Achieving a sustainable food supply, for good health and planetary health, a focus on the international context

Globally, diet quality is poor, with populations failing to adhere to national dietary guidelines.(1) Such failure has been consistently linked with poorer health outcomes.(2) Examples of malnutrition include both under- and over-nutrition, with overweight and obesity now a significant health problem worldwide.(3) Other commonly occurring examples of malnutrition are micronutrient deficiencies with iron, vitamin A and iodine deficiencies being the most frequently occurring globally. These nutritional challenges have been influenced by recent global world events, including the COVID-19 pandemic, the war in Ukraine and the related economic uncertainties;with all of these events influencing food supply and food security. Diet and health status is socio-economically patterned, and such inequalities are likely to have been enhanced as a result of these recent events. In addition to the impact of diet on health outcomes it is increasingly recognised that what we eat, and the resulting food system, has significant environmental or planetary health impacts, and research activity is growing in terms of understanding the detail of these impacts, what changes are required to reduce these impacts and also how the impact of climate change on our food supply can be mitigated. Given the complexity of the interactions between climate change, other world events, food and health, and the different actors and drivers that influence these, a systems thinking approach to capture such complexity is essential.(4) Such an approach will help address the challenges set by the UN 2030 Agenda for Sustainable Development in the form of the Sustainable Development Goals, which are a call to action to end poverty and inequality, protect the planet, and ensure that all people enjoy health, justice and prosperity.(5) Progress against SDGs has been challenging with an ultimate target of 2030. While the scientific uncertainties regarding diet and public and planetary health need to be addressed, equal attention needs to be paid to the structures and systems, as there is a need for multi-level, coherent and sustained structural interventions and policies across the full food system/supply chain to effect behavior change. Such systems-level change must always keep nutritional status, including impact on micronutrient status, in mind. However, benefits to both population and environmental health could be expected from achieving dietary behaviour change towards more sustainable diets.

Number of meals per day during the COVID-19 in Colombia, poverty and mortality due to nutritional deficiencies and anemias.

Background: During the COVID - 19 pandemic in Colombia in the year 2021, changes have been reported in the number of meals consumed per day in households, which merited an analysis of the relationship between this situation with territorial socioeconomic variables and mortality due to nutritional deficiencies and anemias. Method(s): A multiple-group descriptive study was carried out. Result(s): From the analyses, a moderate negative and significant correlation was identified between the consumption of at least three meals a day and mortality due to nutritional deficiencies and anemias, as well as for a higher level of multidimensional poverty at territorial level. Conclusion(s): Population risk factors were identified, such as higher levels of multidimensional poverty that may lead to the use of survival strategies such as the consumption of fewer meals per day by the population, which may have an impact on higher mortality rates due to nutritional deficiencies and anemias during the COVID- 19 pandemic in Colombia.Copyright © 2022 Sociedad Espanola de Nutricion Comunitaria. All rights reserved.

Socio-Demographic Depletion Due to COVID-19 Impact and Government Intervention: A Review in Bangladesh

COVID-19 known as coronavirus disease, has been dominating the headlines all over the world since about a year ago which is now almost under control. The World Health Organization (WHO) has labeled it a pandemic. Bangladesh is struggling with this virus with its scarce resources. Nearly two million people have been reported as confirmed cases of coronavirus disease in 185 countries worldwide in the five months after the virus first emerged in December 2019. The COVID-19 pandemic affected people directly or indirectly all over the world. There has been a slowdown in all sectors worldwide and most of the global population was placed under lockdown. The families of 43.9 percent of the students might live in poverty, and export revenues from RMG fell by 18.12% from the previous year. Households in Chittagong city corporation experienced the least decrease in average income (11.7%) while the households in Sylhet city corporation experienced the most reduction in average income (63.4%). This COVID-19 created a widespread global shock. The government of Bangladesh has declared several stimulus plans worth a combined total of about USD 11.90 billion for the agricultural sector to ensure the country's food and nutritional security, for doctors, nurses, and the homeless for social safety, and for business sectors including small and medium enterprises and cottage industries at the early age of pandemic. There were 23 COVID-19 stimulus packages total across the nation, with a total outlay of USD 1.23 billion which is 4.44% of GDP. Approximately USD 3,529 million for the service sector and the impacted industries, USD 589 million to cover workers' salaries/allowances, and those of staff working in industries focused on exports were allocated as a package to tackle the serious impact of the COVID-19 pandemic.Copyright © 2023, Science Publications. All rights reserved.

