietary intake in Canadian university students during the first year of the COVID-19 pandemic. Two self-reported recall surveys were conducted: after the first lockdown in September 2020 (T1) and following the second lockdown in March 2021 (T2). Eligible participants were full-time undergraduate students attending a Canadian university and residing in Canada during the first year of the pandemic. At T1, 510 students (99 male, 411 female) completed the survey, and of those, 135 (32 males, 103 females) completed the survey at T2 (73% attrition). At both T1 and T2, most participants were 18-24 years of age (93% and 90%, respectively), Caucasian (73% and 78%, respectively), and resided in the province of Ontario (79% and 80%, respectively). Body mass increased from T1 to T2 (+0.91 ± 3.89 kg t(132) = -2.7, p = 0.008). BMI also increased from T1 to T2 (+0.30 ± 1.33 kg/m2 [t(130) = -2.5, p = 0.012), with a greater number of participants within the overweight range (19.8% versus 24.4%, respectively). At T1, 38% of the participants reported a decrease in physical activity, while the number of students reporting a decrease in activity increased to 56% at T2. Dietary energy intake decreased from 1678 ± 958 kcal/day at T1 to 1565 ± 842 kcal/day at T2 [c2(1) = 7.2, p = 0.007]. Diet quality also decreased, with participants not meeting the recommended daily allowance for essential macro and micronutrients. A decrease was observed in daily servings of fruits (-27%, p < 0.001), vegetables (-72%, p < 0.001), and grains (-68%, p < 0.001). In conclusion, despite a small decrease in dietary energy intake, a modest weight gain occurred during the first year of the COVID-19 pandemic in this cohort of Canadian university students, which was potentially related to decreased physical activity and diet quality.

SARS-CoV-2 pandemic and GH treatment: new strategies to abate the distance

SARS-CoV- 2 pandemic induced to develop new strategies to abate the distance between patients, families and paediatricians, especially in cases of patients who need long-term therapies. Furthermore, the need to minimize the inflow of children and adolescents affected by chronic diseases into the hospitals induced paediatric endocrinologists to limit visits and to consider a new setting to assist children in treatment with growth hormone (GH). Telemedicine and smart-working could contribute to maintain a good standard of care in the follow-up of children with GH deficiency, still in treatment with GH. Patients were assisted by telephonic consultations guaranteed by the paediatricians of free choice and by the paediatric specialists. However, patients frequently needed a direct specialistic evaluation in the case of flares, abnormal laboratory parameters and adverse reactions to drugs. We enrolled 85 children (50 M;35 F);Medium age: 12.4 (4-16) years, with GH deficiency, in treatment with GH. A questionnaire were proposed to their parents, with questions about the assistance and problems linked to the disease. The questionnaire highlighted many points: - the central role of the follow-up by the paediatricians of free choice;- the useful digital support strategies (pc, smart phone app, tele consult, etc);- the worsening of dietary intake and increased caloric intake, associated with a decreased regular physical activity. These life style increased BMI in most patients. - the important role of the paediatric endocrinologist consults in important decisions as vaccinations. The new scenario induced paediatric endocrinologists to create new strategies to support patients with special needs, as GHD children and adolescents. However, these strategies can be maintained even beyond the end of the pandemic, as a good assistance practice.

LIFESTYLE CHANGES DURING THE SARS-COV-2 PANDEMIC CONFINEMENT IN EUROPE: A SYSTEMATIC REVIEW

In early 2020, the SARS-CoV-2 pandemic began to spread. Due to the extent and quickness of infection, a more or less strict confinement was declared, depending on each country's government. Therefore, the main objective of this systematic review is to study the changes in lifestyle that occurred during the lockdown due to the COVID-19 pandemic in healthy subjects over 18 years old in 9 European countries. A systematic review was performed according to PRISMA criteria. The "PubMed" database was used for the search;with the following advanced search strategy: "dietary changes" OR "lifestyle changes" AND "covid-19" OR "covid-19 lockdown" AND adults. Finally, 12 articles were included. Most studies showed an increase in energy intake, sweets, snacks and alcohol. Physical activity levels diminished. These unhealthy habits have led to an increase in body weight. Thus, COVID-19 lockdown appears to have modified lifestyle habits in European population. Further research should be done with larger sample sizes to assess the impact of the pandemic and to improve lifestyle recommendations in case of future pandemics. Copyright © 2022 Real Academia de Farmacia. All rights reserved.