New Approaches Related to the Use of Polyamine-Free and Polyamine-Deficient Diets in the List of Nutritional Products for Covid-19 Patients

Researches aimed at finding effective means of pathogenic therapy for this viral infection are extremely relevant. Researches of the last three years have established that some human pathogenic coronaviruses - MERS, SARS-CoV and SARS-CoV-2, contain aliphatic polyamines in their structure, which participate in the packaging of genetic material (DNA, RNA), as well as the nucleocapsid. Virus-host cell interactions also provide adhesion processes on the surface of the cytoplasmic membrane of target cells. In the intra-cellular space, aliphatic polyamines actively affect the translation and replication processes of the genetic material and necessary proteins of the virus itself, as well as the formation of daughter viruses. Long-term persistence in the SARS-CoV-2 infected organism is largely due to the absorption of polyamines by corona-virus localized in target cells of the blood and parenchymatous organs. Unfortunately, the above new facts did not serve as a prerequisite for finding effective means of pathogenetic therapy for COVID-19, based on the inhibition of polyamine-dependent processes that ensure long-term persistence of SARS-CoV-2 in the infected organism. We are talking about specific drugs such as alpha-difluoromethylornithine and its ana-logues, which are successfully used in oncology in the complex treatment of malignant neoplasms with the aim of lowering the level of aliphatic polyamines in the affected areas of malignantly transformed organs. We recommend the use of polyamine-free and polyamine-deficient diets for COVID-19 for the first time. In the planned study, we will present tables with food products of animal and vegetable origin, characterized by extremely low content and/or absence of aliphatic polyamines in them. At the same time, food products with a high content of aliphatic polyamines should be excluded from the general list of products recommended for COVID-19 patients. We also recommend the use of a polyamine-deficient diet (with a preventive purpose) during the COVID-19 pandemic to a wide contingent of practically healthy individuals, convalescents, medical staff of specialized infectious disease clinics, as well as family members of SARS-CoV-2 infected patients. Copyright © 2022, Yerevan State Medical University. All rights reserved.

SEVERE THROMBOCYTOPENIA DUE TO ELECTRON-BEAM POLYSULFONE DIALYZER MEMBRANE REACTION MASQUERADING AS CHRONIC IMMUNE THROMBOCYTOPENIC PURPURA

SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: We describe a case of severe thrombocytopenia due to reaction with an electron-beam sterilized polysulfone (PS) membrane in a patient with a previous diagnosis of reported chronic immune thrombocytopenic purpura (ITP). This phenomenon has been previously described but is rarely reported. Electron-beam (e-beam) sterilized PS membranes are classically more biocompatible than cellulose-based membranes but adverse reactions may occur as demonstrated in our case. CASE PRESENTATION: An 84-year-old woman with ESRD on hemodialysis (HD) and reported chronic ITP refractory to glucocorticoids with severe thrombocytopenia at baseline presented for evaluation of chest pain. She was incidentally found to have severe thrombocytopenia and treated with high dose glucocorticoids with minimal improvement in her thrombocytopenia and transitioned to chronic glucocorticoid taper. She had a severe chronic thrombocytopenia despite glucocorticoids which was suspected to be chronic ITP and diagnosed after initiation of outpatient HD. HD was held the first few days of her admission. She was found to have multifocal pneumonia due to SARS-CoV-2 infection. She developed progressive hypoxemic respiratory failure requiring intubation with sepsis treated with vancomycin & piperacillin-tazobactam. BAL revealed ESBL Escherichia coli & transitioned to ertapenem. She developed recurrent thrombocytopenia following HD and her PLT would improve between HD sessions. Evaluation of usual culprits of thrombocytopenia was unrevealing. Reaction to the PS membrane was suspected and a cellulose-based dialyzer membrane was used instead for subsequent sessions of HD with recovery of the platelet counts to normal. The remainder of her course was significant for tracheostomy with ventilator dependence and surrogate pursued compassionate care. DISCUSSION: We describe an interesting case of severe thrombocytopenia due to PS membrane reaction which was previously labeled as chronic ITP. Usual culprits such as pseudothrombocytopenia, HIT, HIV, HCV, hypersplenism, alcohol use, nutritional deficiencies, and rheumatologic disease were excluded. Synthetic membranes like PS-membranes are traditionally regarded as more biocompatible but filter reactions are described [1]. It is hypothesized that e-beam radiation may affect dialyzer membrane integrity or structure, or produce intermediary products which may cause platelet activation, aggregation, and adsorption, and therefore thrombocytopenia [2]. There is a high prevalence of thrombocytopenia among critically ill patients undergoing HD [3]. CONCLUSIONS: Thrombocytopenia due to PS dialyzer membrane is a rarely reported phenomenon and may be underrecognized in critically ill patients. This entity should be considered in the differential diagnosis of patients undergoing HD who develop thrombocytopenia. Early recognition may reduce incidence of bleeding and need for blood products in these patients. Reference #1: Golli-Bennour EE, Kouidhi B, Dey M et al. Cytotoxic effects exerted by polyarylsulfone dialyser membranes depend on different sterilization processes. Int Urol Nephrol 2011;43: 483–490. Reference #2: Batalini F, Aleixo GF, Maoz A, Sarosiek S. Haemodialysis-associated thrombocytopenia: interactions among the immune system, membranes and sterilisation methods. BMJ Case Rep. 2019 Sep 4;12(9):e229594. doi: 10.1136/bcr-2019-229594. PMID: 31488440;PMCID: PMC6731774. Reference #3: Griffin BR, Jovanovich A, You Z, Palevsky P, Faubel S, Jalal D. Effects of Baseline Thrombocytopenia and Platelet Decrease Following Renal Replacement Therapy Initiation in Patients With Severe Acute Kidney Injury. Crit Care Med. 2019;47(4):e325-e331. doi:10.1097/CCM.0000000000003598 DISCLOSURES: No relevant relationships by Adefemi Adeyemo No relevant relationships by Zachary Chandler No relevant relationships by Bijal Patel No relevant relationships by Vandana Seeram

Impact of demographic profile on nutritional labelling usage by working women population of Varanasi, India

Nutritional labelling is the nutritional description of the food on the label to help the consumer in food selection. The present study aimed to assess the knowledge, attitude and practices adopted by the subjects and correlate them to have a better understanding of their nutritional background. Nutrition labels are a prominent first-glance article that needs to be very catchy and easy to interpret. The organizations responsible for formulating the rules and regulations must keep them updated and devise new formats of the display to enhance the usage of food labels up to the maximum possible level. A cross-sectional research study on 100 working women of Varanasi, aged between 20-50 years was conducted through a self-structured questionnaire to evaluate their KAP level. In view of the COVID-19 pandemic, the questionnaire was administered to the respondents through the online medium using Google forms. It can be inferred from the study that 58 % of the total respondents surveyed were aware of the labels, 61% of them had a positive attitude towards its usage but only 52% practised healthy shopping more often. About 70% of the participants preferred back-of-pack labelling rather than front-of-pack because the former provides elaborative information. The factors like qualification and occupation of women participants had negative associations with the satisfaction of the display format. The women having knowledge regarding traffic light labelling showed a positive association with the usefulness of the same. The average practice percentage adopted by the consumers had a negative association with factors like qualification, income, and occupation. The need for simplifying the display format and providing basic nutrition information to the population is highlighted in this study.

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 .