Myfood24 healthcare, a pilot trial of a new diet tracking app in tier 3 weight management and gastroenterology surgery patients

Healthcare professionals do not have tools needed to track food and nutrient intakes in patients requiring dietary support. Monitoring nutritional intake can promote behaviour change but few existing tools provide electronic dietary recording, comprehensive food composition data, instant nutritional analysis and a platform connecting healthcare teams with patients, providing timely, personalised support. myfood24 has been validated for use in research(1) and is available as an app patients and healthcare professionals. This feasibility randomised controlled trial aimed to assess the use of 'myfood24 Healthcare' in two clinical populations. Tier 3 weight management patients in York and gastroenterology surgery outpatients, Leeds (UK) were randomised into three groups: standard care, myfood24, or myfood24+diet optimisation. Optimisation uses machine learning to suggest diet changes getting patients closer to nutrient targets. Patients were asked to record diet with the app at least four times over eight weeks. Covid restrictions meant all data was collected online. Healthcare professionals viewed patient dietary information and provided semi-structured interview feedback on usability. Patients completed an online survey after 8 weeks to provide demographic details, previous technology experience and feedback on usability and acceptability of myfood24.A total of 48 patients (21 weight management and 27 gastroenterology surgery) were recruited and randomised to the 3 groups. Covid influenced recruitment of patients and altered app delivery. Patients mean age was 51y and self-rated internet ability was only 'fair'. In the app users (n 32) compliance was good, with 25 (78%) using it at least once. Among users, the mean (SD) days recorded was 14.0 (17.5). Mean daily energy intake for weight management patients was 1060kcal (SD 513) and for gastroenterology patients 1209kcal (SD 675). Self-reported nutrient intakes varied by patient group reflecting dietary needs. 9 of the 16 allocated to the optimisation used it. Suggestions were activated on 88% of days recorded, mean 16days (SD 19). Feedback questionnaires were completed by 50%. Despite small numbers, some patients (3/16, 19%) said that symptoms had improved by using myfood24;it gave them confidence to stick to advice (4/16, 25%) and it could help them manage their condition (4/ 16, 25%). Over half said they would use the feedback to ask for advice at their next appointment. The mean System Usability Score was 59 (95% CI, 48 to 70). Patient and healthcare professional feedback indicates that patients found the tool easy to use. Improvements suggested related to user training when using the app and improvement of the search function. This feasibility study conducted during Covid restrictions, led to smaller numbers than anticipated, also potentially affecting response. However, results show that myfood24 Healthcare app is acceptable and useful for patients and healthcare professionals. These data have informed app refinements which are now in place.

Nutritional adequacy and accuracy in long-stay critically ill patients as measured by indirect calorimetry