Bridling at the use of nasal bridles? An observational study of their use at Royal Surrey Hospital Intensive Care Unit during the COVID-19 pandemic

Introduction: Sufficient nutrition has been repeatedly demonstrated to be a vital part of recovery from critical illness.1 Nutrition is often delivered in the intensive care setting via a Nasoenteral (NE) tube if oral diet is impractical or inadequate;this is first line as per ESPEN guidance.2 It has been observed that patients in the intensive care unit (ICU), particularly those who have been intubated due to COVID-19, are at high risk of agitation and delirium which can lead to accidental NE displacement. Nasal Loop Bridles (NLB) are amedical device which can be placed at bedside and are used to reduce the risk of NE tube displacement. The usage of NLBs varies between Trusts. Insertion of a NLB is a medical procedure which should be consented for where possible and clearly documented. Objectives: To identify all patients who had a NLB placed during the second wave of the COVID-19 pandemic at Royal Surrey Hospital (RSH) ICU, ascertain their reason for insertion, and identify any nutritional deficits incurred prior to NLB insertion. Secondary objectives include assessing quality of documentation of NLB insertion. Methods: A literature review was undertaken regarding the safety and efficacy of NLBs. This was followed by a retrospective observation of patients admitted to RSH ICU between December 2020 and March 2021. Data was collected on patients who required a NLB, including accrued nutritional deficit prior to placement and adverse incidents. Documentation of NLB rationale and placement was also noted. Results: 10 patients met inclusion criteria. The most common indications for insertion were delirium and previous tube displacement. Two NLBs were placed prior to any NE displacements therefore resulted in no nutritional losses. In the remaining patients a range of 1-5 NE tubes were accidentally displaced prior to NLB insertion (mean 2.7 tubes). 6-117 hours of feeding were lost prior to NLB placement resulting in a deficit of 744-6843kcal. Two patients were unable to have a NLBwhen indicated due to stock shortages, resulting in a deficit of 4140 and 6480kcal. No standard documentation was utilised for NLB placement. No major incidents occurred in relation to NLBs. Conclusion: This study highlights the benefits of NLBs in respect to nutritional delivery in patients who have undergone emergency sedation and ventilation and are at risk of delirium. It has also highlighted the need for improved documentation of this medical procedure. Inferences made from this study, and work by other centres identified in the literature review, suggest that it may be beneficial to consider early or prophylactic NLB placement in this cohort. Further local research could test criteria for use of NLBs including hyperactive delirium, difficulty of initial NE tube insertion and number of previous displaced tubes, in order to elucidate the most effective timing and indication for their use.

The Role of Vitamin D3 Levels in Covid-19 Disease Severity: Participant or Non-participant

Background: Hospitalised COVID-19 patients are known to exhibit varying degrees of immune dysfunction, few modifiable risk factors have been identified to improve this state of which one is the immune modulator effects of vitamin D. Vitamin D is being prescribed as a treatment of COVID-19 in a few guidelines as there is generalised assumption that vitamin D enhances immunity during this illness. So this is an attempt to find out whether a deficiency of vitamin D is associated with the severity of COVID-19. Aim: To study the relationship of serum 25 hydroxy vitamin D [25(OH)D] deficiency with disease severity in hospitalised COVID-19 patients. Materials and methods: The present case-control study compared serum 25(OH)D levels among Mild to moderate and severe COVID- 19 patients. Around 39 diagnosed and Hospitalised Severe COVID- 19 disease are compared with 39 Hospitalised Mild and Moderate COVID-19 disease in Care Hospital, Bhubaneswar, Odisha, India between April 1, 2021, ad August 31, 2021. Patients were divided into 2 groups. The Group 1-Mild to Moderate infection with CT Severity index < 10/25 and Group 2-Severe Infection with HRCT Chest of CTSI >10/25. As per hospital policy, severe infection patients were kept in Critical Care Area and Mild infection patients were kept in Ward/Cabin areas. Any patients becoming sick and being transferred to critical areas are shifted from Group 1 to Group 2 after HRCT chest. Vitamin D levels (25 D Cholecalciferol) are done on the day of admission by chemiluminescence immunoassay test after taking due consent from the patients/attenders. The level of cut-off used in our study is 20 ng/mL. The association was analysed using regression analysis and other statistical methods. Results: The status of 25(OH)D deficiency (present/absent with cut-off being 20 ng/mL) showed no significant difference among cases and control at p < 0.05. Chi-square statistics with Yates correction is 1.8909. The p value is 0.169099. So there were no significant differences in vitamin D3 levels between Mild to moderate and Severe COVID- 19 patients. Conclusion: 25(OH)D levels appear to have no strong association with disease severity amongst hospitalised COVID-19 patients. Hence, its prescription for COVID-19 treatment as well as prevention needs to be reconsidered.