Introduction: Nutritional optimisation is recognised as having significant impact on clinical and functional outcomes of critically ill patients.1 Clinical recommendations suggest use of indirect calorimetry guided nutrition in the intensive care unit (ICU),2 and a recent systematic review demonstrated improved outcomes from its use.3 The COVID-19 pandemic has seen a greater proportion of patients with prolonged critical illness, a cohort for whom nutritional optimisation is a key unmet need.4 Objectives: To assess rates of over and underfeeding in a tertiary centre ICU and how these relate to markers of catabolism and persistent critical illness. Methods: Serial measurements of REE (resting energy expenditure) and RQ (respiratory quotient) by indirect calorimetry were performed using Q-NRG+ device (COSMED, Rome, Italy). Nutritional intake and estimations of requirements were recorded concurrently together with routine clinical observations, and markers of critical illness, catabolism and over or underfeeding. Results: Across 30 patients, REE was lower than estimated energy requirements, 24.2 (IQR 20.0-28.1) kcal/ day/kg IBW vs. 29.1(IQR 25.4-33.1) kcal/day/kg IBW, p<0.001. 41.8% of measurements showed overfeeding (actual calorie intake >110% of REE), and 23.3% showed underfeeding (actual calorie intake <85% of REE). Obese patients (n=15) were underfed (-98kcal/day deficit) compared to non-obese patients (n=15), who were on average overfed (+256kcal/day surplus), p=0.021. Overfeeding was also associated with greater length of ICU admission (R2 0.159, p<0.005). Median day of ICU admission in overfed patients was 39 days (IQR 24-56), and in underfed patients 21.5 (IQR 7.5-45.25). However, there was no significant association between calorie surplus or deficit, and other markers of overfeeding PaCO2, insulin use, ureacreatinine-ratio. Conclusion: This service evaluation recorded measurements of REE and RQ in critically ill patients with high lengths of ICU stay (up to 66 days). We observed increased rates of overfeeding with increased duration of ICU admission, and increased overfeeding in non-obese patients.

Meeting nutritional requirements in critically-ill patients with COVID-19: Does the patient's position really matter?

Introduction: Prone positioning and veno-venous extracorporeal membrane oxygenation (VV-ECMO) can improve oxygenation in patients with COVID 19-induced acute respiratory distress syndrome (ARDS).1 Enteral feeding in the prone position has challenges, including possible aspiration risk of gastric contents and potential for disruption to enteral feeding.2 National guidelines2 were implemented locally;including a reduction in the maximum acceptable gastric residual volume (GRV) and the avoidance of bolus feeding while patients were in prone position. Objectives: • To explore the nutritional adequacy of patients in the prone position with COVID-19 on our critical care unit during the second surge (November 2020-April 2021) • To compare nutritional adequacy of days when patients were in prone versus supine position • To identify any factors that impacted on nutritional adequacy • To provide recommendations for improvement Methods: Patients with COVID-19 who required intubation, were placed in prone position at any time during their admission and had been assessed by the dietitian, were included. Total daily energy and protein intakes, from enteral (EN) and parenteral nutrition (PN), propofol and intravenous glucose were obtained from our computerised information system (Metavision) for each full day. If nutritional aims were not met then reasons for this were investigated. Nutritional adequacy was defined as ≥ 80% of energy and protein received per day.3 Results: Data for 34 patients was collected (see Table 1). A total of 1142 ICU days were included: 106 (9.3%) prone position days and 1036 (90.7%) supine position days. Patients received EN on 1098 days (96.1%) and PN on 44 days (3.9%). Only 4 of the 44 PN days occurred whilst a patient was in the prone position (0.4%). On prone position days, patients received an average 80% of their prescribed energy and 56% of their prescribed protein requirements, compared with 95% prescribed energy and 84% prescribed protein on supine position days. The average received across both prone and supine position days was 94% energy and 82% of protein. The 4 most frequent barriers to meeting protein requirements when in prone position were: • Reduction of NG feed rate when GRV's were higher than maximum acceptable volume • Use of a standard 4g protein/100ml 'Out of Hours' enteral feed • Fasting for procedures • Failure to give protein supplement boluses when patient returned to supine position Conclusion: Patient position affected nutritional intake, with energy and protein intake being lower on prone position days compared with supine position days. As only 9.3% of total ICU days were prone position days, average energy and protein received across all days still achieved nutritional adequacy. An increase in a patient's prone position days during ICU admission is likely to result in greater nutritional deficit, particularly for protein. Recommendations to improve nutritional adequacy on prone position days: • Consider use of post-pyloric feeding to increase feed tolerance • Use of a higher protein 'out of hours' enteral feed • Raised awareness of standard fasting times to ensure minimum disruption to feeding • Consider administration of protein supplement boluses in prone position when GRV's are within the accepted range .