The provision of parenteral nutrition for patients with COVID-19 on the intensive care unit: experience at a district general hospital

Up to 10% of COVID-19 patients require respiratory and hemodynamic support in the ICU and are at an increased risk of malnutrition (1). Where enteral nutrition is impossible, contraindicated, or insufficient then parenteral nutrition (PN) is warranted, and considered safe in the critically ill cohort (2, 3). We report the characteristics and outcomes for ventilated patients with COVID-19 who received PN on ICU. A retrospective observational study was undertaken of COVID-19 ICU patients between March-April 2020 (“wave1”) and December-March 2021 (“wave2”). Nutritional risk was calculated using The NUTRIC score (4). Data was analysed in Microsoft Excel. In total, 17 patients with COVID-19 (7 in “wave1”, 10 in “wave2”) received PN for an average of 8.6 ± 4 (range 4-16) days during their admission. 1. Patient characteristics (n=17) [Formula presented] Indications for PN were high gastric residual volumes (GRVs) (70%), haemodynamic instability and impaired feed delivery. In wave 2, bedside Naso-jejunal tube (NJT) placement was available. Six patients had successful NJT insertion, all of which subsequently achieved nutritional targets enterally, and PN was discontinued. 35% of patients had a NUTRIC score ≥5 and required longer on PN (mean 10.5 days) versus those with a NUTRIC score <4 (mean 7.1 days). Biochemical refeeding was seen in 50% of patients. In conclusion, ventilated COVID-19 patients on the ICU who required PN had complex nutritional needs, and significant levels of refeeding. Accrued nutritional deficit due to high GRV’s was our primary indication for PN commencement. They had a high mortality rate, when compared to national ICNARC mortality data (5), suggesting PN was provided at the point of worsening multi-organ failure. 1. Thibault R, Seguin P, Tamion F, et al. Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. Crit Care 2020;24: 447. 2. Harvey S E, Parrott F, Harrison D A, et al. Trial of the route of early nutrition support in critically ill adults. N Engl J Med 2014;371: 1673-1684. 3. Singer P, Blaser A, Berger M, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38: 48-79. 4. Heyland D K, Dhaliwal R, Jiang X, et al. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011;15: R268. 5. ICNARC report on COVID-19 in critical care: England, Wales and Northern Ireland 3 June 2021 (Accessed June 14, 2021, at )

Considerations for Transplant Risk Assessment in the Setting of Co-occurring Alcohol Use Disorder and Eating Disorder

Background: Rates of alcohol use disorder amongst women have increased markedly since the start of the Covid-19 Pandemic with some studies showing as much as a 41% increase in heavy drinking days (1). Among women with alcohol use disorder, there is a high degree of comorbidity with eating disorders (ED) with studies suggesting rates of co-occurring disease as high as 23-50%(2). However, there is little data on the assessment of transplant recipients presenting with co-occuring ED and AUD. Case: A 34-year-old woman with no known past psychiatric or substance use history presented to our hospital in acute hepatic failure (MELD Score 34) in the context of escalating alcohol use over the course of the COVID-19 Pandemic. As the patient did not respond to multiple medical therapies, evaluation for liver transplantation was initiated. The patient was assessed using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), and found to be a high risk candidate. During the course of our evaluation, the patient demonstrated a lack of interest in eating food, refusing to eat food that required chewing, and expressed multiple consequences about the aversive consequences of eating. She described extremely restrictive eating patterns with her lowest weight being 95 lbs (BMI < 16), leading to nutritional deficiencies, peripheral neuropathy and anemia. Given the absence of excessive concern regarding appearance or body weight, a diagnosis of avoidant restrictive food intake disorder (ARFID) was made. Despite efforts to engage the patient, she demonstrated little understanding of her ED. The patient was declined for listing and medically stabilized. She was declined by all inpatient substance use programs given the extent of her ED and rejected recommendations for targeted ED treatment. She was ultimately discharged to an intensive outpatient program for AUD. Discussion: There is a paucity of information regarding liver transplantation in patients with co-occurring AUD and EDs. However, there are many unique considerations in the management of this patient population in both the pre- and post- transplant period. Existing screening methods such as the SIPAT do little to evaluate transplant risk in patients with EDs relative to other psychiatric illnesses. And while predictive risk factors for recurrence of alcohol use after transplant have been identified, little is known about the risk factors for ED relapse. It appears that the emphasis on abstinence from alcohol in the post-transplant period can be a potent trigger for ED relapse(3). Post-transplant, patients with ED have an increased risk of relapse to alcohol and poorer retention in residential treatment(4). Conclusion: Patients with co-occurring ED and AUD requiring liver transplantation are a challenging patient population with complex pre- and post-transplant considerations. References: 1. Pollard M, et al. "Changes in Adult Alcohol Use and Consequences During COVID-19 Pandemic in the US." JAMA Netw Open. 2020;3(9). 2. Bulik, Cynthia, et al. “Alcohol Use Disorder Comorbidity in Eating Disorders: A Multi-center Study.” Journal of Clinical Psychiatry. 65:7, July 2004. 3. Coffman K L, et al. Treatment of the Postoperative Alcoholic Liver Transplant Recipient With Other Addictions." Liver Transpl Surg. 1997;3:322–327. 4. Elmquist, J. et al., "Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report." Journal of Dual Diagnosis, 11(3-4), 233–237. https://doi.org/10.1080/15504263.2015.1104480.2015.

Telogen Effluvium as Sequela of COVID-19 in Patients from Central India: A Retrospective Observational Study

Introduction: Corona virus disease has several dermatological symptoms. Telogen effluvium is one of them. The present study presents a case series of post COVID Telogen effluvium from Central India region. Material and Method: This retrospective observational study included 72 patients (61 females & 11males), aged 29 to 62 years (median 49 yrs). The patient’s demography, history of hair fall, signs and symptoms, co morbidities and the treatment received for COVID-19 infection, Psychological perceived stress score, triggering factors for Telogen effluvium, Vitamin B12, Vitamin D and Ferritin levels were recorded & analysed. Result: The included patients were suffering from at least one co morbidity. Thirty patients had severe COVID-19 infection and were hospitalized. Psychological perceived stress score was low (12) in two, moderate (16-24) in twenty and high (29-38) in fifty patients. Vitamin B12 was low in twelve and Ferritin in ten patients. Seventy patients (97.2%) had positive hair pull test and 69 (95.8 %) had diffuse loss of hair. Discussion: Post covid Telogen effluvium was seen generally in females, and in middle aged. Most, 70/72 had moderate to severe psychological stress, Psychological perceived stress score was more than 16. Patients reported 2.2 to 6 months (median 3.5 months) after COVID-19 infection. Most 69 (95.8%) had diffuse hair loss. Post Covid patients may have several triggering factors for Telogen effluvium like psychological stress, nutritional deficiency or the drugs (heparin). Conclusion: Post Covid Telogen effluvium could be triggered by psychological stress, nutritional deficiencies (Vitamin B12, Iron) or drugs (heparin). Such cases could be managed by identification of triggering factors, proper counselling, high protein diet with vitamin supplementation.

The relationship between nutritional deficiencies and mental health

The objective of this mini review was to discuss the relationship between nutritional deficiencies and mental health, and to present a structure that helps to visualize these associations based on a literature review and the scenarios of the COVID-19 pandemic. The study was conducted to demonstrate the effect of the nutritional deficiencies on the occurrence and/or worsening of mental health problems, mainly related to the most drastic measures of social distance during the COVID-19 pandemic. Studies have already shown that a nutritionally unbalanced diet may be associated with greater chances of mental health problems. Insufficient levels of micronutrients can, by regulating the stress response, immune and oxidative systems, negatively affect brain functions and, consequently, cognitive functions and mental health of individuals. The current pandemic of COVID-19 reveals an increase in food and nutritional insecurity, and a worsening of this situation among already vulnerable populations. Micronutrient deficiencies may be exacerbated in a context of increased food insecurity and the COVID-19 pandemic, which may contribute to increased mental health problems.