IMPACT of the SARS-COV 2 PANDEMIC and RELATED EPIDEMIOLOGICAL RESTRICTIONS on the CARE of PATIENTS with OSTEOPOROSIS-EXPERIENCES of A HUNGARIAN CENTRE

Background: Treatment of patients with osteoporosis was inadequate even before the COVID-19 pandemic. Not only patients without fracture, but only a small proportion of patients with osteoporotic fracture have treated. In Hungary only 30% of patients with osteoporosis received adequate antiporotic treatment before the pandemic. Almost 90% of whom were women, less than 10% of men. The incidence of fractures is increasing dramatically worldwide. In 2010, the vertebral fracture rate was 3.5 million in Europe but it is expected to reach 4.5 million by 2025. In 1990, osteoporosis caused 1.26 million hip fractures and by 2025 this is estimated at 2.6 million worldwide. The care for patients with osteoporosis was further aggravated by the restrictions necessarily imposed due to the coronavirus. Objectives: The aim of the study was to explore the extent and consequences of diagnostic and therapeutic failure in patients with osteoporosis. Methods: I determined the number of osteoporosis examinations performed in our centre in 2019-2021 from the medical database. I surveyed how many patients were discontinued the antiporotic treatment during the pandemic according to the different drug groups in Hungary and also in our centre as well as the prevalence of wrist and hip fractures due to minor trauma in our county in the pre-and post-pandemic period. Results: In our centre an average of 30 DEXA examinations were performed daily in the pre-pandemic period. From the end of October 2021 to the end of May 2021 there was not perform any ODM examinations. It means 3.980 missed exams and at least 1.000 missed osteoporosis diagnoses and therapy starts. More than 20% of patient were lost from the antiporotic care in Hungary. Drop-out was mainly seen in patients treated with bisphosphonates. There were 20730 bisphosphonate-treated patient in 2019, 19813 in 2020 and 17315 in 2021. Antiporotic treatment was discontinued in 30% of patients treated with bisphosphonate+vitamin-D (7849 in 2019, 6950 in 2020, 5484 in 2021) or bisphosphonate+calcium+vitamin-D fxed combination products (3256-2876-2289). In our centre, the prescribing of bisphosphonates has also decreased more than half. Patients treated with iv. bisphosphonates were interrupted or switched to oral formulations. Denosumab therapy was continuous: 581 injections were prescribed in the 12 months before and 579 during the pandemic. However, no new treatment started. In case of teriparatide, the initiated therapies were continued and even the number of prescriptions increased. As a consequence, an increase in the occurrence of fractures due to minor trauma is expected. Although epidemiological restrictions in this regard, the curfew has had some positive effects. According to international data, the number of wrist fractures has almost halved, while the data for hip fractures are controversial. The decrease of wrist fractures can also be verifed in our county. The number of wrist fractures was 598 in April-May 2019, 393 in the same period in 2020, and 372 in 2021. After a signifcant reduction in hip fractures in 2020, there is already an upward trend in 2021 (470 in 2019, 358 in 2020, 393 in 2021). The real consequences of failure to treat osteoporosis are expected only after years. Conclusion: Missed doctor-patient appointments were associated with missed diagnoses and interruptions of ongoing treatments. Fear of the virus, immobilisation due to home office and curfews, lack of exercise, sun exposure, caused depressive symptoms, increased alcohol consumption and caloric intake are all increase the risk of osteoporosis. Thus, traditional risk factors for osteoporosis expanded with the direct effects and the introduced restrictions because of the pandemic.

Applying learning from 1st to the 3rd wave of the COVID19 pandemic: nutritional provision in critical care