Pediatric reference intervals: Gaps and recent advances

Clinical laboratory reference ranges serve as health-associated benchmarks that enable clinicians to interpret laboratory test results and facilitate clinical decision-making. Unfortunately, critical gaps currently exist in accurate and up-to-date pediatric reference ranges for accurate interpretation of laboratory tests performed in children and adolescents, which may contribute to erroneous diagnosis or misdiagnosis of many diseases. Several initiatives have been established internationally to address these gaps, including the KiGGS initiative in Germany, the Aussie Normals in Australia, the AACC-National Children Study in the USA, the NORICHILD Initiative in Scandinavia, and the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) program in Canada. Since 2009, CALIPER has recruited more than 12,000 healthy children and adolescents, thereby establishing a comprehensive database of pediatric reference ranges for over 185 biomarkers of health and disease (www.caliperdatabase.org). However, evidence gaps continue to exist for special markers and new laboratory instruments. To address these gaps, our team has recently completed or is currently undertaking studies to establish pediatric reference ranges for: 1) chemistry and immunological markers on new analytical systems (Abbott Alinity, Siemens Attelica), 2) hematological markers on multiple platforms (Sysmex, Beckman, Mindray), 3) critical care markers on point of care testing platforms, 4) markers of inflammatory disease (cytokines, calprotectin, autoimmune), 5) markers of nutritional deficiency (essential trace elements), and 6) markers of environmental toxicity (heavy metals). CALIPER is also embarking on specific sub-studies regarding maternal, child, and adolescent health, such as the Mother & Child Health Initiative, COVID-19 Seroprevalence Study, and Lipid Metabolism in Adolescents with obesity. In this presentation, I will review the recent worldwide initiatives on pediatric reference ranges as well as discuss the concept and feasibility of common reference ranges. I will also discuss the progress made by the CALIPER program, the CALIPER database, and future research directions.

Food supplements in nurses’ diet during COVID-19 pandemic

Introduction: The study aims at investigating the impact of COVID-19 pandemic on the frequency of nurses’ food supplementation. Material and Methods: The study was carried out in the winter of 2020-2021 in the City of Zagreb and comprised a total of 148 nurses affiliated with the PHCC “Centar”. Data were collected via a questionnaire adapted to the purpose. The research was approved by the Ethics Committee of PHCC. Differences between the group which changed its food supplementation during the COVID-19 pandemic and the group that did not were tested using the χ2 test. Results: The results reveal the consumption of some food supplements to be habitual to nurses. COVID-19 pandemic urged over a third of them to start taking food supplements, or to increase the amount and frequency of their use (38.5%). As for vitamins, during the pandemic nurses increased D vitamin intake (P<0.001). Significant differences in the consumption of minerals & proteins seen between the group that changed its food supplementation habits and the one that did not, arose primarily due to the changes in magnesium (P=0.020) and zinc intake (P=0.030). On top of that, a significant rise in beta glucan (P=0.015), and homeopathic preparations’(P=0.010) intake was documented. Conclusions: COVID-19 pandemic significantly impacts food supplementation in nurses. Based on the dietary recommendations, during the pandemic the focus should be shifted to healthy diet principles. In case of an increased risk of COVID-19 disease or nutrient deficiency, food supplements should be introduced, too.

Chronic Disease Burden - Nutrition and Lifestyle affecting Lives and Livelihoods in the Covid-19 Pandemic

Introduction: The covid-19 pandemic had widened the health gap, further exposing the challenges that workers face. These individuals are often marginalised by job role, geographical location changes due to migration or societal stigma in terms of ethnic origin, gender and disability. This paper further explores the challenges that vulnerable workers face in terms of nutrition and lifestyle factors (as defined by the United Nations Sustainable Development Goals) that play an important role in dis-ease. Materials and Methods: A case series of workers globally affected by the above factors were researched and nutritionally relevant health factors analysed. This series covers all continents and was able to cover the burden of poor nutritional status as a contributing factor to covid 19 related mortality and morbidity. In particular, the effects nutrition being of relevance in the management of Long Covid was also flagged. Results: Poor nutritional status, in particular micronutrient deficiency and the double edged effects of both under and over nutrition have had direct and indirect effects on the susceptibility and recovery from covid-19. The findings further support that prevention and disease management is noted to be a key variable in the vulnerable worker population. Conclusions: The implementation of key nutritional parameters as part of the health and economic ecosystem is a significant factor in the saving of Lives and Livelihoods !

Sars-Cov-2 Infection Associated with Aplastic Anemia and Pure Red Cell Aplasia

Introduction: Aplastic anemia (AA) is a life-threatening disorder characterized by pancytopenia and a hypocellular bone marrow. Pure red cell aplasia (PRCA) is a similar disorder with primary reduction in the red blood cell population and virtual absence of erythroid precursors in the bone marrow. While the etiology of immune mediated marrow failure is multifactorial, preceding viral infections have been associated with the disease;these include parvovirus B19, cytomegalovirus, and Epstein-Barr virus. We present four cases of immune mediated marrow failure with either preceding or simultaneous SARS-CoV-2 infection. Methods: The medical records of patients treated for AA or PRCA at the University of Texas Southwestern Medical Center, Parkland Hospital, and the National Institutes of Health (NIH) were reviewed for SARS-CoV-2 infection. Four patients without prior hematological diseases were identified who had SARS-CoV-2 infection prior to or with simultaneous the diagnosis of AA or PRCA. Results: Patient #1 was a 22-year-old white female who was diagnosed with asymptomatic COVID-19 10 days prior to her pancytopenia and AA diagnosis was confirmed by bone marrow biopsy (5% cellularity;Table 1). Her extensive work-up including HIV, hepatitis panel, immunoglobulins, B12 and folate was negative, and she underwent HLA-matched family donor hematopoietic stem cell transplant. Patient #2 was a 69-year-old Asian female who presented to her primary care physician with symptoms of fatigue and was found to be pancytopenic. CBC from a few months prior was completely normal. Further work-up was positive for COVID-19 and negative for HIV, nutritional deficiency, or hemolysis. She did not have respiratory symptoms, was eventually diagnosed with pRBC and platelet transfusion-dependent severe AA (5-10% cellularity on bone marrow), and underwent treatment with cyclosporine, equine antithymocyte globulin, and eltrombopag. She has had a partial response to this therapy. Both patients had bone marrow specimens stained for SARS-CoV-2 by immunohistochemistry that were negative. Patient #3 was a 76-year-old white male who was diagnosed with COVID-19 4 months prior to presenting with a non-ST segment myocardial infarction and found to be profoundly anemic, requiring pRBC transfusion. He re-presented with chest pain one week later and was found to be anemic again, and required transfusion. A trial of darbepoetin alfa was unsuccessful. Extensive work-up for malignancy, infection, and autoimmune etiologies were negative. He was diagnosed with PRCA based on the bone marrow biopsy and initiated treatment with cyclosporine. Patient # 4 was diagnosed with severe AA (presenting as pancytopenia) and COVID-19 infection. He had fatigue for one month and fever, chills and sore throat one-week prior seeking medical care. Testing for hepatitis, HIV, EBV, and CMV was negative. He was treated on a clinical trial (NCT04304820) at NIH with cyclosporine and eltrombopag until SARS-CoV-2 PCR was negative then received equine anti-thymocyte globulin. He has achieved a complete hematologic response at 6 months and remains well at last follow-up. Conclusion: The four patients described had minimal respiratory COVID-19 symptoms, but they presented with cytopenia and were eventually diagnosed with bone marrow failure. It is possible that this is co-incidental due to the high prevalence of SARS-CoV-2. However, there is emerging evidence that COVID-19 pneumonia is a hyperinflammatory and immune dysregulated state improved by dexamethasone therapy. Other immune mediated hematologic conditions, such as autoimmune hemolytic anemia and immune thrombocytopenia, have been reported. The onset from infection to cytopenia appears rapid, although patients often presented with symptoms for many days prior to diagnosis and thus testing may have been delayed from the onset of infection. This case series does not provide a mechanistic link between SARS-CoV-2 infection and bone marrow failure, but it raises the possibility that SARS-CoV-2 may mediate an immunologic response that cont ibutes to marrow failure. Patients appear to respond well to standard immunosuppressive treatment. Further cases and studies are needed to determine if this is directly linked to SARS-CoV-2 and whether the natural history and response to standard therapy is different than idiopathic cases. [Formula presented] Disclosures: Young: Novartis: Research Funding.