The aim of this analysis was to compare route and adequacy of nutrition support in patients with COVID19 admitted to an intensive care unit (ICU) between March-June 2020 (T1) compared to January-April 2021 (T2). Parameters related to nutrition support were collected from the records of all patients admitted to ICU with COVID19 with length of stay of ≥7days on mechanical ventilation requiring artificial nutrition support. Data was collected during the late acute phase which was defined as day 4-7 post intubation. Energy and protein intake was compared to calculated estimated nutritional requirements. 35 patients met the inclusion criteria in T1, 94% were on enteral nutrition (EN), 3% parenteral nutrition (PN) and 3% EN+PN. In T2, there were 54 patients (92% EN, 2% PN and 6% EN+PN). [Formula presented] Of patients who achieved <70% of energy and protein requirements in T1 (n=17) 35% had constipation or ileus and 47% had GI intolerance (high gastric residual volumes or vomiting). In T2 (n=19), 84% experienced constipation or ileus and 63% had GI intolerance. 35% of patients in T1 had hypernatraemia vs. 47% in T2 and 41% in T1 had hyperglycaemia vs. 100% in T2 despite only 12% and 32% of patients respectively having a history of diabetes. Despite a higher incidence of GI intolerance in T2, a statistically significant improvement in achieving energy targets was noted. Learning from T1 showed that where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutritional intake. There was a clinically significant trend in protein intake which may be attributed to prompt initiation of modular protein supplements or perhaps an earlier transition from fat-based sedation. Meeting protein requirements while preventing overfeeding remains a challenge in the ICU. Disclosure of Interest: None Declared

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.

Nutrition in critical care: An audit of protein and energy intakes compared to international recommendations

Adequate protein and energy provision in critical care is associated with better clinical outcomes. The aim of this audit was to evaluate compliance with achieving recommended protein and energy targets in our Intensive Care Unit (ICU) and to explore the reasons for any deficits identified. Nutrition parameters were collected on patients admitted to our ICU between March and May 2021. Inclusion criteria were requirement for nutritional support and mechanical ventilation with an ICU length of stay ≥ 4 days. Patients with COVID19 were excluded. Protein and energy intakes were compared to best practice guidelines1. 51 patients met the inclusion criteria: 53% male, 47% female. Mean age was 59.6 years and mean length of stay was 19.9 days (range 5-61 days). Protein and energy intakes achieved as follows: [Formula presented] Of the patients who received < 80% of their nutritional requirements, the main barriers to achieving targets identified were fasting and constipation in this cohort. Cumulative deficit ranged from 0 - 903g protein and 0 - 12717kcal over duration of ICU stay. Mean deficit was 315g protein and 2945kcal. Of concern, 12 patients had a deficit of > 500g protein and 7 patients had > 5000kcal deficit. While 69% of patients met ≥ 80% protein requirements and 77% of patients met ≥ 80% energy requirements, we have identified areas to consider to improve nutritional adequacy including increasing awareness of minimising fasting times and the introduction of a bowel management protocol. References 1. Singer P, Blaser AR, Berger MM. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 1;38(1):48-79. Disclosure of Interest: None Declared

Malnutrition risk and the need for dietetic intervention post COVID-19 infection on a care of the elderly rehab ward

Patients recovering from COVID-19 are at high risk of malnutrition, reduced nutritional intake and decline in muscle mass and strength with many requiring significant rehabilitation. The aim of this service evaluation is to quantify the risk of malnutrition and provide an overview of nutritional status and outcomes with dietetic input on a care of the elderly rehab ward. Demographics were collected from patient electronic records. Malnutrition risk, handgrip strength and Vitamin D levels were measured along with calculation of nutritional requirements. Of sixteen patients on the rehab wards post COVID-19, 81% (n=13) required dietetic input. [Formula presented] There was an average weight loss of 5.1kg (6.6%) (p=0.64). Eighty one percent had a reduction in their BMI, with 31% moving into a lower BMI category. Measurably reduced and impaired muscle function was evident when handgrip strength was measured. Eighty five percent required oral nutrition support. Additional advice for dysphagia, diabetes and renal disease was provided to 65% of patients. Following dietetic intervention, energy and protein intake improved in all patients. Sixty four percent were either insufficient or deficient in Vitamin D. The data obtained demonstrates the high prevalence of malnutrition in patients on a rehab ward post COVID-19. Furthermore the data highlights the clear need for dietetic intervention in this nutritionally vulnerable group to optimize nutritional status. References I. Stam. HJ, Stucki.G, Bickenbach.J. COVID-19 and post intensive care syndrome: A call for action. Journal of Rehabilitation Medicine. 2020;52 (4)